Quality Improvement Initiatives to Optimize the Management of Chronic Obstructive Pulmonary Disease in Patients With Lung Cancer

Abstract

Purpose: Patients with lung cancer (LC) frequently have chronic obstructive pulmonary disease (COPD), the optimization of which improves outcomes. A 2014 Queen's University Hospitals audit demonstrated that COPD was underdiagnosed and undertreated in outpatients with LC. We sought to improve the diagnosis and management of COPD in this population.

Methods: We implemented change using a Define/Measure/Analyze/Improve/Control (DMAIC) improvement cycle. Data were obtained by chart review from the Cancer Care Ontario database and e-Patient System for patients with newly diagnosed LC, including patient characteristics, pulmonary function test (PFT) data, and bronchodilator therapies. Improvement cycle 1 included engaging stakeholders and prioritizing COPD management by respirologists in the Lung Diagnostic Assessment Program. Improvement cycle 2 included physician restructuring and developing a standard work protocol. Data were analyzed monthly and presented on statistical process control P-charts, which assessed differences over time. The χ² and McNemar tests assessed for significance between independent and dependent groups, respectively.

Results: A total of 477 patients were studied (165 patients at baseline, 166 patients in cycle 1, and 127 patients in cycle 2). There was no change in PFT completion over time, although respirology-managed patients were significantly more likely to undergo a PFT than patients who were not managed by respirology (56.7% v 96.1%; P < .00001). The proportion of respirology-managed patients with LC with airflow obstruction receiving inhaled bronchodilator significantly increased (baseline, 46.3%; cycle 1, 51.0%; and cycle 2, 74.3%). By cycle 2, patients with airflow obstruction were more likely to receive a long-acting bronchodilator if managed by respirology (74.3% v 44.8%; P = .0009).

Conclusion: COPD is underdiagnosed and undertreated in outpatients with LC. A DMAIC quality improvement strategy emphasizing COPD treatment during LC evaluation in the Lung Diagnostic Assessment Program significantly improved COPD management.