Evaluating the Quality of Lung Cancer Care: Real-world measurement of variation, survival outcomes, and quality indicator development

Quality of care improvements in lung cancer requires clinically meaningful, measurable, and outcome-relevant quality indicators (QIs). However, in real-world practice there exist significant gaps in the development, application, and validation of QIs. This thesis aimed to assess the care received by patients with lung cancer using QIs at the population level. A cohort of over 12,000 patients was analysed from linked cancer registry and administrative datasets in New South Wales, to evaluate the feasibility of applying QIs, their capacity to detect disparities in care, and their association with survival outcomes. A cancer-specific conceptual framework was developed to overcome limitations of conventional healthcare models by integrating domains relevant to oncology, and this guided a structured review of existing lung cancer QIs. Literature review revealed a disproportionate focus on surgical processes and limited representation of radiotherapy (RT) and systemic therapy and patient-reported QIs, despite their broader applicability across the patient population. Selected feasible QIs were identified as measurable and revealed variations in care across sociodemographic and service-level factors. A domain-based set of QIs was subsequently evaluated for association with survival, demonstrating that compliance was linked to improved outcomes. This represents the most comprehensive Australian analysis to date, applying QIs to evaluate real-world care disparities in lung cancer and survival-linked validation from routinely collected data. Although these results demonstrate the capacity to capture variations in care at a population level and showed association with clinically relevant outcomes, it also revealed substantial barriers related to data quality, missingness, and delays in data collection. This not only limits the accuracy but also timeliness of lung cancer QI measurement in real-world health settings and their potential implementation. To address existing limitations in the measurement of RT quality in lung cancer care, RT specific QIs were developed through an international modified Delphi consensus process. Future initiatives should prioritise the establishment of a prospectively collected, population-level lung cancer registry to facilitate the application, monitoring, and utility of QIs. This approach would support their broader use in health service evaluation, benchmarking and guiding quality improvement and policy development in lung cancer care.