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Publication Briefs

Study Identifies Preventable Delays in Lung Cancer Diagnosis


  • Preventable delays in lung cancer diagnosis among Veterans at two VA medical centers arose mostly from failure to recognize abnormal imaging results documented in the patients' electronic health records (EHR) - and failure to complete key diagnostic procedures in a timely manner.
  • Missed diagnostic opportunities were identified in 222 of the 587 (37.8%) cases in this study. Patient adherence contributed to 44% of the missed opportunities.
  • Among missed opportunities attributed to failure to recognize a clinical clue documented in the EHR, the most frequently missed clue was an abnormal chest x-ray. Delays in completing follow-up of an abnormal chest x-ray and in performing first needle biopsy were the most common causes of missed opportunities related to failure to complete a requested clinical action.
  • Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively.
  • The authors suggest several potential solutions, including using VA's electronic health record to improve clinician recognition and tracking of abnormal test results.

Missed and delayed cancer diagnoses are associated with substantial disability and costs, and are a frequent cause for ambulatory malpractice claims. Early diagnosis depends on timely recognition and action on clinical clues. Although patient care-seeking delays are well-documented, treatment delays also may be related to the diagnostic process following the patient's first presentation with signs and symptoms. This retrospective cohort study sought to identify characteristics and predictors of missed opportunities for earlier diagnosis of lung cancer at two VA medical centers. Cases of primary lung cancer for 587 Veterans diagnosed between 7/04 and 6/07 were reviewed using data from VA's electronic health record (i.e., progress notes, lab and radiology reports, consultations). Type I missed opportunities for diagnosis were defined as failure to recognize pre-defined clinical clues (e.g., no documented request for follow-up) within 7 days of the clue being recorded in the medical record; Type II missed opportunities were defined as failure to complete a requested follow-up action (e.g., diagnostic procedure, consultation) within 30 days. Investigators also assessed the median wait times associated with each type of diagnostic clue or follow-up action.


  • This study lacked comparison information from comparable healthcare systems.
  • It is not clear from this study whether reducing diagnostic delays would improve outcomes.
  • Data may not reflect current performance in VA, which is currently supporting national improvement collaboratives to improve timely, appropriate care of lung cancer and other cancers.

The Office of Quality and Performance will be releasing national facility-level data on 27 lung cancer quality indicators, including two measures related to timeliness of diagnosis and treatment, later this year. A Lung Cancer Toolkit, developed by the Quality Enhancement Research Initiative (QUERI) and the Indianapolis Veterans re-Engineering Resource Center (VERC), will accompany the measures and provide tools to help facilities improve performance in specific areas.

This study was partly supported by HSR&D. Dr. Singh is part of HSR&D's Houston Center for Quality of Care and Utilization Studies.

PubMed Logo Singh H, Hirani K, Kadiyala H, et al. Characteristics and Predictors of Missed Opportunities in Lung Cancer Diagnosis: An Electronic Health Record Based Study. Journal of Clinical Oncology June 7, 2010, e-pub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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