NLCA clinical indicators: what are they and how do we choose them?

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Ian Woolhouse, senior clinical lead for the National Lung Cancer Audit (NLCA), discusses the use of clinical indicators in the audit. 

I am often asked this question, and the short answer is that the clinical indicators are the key areas of care that we have identified which allow us to measure how well a lung cancer team is performing.

There are many different indicators that could be used, but I believe we should use those that best reflect the most important aspects of diagnosis and treatment. Where possible, we have aligned our indicators to the National Institute for Health and Care Excellence (NICE) lung cancer guidelines and quality standard to ensure that there is consistency across the board. However, an additional role for us as the audit suppliers is to set targets or standards for each indicator. This is fairly straightforward for some indicators, for example the proportion of patients who are seen by a clinical nurse specialist (this should be nearly all patients), but can be more challenging for others, such as treatment rates.

Treatment rates will depend on the type of patient seen by the lung cancer team. Some teams will see sicker patients who are less fit for treatment and, while the aim is to increase treatments for lung cancer, I am conscious of the fact that we should not encourage overtreatment of patients who are unlikely to benefit. To help us with this, we can perform ‘risk adjustment’ of the indicator. It took me a while to get my head around this, but essentially risk adjustment is just a way of taking into account things like the performance status of the patient and the stage of the lung cancer. Like most statistical techniques it is not perfect, in particular the way that other diseases are taken into account, but I am confident that we currently have the best system there is.

Another important role that I have is to oversee the annual review of the indicators. We have a dedicated clinical reference group of experts from all areas of lung cancer care to help with this task. Each indicator is reviewed to check whether it is still relevant and, if so, whether the target should be increased. There is also a ‘one in, one out’ policy for new indicators, so that lung cancer teams can focus on a set number of indicators at any one time. For example, we have introduced a new indicator for small-cell lung cancer, so the indicator relating to CT scan before bronchoscopy will be dropped.

I very strongly encourage all lung cancer teams to review their own clinical indicator results and to celebrate success where they are performing well, but – critically – to review areas where performance is less good. I am very keen to hear about success stories, so that we can share them with the wider lung cancer community.

Ian Woolhouse, NLCA senior clinical lead