Introduction
Lung cancer continues to be the primary cause of cancer-related deaths worldwide. In South Korea, the increasing rate of early lung cancer detection through national health screening programs, and the rising incidence of lung cancer in female non-smokers, have drawn significant attention [1-5]. Over the past decade, advances in targeted therapies and immune checkpoint inhibitors have transformed the landscape of lung cancer treatment, leading to improved survival outcomes [6,7]. Consequently, accurate diagnosis and appropriate treatment have become more critical than ever.
However, despite well-established clinical guidelines, discrepancies exist between recommended best practices and actual clinical care. To enhance the quality of lung cancer treatment, reduce disease burden, and optimize healthcare resource allocation, the Health Insurance Review and Assessment Service (HIRA) in Korea has been conducting adequacy evaluations based on lung cancer claims.
Previous assessments were primarily conducted for lung cancer patients who underwent surgery or received chemo-radiotherapy, while excluding those who received only chemotherapy, or whose condition was such that treatment could not be administered [8]. As a result, prior assessments failed to comprehensively reflect the overall quality of cancer treatment. In response to the evolving medical landscape—characterized by advances in treatment options, and an increasing number of cancer survivors following surgical treatment—HIRA restructured its lung cancer assessment framework [8]. To better address the needs of cancer patients and reflect the current standards of lung cancer management, the second cycle of the adequacy evaluation, initiated in 2022, emphasizes a more patient-centered and outcome-driven approach [9].
This study analyzes the second-cycle HIRA assessment data to evaluate the current state of lung cancer care in Korea, and provide insights into the findings.
Materials and Methods
1. Data sources and patient selection
This study evaluated the adequacy of lung cancer treatment in South Korea based on claims data from the HIRA. The evaluation covered 12 months from July 1st, 2022 to June 30th, 2023 inclusive. The study included hospitalized patients aged 18 years or older who received treatment for primary lung cancer, including surgery, chemotherapy, or radiotherapy. Eligible institutions consisted of tertiary care hospitals, general hospitals, hospitals, and clinics that provided lung cancer treatment and submitted claims for medical expenses, while institutions reporting fewer than five eligible cases were excluded from the analysis. In South Korea, tertiary care hospitals are the highest-level institutions designated by the Ministry of Health and Welfare, requiring at least 300 inpatient beds and a specified number of medical specialists. General hospitals must have at least 100 beds, and operate departments covering key medical specialties. Patients are able to visit general hospitals, but to receive insurance-covered treatment at a tertiary hospital, a referral from a primary or secondary hospital is normally required.
This study did not involve human participants, animal experiments, or patient data requiring ethical approval.
2. Indicators for quality assessment
The second-cycle lung cancer adequacy evaluation indicators can be broadly classified into ‘evaluation indicators,’ and ‘monitoring indicators.’ Evaluation indicators are further categorized into structural aspects of lung cancer care, processes in lung cancer treatment, and treatment outcomes. As they are used to calculate adequacy assessment scores, they are key metrics to evaluate healthcare quality and directly impact patient treatment outcomes. They play a crucial role in assessing treatment processes and outcomes, facilitating inter-institutional comparisons and grading assessments. Structural evaluation indicators include the presence of specialized medical personnel. Process evaluation indicators encompass the proportion of multidisciplinary care for cancer patients, the percentage of patients undergoing surgery within 30 days of a confirmed lung cancer diagnosis, the proportion of critically ill patients among surgical patients, and the implementation rate of cancer patient education and counseling. Outcome evaluation indicators include in-hospital mortality or mortality within 90 days post-surgery, the 30 days readmission rate following discharge after surgery, and prolonged hospital stay indicators. Critically ill patients are defined as those aged 80 or older, or with a Charlson comorbidity index of 3 or higher.
The lengthiness index (LI) is a standardized metric used to evaluate the relative length of hospital stay across institutions. The calculation accounts for differences in patient characteristics by applying diagnosis-related group (DRG) adjustment, and reflects how the mean length of stay at a given institution compares to the national average for the corresponding disease group. An LI of 1.0 represents the national average, whereas LI greater than 1.0 indicates a longer-than-average hospitalization, while LI of less than 1.0 indicates a shorter-than-average hospitalization.
The costliness index (CI) indicates how high the inpatient medical expenses of a given healthcare institution are compared to the national average, after adjusting for the institution’s patient case mix based on DRG, where a CI of 1.0 represents the average, CI below 1.0 indicates lower-than-average costs, while CI above 1.0 indicates higher-than-average costs. The intensive care unit (ICU) admission rate before death is an indicator where lower values indicate better practice, as it reflects the proportion of cancer patients admitted to the ICU within 30 days prior to death.
The monitoring indicators include metrics that include the cost burden of inpatient care, the rate of ICU admissions among terminal cancer patients, the proportion of terminal cancer patients receiving chemotherapy before death, and the hospice counseling rate for cancer patients. Unlike evaluation indicators, these metrics are not used for official score calculations or grading, but are reference indicators for long-term healthcare quality improvement.
3. Average comprehensive scoring and grading
The comprehensive score was calculated by applying weighted values based on the importance of the evaluation indicators. Monitoring indicators were excluded from the calculation of the average comprehensive score. Eligibility was limited to institutions that reported evaluation indicator results. Only institutions with at least 10 cases both in the surgical mortality rate denominator, and the 30 days readmission rate after discharge denominator, were included.
Based on the calculated scores, institutions were classified into five grades in 10-point increments. Institutions with a comprehensive score of 90 or higher were classified as grade 1. Scores ranging 80 to 89.9 were classified as grade 2, 70 to 79.9 as grade 3, 60 to 69.9 as grade 4, and below 60 as grade 5. Institutions excluded from the comprehensive score calculation were not assigned a grade.
Results
1. Comparison of lung cancer quality assessment indicators between the first and second cycles
Among the indicators used in the first cycle of cancer adequacy evaluation, nine out of 12 were newly introduced in the second cycle, with only three indicators retained from the first cycle (Figure 1). The first-cycle evaluation primarily focused on surgical treatment and early-stage management of patients, emphasizing diagnosis and surgical procedures. In contrast, the second-cycle evaluation was restructured to provide a comprehensive assessment of cancer care, encompassing treatment planning, cancer therapy, and end-of-life care.
Notably, many indicators related to the diagnostic process in the first cycle were removed, while new outcome-based indicators were introduced. Indicators assessing treatment process quality, such as documentation completeness, were eliminated in the second cycle. Instead, outcome-related indicators, including surgical mortality, readmission rates, and ICU admission rates, were incorporated. In addition, patient-centered evaluation criteria were introduced, such as multidisciplinary care, surgery within 30 days of diagnosis, counseling on treatment procedures, and hospice/palliative care involvement.
Another significant change was the shift from cancer-specific indicators in the first cycle, to the development of common indicators applicable to multiple cancer types in the second cycle. This revision facilitates the introduction of future evaluations for other high-prevalence cancers. Unlike other cancers, no indicators specific to lung cancer were established in the second-cycle evaluation.
2. Study population
The evaluation covered 12 months from July 2022 to June 2023, including 106 institutions and 21,517 cases. Among these, tertiary care hospitals accounted for 44 institutions (41.5%) and 16,328 cases (75.9%), while general hospitals comprised 62 institutions (58.5%) and 5,189 cases (24.1%). Among the 106 hospitals, 23 general hospitals were excluded from the grading assessment due to missing indicators (indicators not applicable for evaluation). As a result, the grading assessment was conducted on 83 institutions.
A total of 21,240 patients with lung cancer were enrolled in the study, of whom 14,021 (66%) were male, and 7,219 (34%) were female (Figure 2A). Age distribution analysis revealed that 44 patients (0.2%) were aged 18−30 years, 216 (1.0%) were 31−40 years, 896 (4.2%) were 41−50 years, 3,225 (15.2%) were 51−60 years, 8,057 (37.9%) were 61−70 years, 6,831 (32.2%) were 71−80 years, and 1,971 (9.3%) were 81 years or older (Figure 2B). More than half of the lung cancer cases occurred in patients aged 61−80 years, with the highest prevalence observed in the 61−70 age group, similar to trends seen in gastric and colorectal cancers.
Regarding the regional distribution of enrolled patients, Seoul (9,292 cases, 43.2%) and Gyeonggi province (4,813 cases, 22.4%) accounted for more than half of all lung cancer diagnoses (Figure 2C). A total of 106 institutions (44 tertiary care hospitals and 62 general hospitals) participated in the study, with the highest representation from Seoul and Gyeonggi Province (n=30 each, 28.3%) (Figure 2D). In terms of treatment modalities, surgery alone was the most common approach, and was performed in 10,578 cases (49.2%), followed by chemotherapy alone in 5,045 cases (23.4%), and combined chemotherapy and radiotherapy in 1,726 cases (8.0%) (Table 1).
3. Evaluation indicators
1) Structural aspects of lung cancer care
The composition of specialized medical personnel, which was retained as a key evaluation criterion from previous assessments, showed notable improvements in this cycle. A higher percentage in this criterion indicates better adequacy. In lung cancer treatment, specialized personnel include thoracic surgeons, pulmonologists, medical oncologists, radiation oncologists, pathologists, radiologists, and nuclear medicine specialists. The overall average composition rate of specialized personnel for lung cancer was 95.5%, which was higher than that of other cancer types (stomach cancer 85.2%, colon cancer 83.5%) [9]. Notably, in tertiary care hospitals, all 44 institutions met the requirement for a complete team of specialized professionals. This reflects significant improvements in this cycle, reinforcing the availability of trained experts essential for high-quality lung cancer care (Table 2).
2) Process in lung cancer treatment
The rate of multidisciplinary consultations for cancer patients, introduced to facilitate comprehensive treatment planning by involving multiple specialists, was 30.8% for lung cancer, exceeding the target value of 12.6% by more than two-fold. This indicator highlights the extent to which patients receive coordinated and personalized treatment strategies. Notably, the multidisciplinary consultation rate in tertiary care hospitals was 30.2%, while in general hospitals, it was slightly higher at 33.1%, indicating a more significant proportion of multidisciplinary consultations than tertiary care hospitals (Table 2). This result might be influenced by the level of proactiveness in the response of each institution to the lung cancer adequacy assessment.
The proportion of patients undergoing surgery within 30 days of a confirmed cancer diagnosis, an indicator designed to enhance treatment outcomes through early surgical intervention, was 93.2% for lung cancer. A higher percentage in this criterion indicates better adequacy. Notably, this rate was higher in general hospitals (96.0%), compared to tertiary care hospitals (92.6%) (Table 2).
The proportion of critically ill patients among surgical patients is not a metric that can be simply interpreted as ‘higher is better,’ or ‘lower is better.’ Among patients undergoing lung cancer surgery, the proportion of critically ill patients was 27%, which was lower than that observed in other cancer types (42% in colon cancer, 44.8% in gastric cancer). Also, the proportion of critically ill patients was higher in general hospitals (30.2%), than in tertiary care hospitals (26.3%) (Table 2).
The rate of lung cancer patient education and counseling sessions, which enables patients and caregivers to understand disease progression better and engage in self-management to prevent complications, was 94.0%. Tertiary care hospitals (94.6%) demonstrated higher rates of patient education, compared to general hospitals (91.7%) (Table 2).
3) Treatment outcomes
As a key outcome measure, the surgical mortality rate refers to the proportion of patients who died either during hospitalization following lung cancer surgery, or within 90 days postoperatively, with lower values indicating better outcomes. The overall surgical mortality rate for lung cancer was 1.19%, with tertiary care hospitals reporting a lower rate of 1.04%, compared to 1.88% in general hospitals. Furthermore, the predicted surgical mortality rate in tertiary care hospitals was 1.14%, while the actual observed rate was lower at 1.04%. In contrast, general hospitals had a predicted mortality rate of 1.40%, but the actual rate was higher at 1.88%, indicating a more significant discrepancy between expected and observed outcomes (Table 2).
Another critical outcome measure, the re-admission rate within 30 days of discharge following surgery, refers to the proportion of patients re-hospitalized within 30 days after being discharged following lung cancer surgery. The overall 30 days readmission rate for lung cancer was 2.26%, with tertiary care hospitals reporting a lower rate of 2.09%, compared to 3.06% in general hospitals. As well, the predicted readmission rate for tertiary care hospitals was 2.24%, while the actual rate was lower at 2.09%. In contrast, general hospitals had a predicted readmission rate of 2.32%, but the actual rate was higher at 3.06%, indicating a greater-than-expected re-admission burden in general hospitals (Table 2).
An LI below 1.0 indicates a shorter-than-average hospital stay, while an LI above 1.0 signifies a longer-than-average stay. The average length of hospitalization for lung cancer was 8.4 days, with tertiary care hospitals averaging 7.9 days, and general hospitals 10.5 days. Among all institutions, 68 facilities (71.6%) had an LI exceeding 1.0, indicating longer-than-average hospital stays for lung cancer. This proportion was slightly higher in tertiary care hospitals, where 33 institutions (75.0%) had an LI above 1.0, compared to 35 general hospitals (68.6%). The minimum to maximum LI ranged 0.66 to 1.71 across institutions (Table 2).
4. Monitoring indicators
1) Cost and utilization indicators
The average inpatient cost for lung cancer was 12,768,000 Korean won (KRW), with tertiary care hospitals averaging 12,665,000 KRW, and general hospitals 13,296,000 KRW. The CI is standardized to 1.0, where values below 1.0 indicate lower-than-average costs, while values above 1.0 indicate higher-than-average costs. Among all institutions, 66 facilities (71.0%) had a CI exceeding 1.0, indicating higher-than-average costs for lung cancer treatment. This proportion was 75.0% (33 institutions) in tertiary care hospitals, and 67.3% (33 institutions) in general hospitals (Table 2).
For lung cancer, the ICU admission rate before death was 22.5%, which was higher when compared to other cancer types (colon cancer 17.5% and gastric cancer 16.6%). The rate was 22.9% in tertiary care hospitals, and 21.8% in general hospitals, indicating a lower ICU admission rate before death in general hospitals (Table 2).
The chemotherapy administration rate before death is an indicator where lower values indicate better practice, as it reflects the proportion of cancer patients who received chemotherapy within 14 days prior to death. For lung cancer, this rate was 13.6%, which was higher compared to other cancer types (colon cancer 5.9% and gastric cancer 9.3%) [9]. The rate was 15.8% in tertiary care hospitals, and 9.9% in general hospitals, indicating that chemotherapy administration within 14 days before death was more frequent in tertiary care hospitals than in general hospitals (Table 2).
2) Hospice and palliative care services
The hospice counseling rate for cancer patients refers to the proportion of lung cancer patients who received hospice counseling within 6 months before death, with higher values generally indicating better end-of-life care. Among lung cancer patients, 56.8% received hospice counseling within this period, which was lower, when compared to other cancer types (colon cancer 79.4% and gastric cancer 73.7%). The rate was 56.4% in tertiary care hospitals, and 57.5% in general hospitals, indicating a slightly higher hospice counseling rate in general hospitals (Table 2).
5. Overall scores
Among the 106 institutions evaluated, 23 were excluded from comprehensive scoring. A total of 83 institutions met these criteria, including 44 tertiary care hospitals, which accounted for 16,328 cases, and 39 general hospitals, which accounted for 4,540 cases (Table 3).
The average±standard deviation comprehensive score for lung cancer treatment across all institutions was 91.09±3.76, with tertiary care hospitals scoring 91.48±2.53, and general hospitals scoring 90.65±4.78 (Table 3).
Notably, for lung cancer, as many as 67 out of 83 institutions (80.7%) were classified as grade 1, representing a substantially higher proportion compared to colorectal cancer (45.4%) and gastric cancer (50.7%), which suggests a relatively higher level of adequacy in lung cancer treatment. These findings indicate that lung cancer treatment institutions in South Korea generally meet high adequacy standards (Table 3).
Discussion
The findings of this study indicate that compared to other cancers, such as gastric and colorectal cancer, the overall quality of lung cancer care in South Korea is relatively high. The comprehensive evaluation score for lung cancer was 91.09, which was notably higher than that of colorectal cancer and gastric cancer. While differences in evaluation criteria may influence these results, the data suggest that the quality of lung cancer treatment in South Korea is generally well-maintained, while being evenly distributed across different regions, ensuring a high standard of care nationwide.
In contrast to the first cycle of the adequacy assessment, which primarily focused on evaluating patients who underwent surgical treatment or concurrent chemo-radiotherapy, the second cycle aimed to assess the entire cancer care continuum, including patients with advanced-stage disease. This expansion of evaluation scope reflects an effort to comprehensively examine the quality of lung cancer management beyond curative treatment. Notably, new indicators were introduced in this cycle, such as cancer patient education and counseling rates, and hospice consultation rates. These additions acknowledge the importance of optimizing oncologic treatment and addressing patients' holistic needs, including physical, psychosocial, and spiritual well-being. Integrating hospice consultation into the evaluation framework underscores the commitment to improving quality of life and dignified end-of-life care.
Furthermore, recent advancements in lung cancer treatment, including immune checkpoint inhibitors as consolidation therapy following chemo-radiotherapy and the increasing role of neo-adjuvant and adjuvant immunotherapy in surgical patients, have emphasized the need for multidisciplinary team approaches in treatment planning [6,10,11]. To address this need, the current assessment cycle introduced multidisciplinary consultation rates as a new evaluation metric, highlighting the growing significance of collaborative decision-making in lung cancer care. This addition represents a meaningful step toward ensuring that patients receive comprehensive and individualized treatment strategies, based on expertise from multiple specialties.
While this assessment provides valuable insights into the adequacy of lung cancer treatment, further analysis is needed to evaluate its real-world clinical impact on patient outcomes. Specifically, examining the relationship between key adequacy indicators—such as multidisciplinary consultation rates and early surgical intervention—and long-term survival outcomes, including overall survival and progression-free survival, would provide a more comprehensive understanding of treatment effectiveness.
Another key focus of this assessment was evaluating end-of-life care quality, particularly by analyzing ICU admission and chemotherapy administration rates before death. These indicators were included to discourage medically futile interventions for terminal cancer patients, and to promote appropriate palliative care strategies. By assessing the extent of aggressive medical interventions at the end of life, this evaluation aimed to foster a healthcare environment that prioritizes patient-centered, value-based care, rather than unnecessary prolongation of life through ineffective treatments [12-14]. The findings from this assessment can serve as a foundation to further improve quality of end-of-life care, and ensure that terminally ill patients receive appropriate, compassionate, and ethically guided medical support [15-17].
When interpreting these findings, several limitations and contextual factors of the current adequacy assessment should be considered. The higher multidisciplinary care rate in general hospitals may be due to their role as primary care institutions, where diagnostic uncertainties remain. In contrast, tertiary hospitals often receive referred cases with established treatment plans, possibly resulting in lower collaboration rates. However, the advanced infrastructure and resources in tertiary hospitals may contribute to better outcomes, including lower mortality.
In addition, the hospice consultation rate for lung cancer patients is 56.8%, significantly lower than that of gastric cancer (73.7%), or colorectal cancer (79.4%). This disparity is attributed to the rapid disease progression and difficulty in prognostication in lung cancer, which often leads to continued aggressive treatment, such as chemotherapy (13.6%) and ICU admission (22.5%) near the end of life. Terminal lung cancer patients frequently experience respiratory emergencies, making it challenging to initiate hospice discussions in time.
One of the most significant limitations of the adequacy assessment data appears to be the lack of detailed clinical staging information, as reflected by the treatment patterns observed. Notably, 49.2% of patients in our dataset underwent surgery alone, while only 8% received concurrent chemoradiotherapy (CCRT), which is a standard treatment for stage III disease. As noted, the number of patients who received a combination of surgery with chemotherapy and/or radiotherapy was very small: 39 cases (0.2%) for surgery+chemotherapy, 12 cases (0.1%) for surgery+radiotherapy, and four cases (0.0%) for all three modalities. The adequacy assessment included patients who had been hospitalized at least once for surgery, chemotherapy, or radiotherapy for primary lung cancer. While surgical patients are invariably hospitalized, patients receiving chemotherapy or radiotherapy are often treated on an outpatient basis without admission. Therefore, there may be a discrepancy between the patients included in the adequacy evaluation, and those encountered in actual clinical practice. However, as an increasing number of patients are currently receiving chemotherapy, radiotherapy, or CCRT in outpatient settings, future evaluations should consider including these patient populations to provide a more comprehensive and representative assessment of lung cancer care.
In addition, 56.6% of lung cancer care institutions and 65.6% of diagnosed cases are concentrated in Seoul and Gyeonggi Province, even though these regions account for only 50.7% of the national population. This likely reflects the centralization of advanced cancer care services and infrastructure in the capital area. Many patients from rural or other provinces may travel to Seoul or Gyeonggi to receive diagnosis and treatment at tertiary hospitals. Therefore, the observed imbalance may not reflect an actual gap in care delivery, but rather a migration of patients toward high-capacity institutions.
Ultimately, this second-cycle evaluation marks a significant milestone as the first patient-centered and outcome-focused assessment of lung cancer care in South Korea. The results provide valuable insights into current treatment practices and areas for improvement. The revised assessment program emphasized patient-centered care, multidisciplinary approaches, and dignity in end-of-life care. These changes likely raised awareness among clinicians, potentially influencing practice patterns to align more closely with quality-of-life considerations. Compared to the evaluation indicators in the United States and the United Kingdom, which emphasize surgical or chemotherapeutic treatment [18,19], Korea's recent lung cancer adequacy assessment appears to take a more patient-centered approach. It places greater emphasis on hospice care, quality of life, and dignified death, rather than solely focusing on the disease itself. Based on these findings, quality improvement initiatives should be continuously implemented. In addition, by actively incorporating feedback from medical professionals and field experts, the assessment criteria can be further refined to reflect evolving clinical practices and patient needs. Through these ongoing improvements, the overall quality of lung cancer treatment in South Korea is expected to advance further, ensuring that patients receive the highest standard of care across all stages of the disease.
In conclusion, the first phase of the second-cycle adequacy assessment for lung cancer aimed to comprehensively evaluate treatment across all stages of the disease by integrating patient-centered and outcome-based indicators. The inclusion of multidisciplinary consultation for lung cancer reflects the growing importance of collaborative treatment planning, particularly with the introduction in recent years of immune checkpoint inhibitors. As well, the addition of hospice care indicators that focus on alleviating the physical, psychosocial, and spiritual distress of terminal cancer patients underscores the commitment to providing both optimal treatment, and appropriate end-of-life care. These advances in the evaluation framework are anticipated to play a pivotal role in enhancing the adequacy of lung cancer management. Looking ahead, ongoing refinement of assessment criteria will be crucial to keeping pace with rapid medical innovations and evolving clinical paradigms, thereby ensuring that lung cancer care remains both evidence-based, and patient-centered.
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