Nationwide Quality Assessment of Lung Cancer Management in Korea: Based on Second-Cycle Health Insurance Review and Assessment Service Evaluation

Article information

Tuberc Respir Dis. 2025;88(4):708-717

Publication date (electronic) : 2025 June 20

doi : https://doi.org/10.4046/trd.2025.0038

Seunghun Lee^1,*, So-Yun Kim^2,*, Cheol-Kyu Park³, Seong-Hoon Yoon⁴, Chaeuk Chung^,2, Sung Yong Lee^,1, on Behalf of Korean Molecular Lung Cancer Study Group (KMLS) in The Korean Academy of Tuberculosis and Respiratory Diseases (KATRD)

¹Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea

²Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Republic of Korea

³Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Republic of Korea

⁴Department of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea

Address for correspondence Sung Yong Lee Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea E-mail syl0801@korea.ac.kr

Address for correspondence Chaeuk Chung Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea E-mail universe7903@gmail.com

*These authors contributed equally to the manuscript as first author.

Received 2025 March 7; Revised 2025 April 27; Accepted 2025 June 19.

Abstract

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

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.

Fig. 1.

Changes in quality assessment indicators for lung cancer between the first and second evaluation cycles. Overview of the changes in lung cancer quality assessment indicators between the first and second evaluation cycles. The indicators are categorized into structural aspects (blue), process indicators (green), and outcome indicators (orange). ^*Monitoring indicators represent reference measures for healthcare quality improvement, but are not included in the official score calculations. This classification highlights the shift towards a more outcome-oriented evaluation framework, with greater emphasis on multidisciplinary care, timely interventions, and patient-centered metrics. SCLC: small cell lung cancer; LS: limited stage; CCRT: concurrent chemoradiotherapy; NSCLC: non-small cell lung cancer; LI: lengthiness index; CI: costliness index; ICU: intensive care unit.

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.

Fig. 2.

Demographic of patients and regional distribution of lung cancer cases in the second cycle of lung cancer quality assessment. The graph illustrates the (A) age, and (B) sex, distribution, showing a higher prevalence in males (66.0%), and in the 61 to 80 age group (70.1%). (C) The geographic distribution of lung cancer cases, with Seoul (43.2%) and Gyeonggi (22.4%) accounting for most cases. (D) The geographic distribution of institutes that were evaluated; this figure provides an overview of the key demographic and regional characteristics of the patient population evaluated.

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).

Table 1.

Distribution of treatment modalities of lung cancer cases

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).

Table 2.

Summary and result of quality assessment of lung cancer indicators

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).

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).

Table 3.

Overall score results of quality assessment of lung cancer

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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