Recurrence-Free Survival in Patients With Surgically Resected Non-Small Cell Lung Cancer: A Systematic Literature Review and Meta-Analysis

BACKGROUND

Standard treatment for early-stage or locoregionally advanced non-small cell lung cancer (NSCLC) includes surgical resection. Recurrence after surgery is commonly reported, but a summary estimate for postsurgical recurrence-free survival (RFS) in patients with NSCLC is lacking.

RESEARCH QUESTION

What is the RFS after surgery in patients with stage I-III NSCLC at different time points, and what factors are associated with RFS?

STUDY DESIGN AND METHODS

A systematic search was performed in MEDLINE, EMBASE, and Cochrane databases between January 2011 and June 2021. The primary outcome was RFS at 1, 2, 3, and 5 years postresection. Single-arm, random-effects meta-analyses were done to calculate effect estimates and 95% CIs. Analyses were stratified by stage/substage as per the AJCC Cancer Staging Manual, and RFS was estimated (1) after pooling studies, using seventh or eighth edition staging criteria; and (2) among studies using only the eighth edition. Meta-regressions were performed to assess associations between RFS and patient demographic/clinical characteristics of interest.

RESULTS

Data from 471 studies comprising 1,060 surgical study arms were extracted. RFS estimates from 60,695 patients staged with the seventh or eighth edition were analyzed. RFS ranged from 96% at 1 year postresection to 82% at 5 years for stage I, and from 68% at 1 year to 34% at 5 years for stage III. Estimates for patients staged using only eighth edition criteria were slightly higher. Older age, higher percentage of male patients, advancing stage, larger tumor size, and geographic region (North America/Europe vs Asia) were significantly associated with worse RFS.

INTERPRETATION

This study presents a comprehensive assessment of reported RFS from published clinical literature, offering estimates at multiple postsurgical time points and by geographic region. Findings can inform treatment decisions, clinical trial design, and future research to improve outcomes among patients with NSCLC.

Quantifying the Value of Reduced Health Disparities: Low-Dose Computed Tomography Lung Cancer Screening of High-Risk Individuals Within the United States

OBJECTIVE

This study aimed to measure the value of increasing lung cancer screening rates for high-risk individuals and its impact on health disparities.

METHODS

The model estimated changes in health economic outcomes if low-dose computed tomography screening increased from current to 100% compliance, following clinical guidelines. Current low-dose computed tomography screening rates were estimated by income, education, and race, using 2017-2019 Behavioral Risk Factor Surveillance System data. The model contained a decision tree module to segment the population by screening outcomes and a Markov chain module to estimate cancer progression over time. Model parameters included information on survival, quality of life, and costs related to cancer diagnosis, treatment, and adverse events. Distributional cost-effectiveness analysis estimated the net monetary value from reduced health disparities-measured using quality-adjusted life expectancy-across income, education, and race groups. Outcomes were assessed over 30 years.

RESULTS

Lung cancer screening eligibility using US Preventive Services Task Force guidelines was higher for individuals with income <$15 000 (47.2%) and without a high-school education (46.1%) than individuals with income >$50 000 (16.6%) and with a college degree (13.5%), respectively. Increasing lung cancer screening to 100% compliance was cost-effective ($64 654 per quality-adjusted life-year) and produced economic value by up to $560 per person ($182.1 billion for United States overall). Up to 32.2% of the value was due to reductions in health disparities.

CONCLUSIONS

Significant value in increasing lung cancer screening rates derived from reducing health disparities. Policy makers and clinicians may not be appropriately prioritizing cancer screening if value from reducing health disparities is unconsidered.

Patient Preferences for Lung Cancer Interception Therapy

Importance

Interception therapy requires individuals to undergo treatment to prevent a future medical event, but little is known about preferences of individuals at high risk for lung cancer and whether they would be interested in this type of treatment.

Objective

To explore preferences of individuals at high risk for lung cancer for potential interception therapies to reduce this risk.

Design, Setting, and Participants

This survey study used a discrete-choice experiment and included hypothetical lung cancer interception treatments with 4 attributes: reduction in lung cancer risk over 3 years, injection site reaction severity, nonfatal serious infection, and death from serious infection. Respondents were assigned to a baseline lung cancer risk of 6%, 10%, or 16% over 3 years. The discrete-choice experiment was administered online (July 13 to September 6, 2022) to US respondents eligible for lung cancer screening according to US Preventive Services Task Force guidelines. Participants included adults aged 50 to 80 years with at least a 20 pack-year smoking history. Statistical analysis was performed from September to December 2022.

Main Outcomes and Measures

Attribute-level preference weights were estimated, and conditional relative attribute importance, maximum acceptable risks, and minimum acceptable benefits were calculated. Characteristics of respondents who always selected no treatment were also explored.

Results

Of the 803 survey respondents, 495 (61.6%) were female, 138 (17.2%) were African American or Black, 55 (6.8%) were Alaska Native, American Indian, or Native American, 44 (5.5%) were Asian or Native Hawaiian or Other Pacific Islander, 104 (13.0%) were Hispanic, Latin American, or Latinx, and 462 (57.5%) were White, Middle Eastern or North African, or a race or ethnicity not listed; and mean (SD) age was 63.0 (7.5) years. Most respondents were willing to accept interception therapy and viewed reduction in lung cancer risk as the most important attribute. Respondents would accept a greater than or equal to a 12.0 percentage point increase in risk of nonfatal serious infection if lung cancer risk was reduced by at least 20.0 percentage points; and a greater than or equal to 1.2 percentage point increase in risk of fatal serious infection if lung cancer risk was reduced by at least 30.0 percentage points. Respondents would require at least a 15.4 (95% CI, 10.6-20.2) percentage point decrease in lung cancer risk to accept a 12.0 percentage point increase in risk of nonfatal serious infection; and at least a 23.1 (95% CI, 16.4-29.8) percentage point decrease in lung cancer risk to accept a 1.2 percentage point increase in risk of death from serious infection. Respondents who were unwilling to accept interception therapy in any question (129 [16.1%]) were more likely to be older and to currently smoke with no prior cessation attempt, and less likely to have been vaccinated against COVID-19 or examined for skin cancer.

Conclusions and Relevance

In this survey study of individuals at high risk of lung cancer, most respondents were willing to consider interception therapy. These results suggest the importance of benefit-risk assessments for future lung cancer interception treatments.

The Effect of Definitions and Cancer Prevalence on Diagnostic Yield Estimates of Bronchoscopy: A Simulation-based Analysis

Rationale: Studies of bronchoscopy have reported diagnostic yield (DY) using different calculation methods, which has hindered comparisons across studies. Objectives: To quantify the effect of the variability of four methods on DY estimates of bronchoscopy. Methods: We performed a simulation-based analysis of patients undergoing bronchoscopy using variations around base case assumptions for cancer prevalence (60%), distribution of nonmalignant findings, and degree of follow-up information at a fixed sensitivity of bronchoscopy for malignancy (80%). We calculated DY, the rate of true positives and true negatives (TNs), using four methods. Method 1 considered malignant and specific benign findings at index bronchoscopy as true positives and TNs, respectively. Method 2 included nonspecific benign findings as TNs. Method 3 considered nonspecific benign findings cases as TNs only if follow-up confirmed benign disease. Method 4 counted all cases with a nonmalignant diagnosis as TNs if follow-up confirmed benign disease. A scenario analysis and probabilistic sensitivity analysis were conducted to demonstrate the effect of parameter estimates on DY. A change in DY of >10% was considered clinically meaningful. Results: Across all pairwise comparisons of the four methods, a DY difference of >10% was observed in 76.7% of cases (45,992 of 60,000 comparisons). Method 4 resulted in DY estimates that were >10% higher than estimates made with other methods in >90% of scenarios. Variation in cancer prevalence had a large effect on DY. Conclusions: Across a wide range of clinical scenarios, the categorization of nonmalignant findings at index bronchoscopy and cancer prevalence had the largest impact on DY. The large variability in DY estimates across the four methods limits the interpretation of bronchoscopy studies and warrants standardization.

A Comparison of Microwave Ablation and Cryoablation for the Treatment of Renal Cell Carcinoma: A Systematic Literature Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis comparing microwave ablation (MWA) and cryoablation for renal cell carcinoma (RCC).

METHODS

The systematic search was performed in MEDLINE, Embase, and Cochrane databases. Studies published in English from January 2006 to February 2022 that assessed adults with primary RCC who received MWA or cryoablation were included. Study arms from RCTs, comparative observational, and single-arm studies were eligible. The outcomes included local tumor recurrence (LTR), overall survival, disease-free survival, overall/major complications, procedure/ablation time, 1- to 3-month primary technique efficacy, and technical success. Single-arm meta-analyses were performed using the random effects model. Sensitivity analyses excluding low-quality studies assessed using the MINORs scale were performed. Univariable and multivariable examined the effects of prognostic factors.

RESULTS

Baseline characteristics were similar between groups and mean tumor size for MWA and cryoablation were 2.74 and 2.69 cm. Single-arm meta-analyses were similar for LTR and secondary outcomes between cryoablation and MWA. Ablation time was significantly shorter with MWA than with cryoablation (meta-regression weighted mean difference 24.55 minutes, 95% confidence interval -31.71, -17.38, P < .0001). One-year LTR was significantly lower with MWA than cryoablation (odds ratio 0.33, 95% confidence interval 0.10-0.93, P = .04). There were no significant differences for other outcomes.

CONCLUSION

MWA provides significantly improved 1-year LTR and ablation time compared with cryoablation for patients with RCC. Other outcomes appeared similar or favorable for MWA; however, results were not statistically significant. MWA of primary RCC is as safe and effective as cryoablation, which should be confirmed with future comparative studies.

Stereotactic body radiation therapy and thermal ablation for treatment of NSCLC: A systematic literature review and meta-analysis

RATIONALE

Stereotactic body radiation therapy (SBRT) is the standard of care for inoperable early stage non-small cell lung cancer (NSCLC). Use of image guided thermal ablation (IGTA; including microwave ablation [MWA] and radiofrequency ablation [RFA]) has increased in NSCLC, however there are no studies comparing all three.

OBJECTIVE

To compare the efficacy of IGTA (including MWA and RFA) and SBRT for the treatment of NSCLC.

METHODS

Published literature databases were systematically searched for studies assessing MWA, RFA, or SBRT. Local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were assessed with single-arm pooled analyses and meta-regressions in NSCLC patients and a stage IA subgroup. Study quality was assessed with a modified methodological index for non-randomized studies (MINORS) tool.

RESULTS

Forty IGTA study-arms (2,691 patients) and 215 SBRT study-arms (54,789 patients) were identified. LTP was lowest after SBRT at one and two years in single-arm pooled analyses (4% and 9% vs. 11% and 18%) and at one year in meta-regressions when compared to IGTA (OR = 0.2, 95%CI = 0.07-0.63). MWA patients had the highest DFS of all treatments in single-arm pooled analyses. In meta-regressions at two and three-years, DFS was significantly lower for RFA compared to MWA (OR = 0.26, 95%CI = 0.12-0.58; OR = 0.33, 95%CI = 0.16-0.66, respectively). OS was similar across modalities, timepoints, and analyses. Older age, male patients, larger tumors, retrospective studies, and non-Asian study region were also predictors of worse clinical outcomes. In high-quality studies (MINORS score ≥ 7), MWA patients had better clinical outcomes than the overall analysis. Stage IA MWA patients had lower LTP, higher OS, and generally lower DFS, compared to the main analysis of all NSCLC patients.

CONCLUSIONS

NSCLC patients had comparable outcomes after SBRT and MWA, which were better than those with RFA.

Detecting Ground Glass Opacity Features in Patients With Lung Cancer: Automated Extraction and Longitudinal Analysis via Deep Learning-Based Natural Language Processing

BACKGROUND

Ground-glass opacities (GGOs) appearing in computed tomography (CT) scans may indicate potential lung malignancy. Proper management of GGOs based on their features can prevent the development of lung cancer. Electronic health records are rich sources of information on GGO nodules and their granular features, but most of the valuable information is embedded in unstructured clinical notes.

OBJECTIVE

We aimed to develop, test, and validate a deep learning-based natural language processing (NLP) tool that automatically extracts GGO features to inform the longitudinal trajectory of GGO status from large-scale radiology notes.

METHODS

We developed a bidirectional long short-term memory with a conditional random field-based deep-learning NLP pipeline to extract GGO and granular features of GGO retrospectively from radiology notes of 13,216 lung cancer patients. We evaluated the pipeline with quality assessments and analyzed cohort characterization of the distribution of nodule features longitudinally to assess changes in size and solidity over time.

RESULTS

Our NLP pipeline built on the GGO ontology we developed achieved between 95% and 100% precision, 89% and 100% recall, and 92% and 100% F1-scores on different GGO features. We deployed this GGO NLP model to extract and structure comprehensive characteristics of GGOs from 29,496 radiology notes of 4521 lung cancer patients. Longitudinal analysis revealed that size increased in 16.8% (240/1424) of patients, decreased in 14.6% (208/1424), and remained unchanged in 68.5% (976/1424) in their last note compared to the first note. Among 1127 patients who had longitudinal radiology notes of GGO status, 815 (72.3%) were reported to have stable status, and 259 (23%) had increased/progressed status in the subsequent notes.

CONCLUSIONS

Our deep learning-based NLP pipeline can automatically extract granular GGO features at scale from electronic health records when this information is documented in radiology notes and help inform the natural history of GGO. This will open the way for a new paradigm in lung cancer prevention and early detection.

Diagnostic outcomes of robotic-assisted bronchoscopy for pulmonary lesions in a real-world multicenter community setting

BACKGROUND

Robot-assisted bronchoscopy (RAB) is among the newest bronchoscopic technologies, allowing improved visualization and access for small and hard-to-reach nodules. RAB studies have primarily been conducted at academic centers, limiting the generalizability of results to the broader real-world setting, while variability in diagnostic yield definitions has impaired the validity of cross-study comparisons. The objective of this study was to determine the diagnostic yield and sensitivity for malignancy of RAB in patients with pulmonary lesions in a community setting and explore the impact of different definitions on diagnostic yield estimates.

METHODS

Data were collected retrospectively from medical records of patients ≥ 21 years who underwent bronchoscopy with the Monarch® Platform (Auris Health, Inc., Redwood City, CA) for biopsy of pulmonary lesions at three US community hospitals between January 2019 and March 2020. Diagnostic yield was calculated at the index RAB and using 12-month follow-up data. At index, all malignant and benign (specific and non-specific) diagnoses were considered diagnostic. After 12 months, benign non-specific cases were considered diagnostic only when follow-up data corroborated the benign result. An alternative definition at index classified benign non-specific results as non-diagnostic, while an alternative 12-month definition categorized index non-diagnostic cases as diagnostic if no malignancy was diagnosed during follow-up.

RESULTS

The study included 264 patients. Median lesion size was 19.3 mm, 58.9% were peripherally located, and 30.1% had a bronchus sign. Samples were obtained via Monarch in 99.6% of patients. Pathology led to a malignant diagnosis in 115 patients (43.6%), a benign diagnosis in 110 (41.7%), and 39 (14.8%) non-diagnostic cases. Index diagnostic yield was 85.2% (95% CI: [80.9%, 89.5%]) and the 12-month diagnostic yield was 79.4% (95% CI: [74.4%, 84.3%]). Alternative definitions resulted in diagnostic yield estimates of 58.7% (95% CI: [52.8%, 64.7%]) at index and 89.0% (95% CI: [85.1%, 92.8%]) at 12 months. Sensitivity for malignancy was 79.3% (95% CI: [72.7%, 85.9%]) and cancer prevalence was 58.0% after 12 months.

CONCLUSIONS

RAB demonstrated a high diagnostic yield in the largest study to date, despite representing a real-world community population with a relatively low prevalence of cancer. Alternative definitions had a considerable impact on diagnostic yield estimates.

Machine Learning and Real-World Data to Predict Lung Cancer Risk in Routine Care

BACKGROUND

This study used machine learning to develop a 3-year lung cancer risk prediction model with large real-world data in a mostly younger population.

METHODS

Over 4.7 million individuals, aged 45 to 65 years with no history of any cancer or lung cancer screening, diagnostic, or treatment procedures, with an outpatient visit in 2013 were identified in Optum's de-identified Electronic Health Record (EHR) dataset. A least absolute shrinkage and selection operator model was fit using all available data in the 365 days prior. Temporal validation was assessed with recent data. External validation was assessed with data from Mercy Health Systems EHR and Optum's de-identified Clinformatics Data Mart Database. Racial inequities in model discrimination were assessed with xAUCs.

RESULTS

The model AUC was 0.76. Top predictors included age, smoking, race, ethnicity, and diagnosis of chronic obstructive pulmonary disease. The model identified a high-risk group with lung cancer incidence 9 times the average cohort incidence, representing 10% of patients with lung cancer. Model performed well temporally and externally, while performance was reduced for Asians and Hispanics.

CONCLUSIONS

A high-dimensional model trained using big data identified a subset of patients with high lung cancer risk. The model demonstrated transportability to EHR and claims data, while underscoring the need to assess racial disparities when using machine learning methods.

IMPACT

This internally and externally validated real-world data-based lung cancer prediction model is available on an open-source platform for broad sharing and application. Model integration into an EHR system could minimize physician burden by automating identification of high-risk patients.

Complications After Transthoracic Needle Biopsy of Pulmonary Nodules: A Population-Level Retrospective Cohort Analysis

OBJECTIVE

To provide recent population-based estimates of transthoracic needle biopsy (TTNB) complications and risk factors associated with these complications.

METHODS

This retrospective cohort analysis included adults from a nationally representative longitudinal insurance claims data set who underwent TTNB in 2017 or 2018. Complications that were evaluated included pneumothorax, hemorrhage, and air embolism. Separate logistic regression models estimated the association of pneumothorax or hemorrhage with the setting of care (ie, inpatient or outpatient) and selected baseline patient demographic and clinical characteristics including age, gender, history of chronic obstructive pulmonary disease, diagnosis of pleural effusion, tobacco use, use of oral anticoagulants and antiplatelet agents, prior lung cancer screening, previous bronchoscopy within 1 year, and Elixhauser comorbidity index.

RESULTS

Among 16,971 patients who underwent TTNB, 25.8% experienced a complication within 3 days of the procedure (pneumothorax 23.3%, hemorrhage 3.6%, and air embolism 0.02%). Among patients who experienced pneumothorax, 31.9% required chest tube drainage. Among patients undergoing an outpatient TTNB (n = 12,443), 6.9% were hospitalized within 7 days. Biopsy in an inpatient setting, chronic obstructive pulmonary disease diagnosis, and prior bronchoscopy were associated with higher rates of both pneumothorax and hemorrhage. Prior lung cancer screening was associated with an increased risk of pneumothorax, and prior use of oral anticoagulants or antiplatelets was associated with higher rates of hemorrhage.

CONCLUSION

This contemporary population-based cohort study demonstrated that approximately one-quarter of patients undergoing TTNB experienced a complication. Pneumothorax was the most frequent complication, and hemorrhage and air embolism were rare. Among outpatients, complications from TTNB are an important cause of hospitalization.

Limited duration of antiarrhythmic drug use for newly diagnosed atrial fibrillation in a nationwide population under age 65

INTRODUCTION

Antiarrhythmic drugs (AADs) are commonly used for the treatment of newly diagnosed symptomatic atrial fibrillation (AF), however initial AAD choice, duration of therapy, rates of discontinuation, and factors associated with a durable response to therapy are poorly understood. This study assesses the initial choice and duration of antiarrhythmic drug therapy in the first 2 years after diagnosis of AF in a younger, commercially insured population.

METHODS

A large nationally representative sample of patients age 20-64 was studied using the IBM MarketScan Database. Patients who started an AAD within 90 days of AF diagnosis with continuous enrollment for 1-year pre-index diagnosis and 2 years post-index were included. A Cox proportional hazards model was used to determine factors associated with AAD discontinuation.

RESULTS

Flecainide was used most frequently (26.8%), followed by amiodarone (22.5%), dronedarone (18.3%), sotalol (15.8%), and propafenone (14.0%), with other AADs used less frequently. Twenty-two percent of patients who started on an AAD underwent ablation within 2 years, with 79% discontinuing the AAD after ablation. Ablation was the strongest predictor of AAD discontinuation (hazard ratio [HR], 1.70; 95% confidence interval [CI]: 1.61-1.80), followed by the male gender (HR, 1.10; CI: 1.02-1.19). Older patients (HR, 0.76; CI: 0.72-0.80; reference age 18-49) and those with comorbidities, including cardiomyopathy (HR, 075; CI: 0.61-0.91), diabetes (HR, 0.83; CI: 0.75-0.91), and hypertension (HR, 0.87; CI: 0.81-0.94) were less likely to discontinue AADs.

CONCLUSION

Only 31% of patients remained on the initial AAD at 2 years, with a mean duration of initial therapy 7.6 months before discontinuation.

Improving visual communication of discriminative accuracy for predictive models: the probability threshold plot

Objectives

To propose a visual display-the probability threshold plot (PTP)-that transparently communicates a predictive models' measures of discriminative accuracy along the range of model-based predicted probabilities (Pt).

Materials and Methods

We illustrate the PTP by replicating a previously-published and validated machine learning-based model to predict antihyperglycemic medication cessation within 1-2 years following metabolic surgery. The visual characteristics of the PTPs for each model were compared to receiver operating characteristic (ROC) curves.

Results

A total of 18 887 patients were included for analysis. Whereas during testing each predictive model had nearly identical ROC curves and corresponding area under the curve values (0.672 and 0.673), the visual characteristics of the PTPs revealed substantive between-model differences in sensitivity, specificity, PPV, and NPV across the range of Pt.

Discussion and Conclusions

The PTP provides improved visual display of a predictive model's discriminative accuracy, which can enhance the practical application of predictive models for medical decision making.

Real-world characteristics and readmissions among patients undergoing ablation for ventricular tachycardia: a retrospective database analysis of commercially insured patients in the USA

BACKGROUND

Radiofrequency catheter ablation is an effective treatment to alleviate symptoms and reduce recurrent implantable cardioverter-defibrillator (ICD/CRT-D) shocks in patients with ventricular tachycardia (VT).

OBJECTIVE

To assess the characteristics and outcomes (complications, inpatient readmissions) of commercially insured patients in the USA undergoing ablation for ischaemic or non-ischaemic VT.

METHODS

Patients aged 18-64 years with a primary diagnosis of VT who underwent ablation between 2006 and 2015 were identified using the IBM MarketScan Commercial Database. The rate of complications including vascular complications, pericarditis, pulmonary embolism and pericardial tamponade over a 30-day post-ablation period (including index admission) was examined. Inpatient readmissions (VT-related, heart failure (HF)-related and non-VT arrhythmia-related) over the 12-month post-ablation period were examined. A Cox regression model was used to determine factors associated with inpatient readmissions.

RESULTS

5242 patients (488 with ischaemic and 4754 with non-ischaemic VT) met the study criteria. The majority of VT ablations occurred in an outpatient setting (57% for ischaemic and 66% for non-ischaemic VT). Among complications, vascular complications were most frequent (2.05% among ischaemic and 1.6% among non-ischaemic VT patients) over the 30-day post-ablation period. Among ischaemic VT patients, 17%, 7.6% and 4.7% had VT-related, HF-related and non-VT arrhythmia-related inpatient readmissions, respectively in the 12-month post-ablation period. For non-ischaemic VT patients, these numbers were 7.5%, 1.7% and 3.1%, respectively. Inpatient setting (vs outpatient), baseline ICD/CRT-D implantation, HF comorbidity and ≥2 prior hospitalisations were associated with a higher risk of post-ablation VT-related inpatient readmissions among ischaemic VT patients. Similar factors also were associated with a higher risk of post-ablation VT-related inpatient readmission among non-ischaemic VT patients.

CONCLUSION

Setting of ablation and comorbidity status were found to influence readmission rates. Complication and readmission rates following VT ablation were low indicating towards the favourable safety profile of VT ablation.

Comparison of safety and utilization outcomes in inpatient versus outpatient laparoscopic sleeve gastrectomy: a retrospective, cohort study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most common type of bariatric surgery performed in the United States and may be performed on an outpatient basis. Limited literature exists comparing outcomes of outpatient and inpatient LSG, and study results are conflicting.

OBJECTIVES

To compare safety and utilization outcomes of outpatient versus inpatient LSG.

SETTINGS

Retrospective, multihospital database study (Optum Pan-Therapeutics Database).

METHODS

Patients 18 years of age and older who underwent LSG between October 1, 2015, and December 31, 2018, were identified from the Optum Pan-Therapeutics Database and classified as having undergone outpatient or inpatient surgery. Nearest neighbor propensity score matching and generalized estimating equations accounting for procedural physician-level clustering were used to compare the following outcomes between outpatient and inpatient LSG: all-cause 30-day patient morbidity, hospital readmission, readmission length of stay, bariatric reoperation. and mortality.

RESULTS

We identified 22,945 patients (outpatient: 1542; inpatient: 21,403) meeting the study inclusion criteria. After propensity score matching, the inpatient and outpatient groups contained 1542 and 13,903 patients, respectively. Bariatric reoperation (n = 13) and mortality (n = 5) were rare events occurring in <.1% of all cases. Compared with the inpatient group, the outpatient group had a statistically significant lower readmission length of stay (4.63 versus 3.23 days; P = .0057). Otherwise, there was no significant association between procedure setting and 30-day overall morbidity (4.8% versus 5.3%; P = .5775) or hospital readmission (2.6% versus 2.1%; P = .1841).

CONCLUSIONS

Safety and utilization outcomes were similar between outpatient and inpatient LSG, and outpatient LSG was associated with shorter hospital readmission length of stay.

Real-world outcomes comparison among adults with atrial fibrillation undergoing catheter ablation with a contact force porous tip catheter versus a second-generation cryoballoon catheter: a retrospective analysis of multihospital US database

OBJECTIVE

To compare real-world clinical and economic outcomes among atrial fibrillation (AF) patients undergoing cardiac ablation with the contact force-sensing porous tip THERMOCOOL SMARTTOUCH SF (STSF) catheter versus the Arctic Front Advance Cryoballoon (AFA-CB) catheter.

DESIGN

Retrospective, observational cohort study.

SETTING

Premier Healthcare Database (PHD), between 1 September 2016 and 30 June 2018.

PARTICIPANTS

Patients with AF (≥18 years) were included if they had an index ablation procedure performed using the STSF catheter or AFA-CB catheter at a US hospital that consistently provided inpatient and outpatient data to PHD in the 12-month preindex period. Using 1:1 propensity score matching, patient groups were matched on study covariates.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cost, length of stay (LOS), readmissions, direct current cardioversion (DCCV) and reablation outcomes were compared between matched cohorts of STSF and AFA-CB patients.

RESULTS

A total of 3015 patients with AF met the study criteria, of which 1720 had ablation using the STSF catheter and 1295 had ablation using the AFA-CB catheter. In the propensity-matched sample, patients receiving ablation with the STSF catheter had ~17% lower total costs (US$23 096 vs US$27 682, p≤0.0001) and ~27% lower supply costs (US$10 208 vs US$13 816, p≤0.0001) versus patients receiving ablation with the AFA-CB catheter. A significantly lower likelihood of 4-month to 6-month cardiovascular-related readmission (OR 0.460, 95% CI 0.220 to 0.959) was associated with the STSF catheter versus the AFA-CB catheter. No significant differences in LOS, room and board cost, 4-month to 6-month all-cause and AF-related readmissions, DCCV and reablation were observed among technologies. Sensitivity analysis restricting patient sample by provider ablation volume demonstrated similar results.

CONCLUSION

Lower index ablation total and supply costs were observed among patients with AF undergoing cardiac catheter ablation using the STSF catheter versus the AFA-CB catheter.

Trends and predictors of early ablation for Atrial Fibrillation in a Nationwide population under age 65: a retrospective observational study

BACKGROUND

Catheter ablation (CA) has emerged as an effective treatment for symptomatic atrial fibrillation (AF). However practice patterns and patient factors associated with referral for CA within the first 12 months after diagnosis are poorly characterized. This study examined overall procedural trends and factors predictive of catheter ablation for newly-diagnosed atrial fibrillation in a young, commercially-insured population.

METHODS

A large nationally-representative sample of patients age 20 to 64 from years 2010 to 2016 was studied using the IBM MarketScan® Commercial Database. Patients were included with a new diagnosis of AF in the inpatient or outpatient setting with continuous enrollment for at least 1 year pre and post index visit. Patients were excluded if they had prior history of AF or had filled an anti-arrhythmic drug (AAD) in the pre-index period.

RESULTS

Early CA increased from 5.0% in 2010 to 10.5% in 2016. Patients were less likely to undergo CA if they were located in the Northeast (OR: 0.80, CI: 0.73-0.88) or North Central (OR: 0.91, CI: 0.83-0.99) regions (compared with the West), had higher CHA2DS2-VASc scores, or had Charlson Comorbidity Index (CCI) score of 3 or greater (OR: 0.61; CI: 0.51-0.72).

CONCLUSIONS

CA within 12 months for new-diagnosed AF increased significantly from 2010 to 2016, with most patients still trialed on an AAD prior to CA. Patients are less likely to be referred for early CA if they are located in the Northeast and North Central regions, have more comorbidities, or higher CHA2DS2-VASc scores.

Intracardiac echocardiography use and outcomes after catheter ablation of ventricular tachycardia

Aim: To compare outcomes among patients with implantable cardioverter defibrillator/cardiac resynchronization therapy-defibrillator undergoing outpatient ventricular tachycardia (VT) catheter ablation using intracardiac echocardiography (ICE) versus no ICE. Patients & methods: Patients were classified into ICE (n = 1143)/non-ICE (n = 1677) groups based on ICE procedure codes. Patients in each group were propensity matched on study covariates. Survival analyses were used to assess outcomes. To examine residual confounding, falsification outcomes were evaluated. Results: ICE patients had a 24% lower risk of all-cause readmissions, 24% lower risk of cardiovascular-related and 20% lower risk of VT-related readmissions compared with non-ICE patients. Falsification analyses for ICE use association were nonsignificant. Conclusion: Patients with implantable cardioverter defibrillator/cardiac resynchronization therapy-defibrillator undergoing VT ablation with ICE use had significantly lower likelihood of VT-related readmission.

Real-world outcomes of ventricular tachycardia catheter ablation with versus without intracardiac echocardiography

INTRODUCTION

By providing real-time monitoring of catheter-tissue interface and for complications, intracardiac echocardiography (ICE) during catheter ablation for ventricular tachycardia (VT) may improve outcomes. To test this hypothesis, we compared 12-month readmission rates (all-cause, cardiovascular [CV]-related, and VT-related), repeat ablation, and complications among patients with VT with structural heart disease undergoing ablation with versus without ICE.

METHODS AND RESULTS

Using the 2008-2017 IBM MarketScan Commercial and Medicare Supplemental databases, patients with a history of implantable cardioverter defibrillator/cardiac resynchronization therapy (ICD/CRT-D) who underwent VT ablation with and without ICE use were identified. Propensity matching was performed and regression analysis was used to compare outcomes. After matching, 1324 patients were identified (ICE: 662; non-ICE: 662). The rate of 12-month VT-related readmission (18.13% vs 22.51%; P < .05) and repeat VT ablation (14.35% vs 19.34%; P = .02) postindex discharge were lower among patients in the ICE group compared with the non-ICE group, with a 24% lower risk of 12-month VT-related readmission (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.58-0.99) and a 30% lower risk of repeat ablation (OR, 0.70; 95% CI, 0.52-0.93) vs non-ICE group. The 12-month all-cause (44.56% vs 43.20%; P = .62) and CV-related readmissions (35.20% vs 32.93%; P = 0.38) and complication rates were not significantly different between the two groups.

CONCLUSIONS

VT ablation using ICE was associated with a lower likelihood of 12-month VT-related readmission and repeat ablation compared with non-ICE patients.

Outcomes associated with endovascular treatment among patients with acute ischemic stroke in the USA

BACKGROUND

Few studies have examined the trends in clinical and economic outcomes of patients with acute ischemic stroke (AIS) who receive endovascular therapy (ET) in the real-world setting.

OBJECTIVE

To evaluate characteristics and trends in clinical and economic outcomes among commercially insured patients with AIS undergoing ET between 2011 and 2017.

METHODS

Patients with AIS undergoing ET from January 1, 2011 to June 30, 2017 were identified from administrative claims contained in the IBM MarketScan Commercial and Medicare Supplemental databases. The Mann-Kendall trend test was performed to examine clinical and economic trends.Between 2011 and 2017, 3411 patients (mean age 62.85±15 years) with a primary diagnosis of AIS underwent ET (coverage: Commercial 59%, n=2008; Medicare Supplemental 41%, n=1403). In the Commercial cohort, discharge to home increased significantly (from 29.54% to 39.18%, p<0.05). Length of stay declined significantly among the overall cohort (from 10.96 to 9.05 days, p<0.01) and the Medicare Supplemental cohort (from 10.03 to 8.43 days, p<0.05). All-cause 365-day readmission decreased significantly among the overall cohort (from 47.5% to 36.7%, p<0.05) and the Commercial cohort (from 51.54% to 36.43%, p<0.05) but remained unchanged in the Medicare Supplemental cohort. While index procedure cost did not change significantly ($93 955 to $87 906, p=0.8806), total cost significantly declined in the overall cohort (from $166 922 to $130 678, p<0.05).

CONCLUSIONS

Although with some variation across the samples studied, outcomes including discharge to home, length of stay, readmission, and total cost associated with endovascular stroke therapy seemed to have improved between 2011 and 2017. Index admission cost remained unchanged.

Assessment of obesity prevalence and validity of obesity diagnoses coded in claims data for selected surgical populations: A retrospective, observational study

In many types of surgery, obesity may influence patient selection, prognosis, and/or management. Quantifying the accuracy of the coding of obesity and other prognostic factors is important for the design and interpretation of studies of surgical outcomes based on administrative healthcare data. This study assessed the validity of obesity diagnoses recorded in insurance claims data in selected surgical populations.This was a retrospective, observational study. Deidentified electronic health record (EHR) and linked administrative claims data were obtained for US patients age ≥20 years who underwent a qualifying surgical procedure (bariatric surgery, total knee arthroplasty [TKA], cardiac ablation, or hernia repair) in 2014Q1-2017Q1 (first = index). Patients' body mass index (BMI) as coded in the claims data (error-prone measure) during the index procedure or 180d pre-index was compared with their measured BMI as recorded in the EHR (criterion standard) to estimate the sensitivity and positive predictive value (PPV) of obesity diagnosis codes.Among patients who underwent bariatric surgery (N = 1422), TKA (N = 8670), cardiac ablation (N = 167), or hernia repair (N = 5450), obesity was present in 98%, 63%, 52%, and 54%, respectively, based on measured BMI. PPVs of obesity diagnosis codes were high: 99.3%, 96.0%, 92.8%, and 94.1% in bariatric surgery, TKA, cardiac ablation, and hernia repair, respectively. The sensitivity of obesity diagnoses was: 99.8%, 46.2%, 41.3%, and 42.3% in bariatric surgery, TKA, cardiac ablation, and hernia repair, respectively. Among false-positive patients diagnosed as obese but with measured BMI <30, the proportion with a BMI ≥28 was 40.0%, 67.6%, 60.7%, and 65.8% for bariatric surgery, TKA, cardiac ablation, and hernia repair, respectively.Our data indicate that obesity is highly prevalent in many surgical populations, obesity diagnosis codes have high PPVs, but also obesity is generally undercoded in claims data. Quantifying the validity of diagnosis codes for obesity and other important prognostic factors is important for the design and interpretation of studies of surgical outcomes based on administrative data. Further research is needed to determine the extent to which undercoding of BMI and obesity can be addressed through the use of proxies that may be better documented in claims data.