Lung Cancer Resection at Hospitals With High vs Low Mortality Rates

Association Between Utilization of Services and Perioperative Outcomes for Lung Cancer Resection

INTRODUCTION

Lung cancer resection has largely focused on perioperative outcomes (eg, mortality) to benchmark performance. While variations in perioperative outcomes and in utilization of services (eg, ambulatory procedures, hospitalization) have been independently demonstrated, there has been limited evaluation of associations between these outcomes. We evaluated the association between perioperative outcomes and utilization of services to evaluate provider performance across a broader context of care.

PATIENTS AND METHODS

This was a retrospective cohort study of patients undergoing lung cancer resection in 2017 to 2019. We utilized hierarchical logistic regression models to determine risk- and reliability-adjusted mortality and risk-adjusted utilization of services, at the hospital-level. We then evaluated utilization of services across quartiles of perioperative mortality.

RESULTS

A total of 15,168 patients across 297 hospitals underwent lung cancer resection. Mean risk- and reliability-adjusted 90-day mortality varied between 1.58% (95% CI, 1.54%-1.62%) and 2.74% (95% CI, 2.59%-2.90%) across quartiles. Risk-adjusted utilization of all ambulatory procedures was highest in the best performing (lowest mortality) quartile at 37.7% (95% CI, 33.6%-41.8%). Additionally, risk-adjusted inpatient utilization prior to and after surgery was lowest in the best performing quartile at 15% (95% CI, 13.7%-16.3%) and 19.3% (95% CI, 17.5%-21.0%), respectively.

CONCLUSIONS

Hospitals with the lowest perioperative mortality demonstrated trends towards using more outpatient resources prior to surgery, but fewer inpatient services surrounding lung cancer resection. This correlation highlights the importance of incorporating utilization of services in addition to other metrics to profile the efficiency and effectiveness of centers performing lung cancer resection across a broader spectrum of care.

Comparison of failure to rescue in younger versus elderly patients following lung cancer resection

Objective

Failure to rescue (FTR), defined as in-hospital death following a major complication, has been increasingly studied in patients who undergo cardiothoracic surgery. This study tested the hypothesis that elderly patients undergoing lung cancer resection have greater rates of FTR compared with younger patients.

Methods

Patients who underwent surgery for primary lung cancer between 2011 and 2020 and had at least 1 major postoperative complication were identified using the National Surgical Quality Improvement Program database. Patients who died following complications (FTR) were compared with those who survived in an elderly (80+ years) and younger (<80 years) cohort.

Results

Of the 2823 study patients, the younger cohort comprised 2497 patients (FTR: n = 139 [5.6%]), whereas the elderly cohort comprised 326 patients (FTR: n = 39 [12.0%]). Pneumonia was the most common complication in younger (877/2497, 35.1%) and elderly patients (118/326, 36.2%) but was not associated with FTR on adjusted analysis. Increasing age was associated with FTR (adjusted odds ratio [AOR], 1.55 per decade, P < .001), whereas unplanned reoperation was associated with reduced risk (AOR, 0.55, P = .01). Within the elderly cohort, surgery conducted by a thoracic surgeon was associated with lower FTR risk (AOR, 0.29, P = .028).

Conclusions

FTR following lung cancer resection was more frequent with increasing age. Pneumonia was the most common complication but not a predictor of FTR. Unplanned reoperation was associated with reduced FTR, as was treatment by a thoracic surgeon for elderly patients. Surgical therapy for complications after lung cancer resection and elderly patients managed by a thoracic specialist may mitigate the risk of death following an adverse postoperative event.

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer

PURPOSE

The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care.

PATIENTS AND METHODS

Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes.

RESULTS

From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively.

CONCLUSION

Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

Changes in failure to rescue after gastrectomy at a large-volume center with a 16-year experience in Korea

Failure to rescue (FTR), the mortality rate among patients with complications, is gaining attention as a hospital quality indicator. However, comprehensive investigation into FTR has rarely been conducted after radical gastrectomy for gastric cancer patients. This study aimed to assess FTR after radical gastrectomy and investigate the associations between FTR and clinicopathologic factors, operative features, and complication types. From 2006 to 2021, 16,851 gastric cancer patients who underwent gastrectomy were retrospectively analyzed. The incidence and risk factors were analyzed for complications, mortality, and FTR. Seventy-six patients had postoperative mortality among 15,984 patients after exclusion. The overall morbidity rate was 10.49% (1676/15,984 = 10.49%), and the FTR rate was 4.53% (76/1676). Risk factor analysis revealed that older age (reference: < 60; vs. 60-79, adjusted odds ratio [OR] 2.07, 95% confidence interval [CI] 1.13-3.79, P = 0.019; vs. ≥ 80, OR 3.74, 95% CI 1.57-8.91, P = 0.003), high ASA score (vs. 1 or 2, OR 2.79, 95% CI 1.59-4.91, P < 0.001), and serosa exposure in pathologic T stage (vs. T1, OR 2.74, 95% CI 1.51-4.97, P < 0.001) were associated with FTR. Moreover, patients who underwent gastrectomy during 2016-2021 were less likely to die when complications occurred than patients who received the surgery in 2006-2010 (OR 0.35, 95% CI 0.18-0.68, P = 0.002). This investigation of FTR after gastrectomy demonstrated that the risk factors for FTR were old age, high ASA score, serosa exposure, and operation period. FTR varied according to the complication types and the period, even in the same institution.

Failure to rescue following anatomical lung resection. Analysis of a prospective nationwide database

Background

Rescue failure has been described as an important factor that conditions postoperative mortality after surgical interventions. The objective of this study is to determine the incidence and main determinants of failure to rescue after anatomical lung resections.

Methods

Prospective multicenter study that included all patients undergoing anatomical pulmonary resection between December 2016 and March 2018 and registered in the Spanish nationwide database GEVATS. Postoperative complications were classified as minor (grades I and II) and major (grades IIIa to V) according to the Clavien-Dindo standardized classification. Patients that died after a major complication were considered rescue failure. A stepwise logistic regression model was created to identify predictors of failure to rescue.

Results

3,533 patients were analyzed. In total, 361 cases (10.2%) had major complications, of which 59 (16.3%) could not be rescued. The variables associated with rescue failure were: ppoDLCO% (OR, 0.98; 95% CI, 0.96-1; p = 0.067), cardiac comorbidity (OR, 2.1; 95% CI, 1.1-4; p = 0.024), extended resection (OR, 2.26; 95% CI, 0.94-5.41; p = 0.067), pneumonectomy (OR, 2.53; 95 CI, 1.07-6.03; p = 0.036) and hospital volume <120 cases per year (OR, 2.53; CI 95%, 1.26-5.07; p = 0.009). The area under the curve of the ROC curve was 0.72 (95% CI: 0.64-0.79).

Conclusion

A significant percentage of patients who presented major complications after anatomical lung resection did not survive to discharge. Pneumonectomy and annual surgical volume are the risk factors most closely related to rescue failure. Complex thoracic surgical pathology should be concentrated in high-volume centers to obtain the best results in potentially high-risk patients.

Impact of Volume on Mortality and Hospital Stay After Lung Cancer Surgery in a Single-Payer System

BACKGROUND

There is a literature gap for hospitals in single-payer healthcare systems quantifying the influence of hospital volume on outcomes following major lung cancer resection. We aimed to determine the effect of hospital volume on mortality, and length of stay (LOS).

METHODS

A retrospective cohort study using administrative, population-based data from a single-payer universal healthcare system was performed in adults with non-small cell lung cancer who underwent lobectomy or pneumonectomy between 2008 and 2017. Hospital volume was defined as the average annual number of major lung resections performed at each institution. Length of stay and post-operative mortality was compared using multivariable linear and non-linear regression between hospital volume categories and continuously. Adjusted association between hospital volume and post-operative mortality was determined by multivariable logistic regression.

RESULTS

10,831 lung resections were performed: 1237 pneumonectomies; 9594 lobectomies. Patients undergoing lobectomy at high-volume hospitals had shorter median LOS (6 vs 8 days, p = 0.001) compared with low-volume hospitals. After adjusting for confounders, surgery at a high-volume center was significantly associated with shorter LOS after lobectomy and overall resections (p=<0.001), but not after pneumonectomy (p=0.787). Surgery at a high-volume center was positively associated with improved 90-day mortality in lobectomy and overall procedures (OR 0.607; [0.399-0.925]; and 0.632 [0.441-0.904], respectively). Volume was not a predictor of 90-day mortality after pneumonectomy (OR 0.533 [0.257-1.104], p=0.090).

CONCLUSIONS

Surgery at a high-volume center was positively correlated with improved 90-day survival and shorter hospital LOS. The results support regionalized lung cancer care in a single-payer healthcare system.

Mortality predictors in complicated patients after anatomical lung resection

INTRODUCTION

Failure to rescue (FTR), defined as the mortality rate among patients suffering from postoperative complications, is considered an indicator of the quality of surgical care. The aim of this study was to investigate the risk factors associated with FTR after anatomical lung resections.

METHOD

Patients undergoing anatomical lung resection at our center between 1994 and 2018 were included in the study. Postoperative complications were classified as minor (grade I and II) and major (grade IIIA to V), according to the standardized classification of postoperative morbidity. Patients who died after a major complication were considered FTR. A stepwise logistic regression model was created to identify FTR predictors. Independent variables included in the multivariate analysis were age, body mass index, cardiac, renal, and cerebrovascular comorbidity, ppoFEV1%, VATS approach, extended resection, pneumonectomy, and reintervention. A non-parametric ROC curve was constructed to estimate the predictive capacity of the model.

RESULTS

A total of 2.569 patients were included, of which 223 (8.9%) had major complications and 49 (22%) could not be rescued. Variables associated with FTR were: age (OR: 1.07), history of cerebrovascular accident (OR: 3.53), pneumonectomy (OR: 6.67), and reintervention (OR: 12.26). The area under the ROC curve was 0.82 (95% CI: 0.77-0.88).

CONCLUSIONS

Overall, 22% of patients with major complications following anatomical lung resection in this series did not survive until discharge. Pneumonectomy and reintervention are the most significant risk factors for FTR.

Knockdown of SALL4 inhibits the proliferation, migration, and invasion of human lung cancer cells in vivo and in vitro

Background

This study aimed to investigate the SALL4 expression in lung cancer, determine if SALL4 regulates the biological functions of lung cancer cells at the cellular level, and clarify the possible mechanisms involved.

Methods

Immunohistochemistry was used to detect the SALL4 expression messenger RNA (mRNA) in 62 cases of lung cancer tissue microarray. The correlation of SALL4 with the clinical pathological parameters and overall life cycle of patients and the impact of disease-free life cycle was analyzed. Reverse transcription-polymerase chain reaction (RT-PCR) and western blotting were used to detect the SALL4 expression in lung cancer cell lines and nude mouse models. 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) assay, colony-forming assay, and flow cytometry were used to detect the effects of interference with SALL4 expression on lung cancer cell proliferation and transplant tumor models; the effect of interference with SALL4 expression on the growth of transplanted tumors in vivo was also examined.

Results

SALL4 was highly expressed in lung cancer tissues and cell lines and was closely related to the patient's TNM stage and lymph node metastasis. Compared to patients with a high SALL4 expression, those with a lower SALL4 expression had a longer overall and disease-free survival. The expression of SALL4 is an independent risk factor for the prognosis of lung cancer patients. Interference with SALL4 expression can significantly inhibit cell proliferation and clonal formation. Interfering with the expression of SALL4 can arrest the cells in the G0/G1 phase by inhibiting the expression of the cell cycle-related proteins, cyclin B, cyclin E, and cyclin D1. Furthermore, wound-healing and Transwell assays showed that interference with SALL4 expression could significantly inhibit the migration and invasion of lung cancer cells, while experiments in nude mice showed that interference with SALL4 expression could significantly inhibit the size and weight of transplanted tumors.

Conclusions

SALL4 was highly expressed in lung cancer cell lines. Interference with the expression of SALL4 can effectively inhibit the proliferation, migration and invasion of lung cancer cells, promote cell cycle arrest, and play the function of tumor suppressor genes. SALL4 may be a new target for the diagnosis and treatment of lung cancer.

Nationwide effect of high procedure volume in lung cancer surgery on in-house mortality in Germany

BACKGROUND

The literature reports that hospital caseload volume is associated with survival for lung cancer resection. The aim of this study is to explore this association in a nationwide setting according to individual hospital caseload volume of every inpatient case in Germany.

METHODS

This retrospective analysis of nationwide hospital discharge data in Germany between 2014 and 2017 comprises 121,837 patients of whom 36,051 (29.6 %) underwent surgical anatomic resection. Hospital volumes were defined according to the number of patient resections for lung cancer in each hospital, and patients were categorized into 5 quintiles based on hospital caseload volume. A logistic regression model accounting for death according to sex, age, comorbidity, and resection volume was calculated, and effect modification was evaluated using the Mantel-Haenszel method.

RESULTS

In-house mortality ranged from 2.1 % in very high-volume centers to 4.0 % in very low-volume hospitals (p < 0.01). In multivariable logistic regression analysis, lower in-house mortality in very high-volume centers performing > 140 anatomic lung resections per year was observed compared with very low-volume centers performing < 27 resections (OR, 0.58; CI, 0.46 to 0.72; p < 0.01). This relationship also held for failure to rescue rates (12.9 vs 16.7 %, p = 0.01), although a greater number of extended resections were performed (23.1 vs. 14.8 %, p < 0.01).

CONCLUSIONS

Hospitals with high volumes of lung cancer resections performed surgery with a higher ratio of complex procedures and achieved reduced in-house mortality, fewer complications, and lower failure to rescue rates.

Mortality Predictors In Complicated Patients After Anatomical Lung Resection

INTRODUCTION

Failure to rescue (FTR), defined as the mortality rate among patients suffering from postoperative complications, is considered an indicator of the quality of surgical care. The aim of this study was to investigate the risk factors associated with FTR after anatomical lung resections.

METHOD

Patients undergoing anatomical lung resection at our center between 1994 and 2018 were included in the study. Postoperative complications were classified as minor (grade I and II) and major (grade IIIA to V), according to the standardized classification of postoperative morbidity. Patients who died after a major complication were considered FTR. A stepwise logistic regression model was created to identify FTR predictors. Independent variables included in the multivariate analysis were age, body mass index, cardiac, renal, and cerebrovascular comorbidity, ppoFEV1%, VATS approach, extended resection, pneumonectomy, and reintervention. A non-parametric ROC curve was constructed to estimate the predictive capacity of the model.

RESULTS

A total of 2,569 patients were included, of which 223 (8.9%) had major complications and 49 (22%) could not be rescued. Variables associated with FTR were: age (OR: 1.07), history of cerebrovascular accident (OR: 3.53), pneumonectomy (OR: 6.67), and reintervention (OR: 12.26). The area under the ROC curve was 0.82 (95% CI: 0.77-0.88).

CONCLUSIONS

Overall, 22% of patients with major complications following anatomical lung resection in this series did not survive until discharge. Pneumonectomy and reintervention are the most significant risk factors for FTR.

Quality Control in Anatomical Lung Resection. Major Postoperative Complications vs Failure to Rescue

OBJECTIVES

Failure to rescue (FTR) is defined by the number of deaths among patients experiencing major complications after surgery. In this report we analyze FTR and apply a cumulative sum control chart (CUSUM) methodology for monitoring performance in a large series of operated lung carcinoma patients.

METHODS

Prospectively stored records of cases undergoing anatomical lung resection in one center were reviewed. Postoperative adverse events were coded and included as a binary variable (major, or minor complications). The occurrence of 30-day mortality was also recorded. Patients dying after suffering major complications were considered as FTR. Risk-adjusted CUSUM graphs using EuroLung1 and 2 variables were constructed for major complications and FTR. Points of plateauing or trend inversion were checked to detect intentional or non-adverted changes in the process of care.

RESULTS

2237 cases included. 9.1% cases suffered major complications. The number of cases considered as failures to rescuing was 46 (2.1% of the total series and 22.5% of cases having major complications). The predictive performance of EuroLung1 and 2 models was as follows: EuroLung1 (major morbidity) C-index 0.70 (95%CI: 0.66-0.73); EuroLung2 (applied to FTR) C-index 0.81 (95%CI: 0.750.87). CUSUM graphs depicted improvement in rescuing complicated patients after case 330 but no improvement in the rate of non-complicated cases until case 720.

CONCLUSIONS

FTR offers a complementary view to classical outcomes for quality assessment in Thoracic Surgery. Our study also shows how the analysis of FTR on time series can be applied to evaluate changes in team performance along time.

Predictors of Failure to Rescue After Esophagectomy

BACKGROUND

Failure to rescue (FTR), defined as death after a major complication, is a metric increasingly being used to assess quality of care. Risk factors associated with FTR after esophagectomy have not been previously studied.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent esophagectomy with gastric conduit between 2010 and 2014. Patients with at least one major postoperative complication were grouped according to inhospital mortality (FTR group) and survival to discharge (SUR group). A stepwise logistic regression model was used to identify predictors of FTR.

RESULTS

A total of 1,730 patients comprised the study group, with 102 (5.9%) in the FTR group and 1,628 (94.1%) in the SUR group. The FTR patients were older (69.0 versus 64.0 years, p < 0.0001) compared with the SUR patients. There were no differences in sex, body mass index, preoperative weight loss, smoking status, operation type, or surgeon specialty between the two groups. Age greater than 75 years (adjusted odds ratio 2.68, p < 0.0001), black race (adjusted odds ratio 2.75, p = 0.001), American Society of Anesthesiologists class 4 or 5 (adjusted odds ratio 1.82, p = 0.02), and the occurrence of pneumonia, respiratory failure, acute renal failure, sepsis, or acute myocardial infarction were predictive of FTR based on multivariable logistic regression.

CONCLUSIONS

Nearly 6% of patients who have a major complication after esophagectomy do not survive to discharge. Age greater than 75 years, black race, American Society of Anesthesiologists class 4 or 5, and complications related to major infection or organ failure predict FTR. Further research is necessary to investigate how these factors affect survival after complications in order to improve rescue efforts.

Care of the Postoperative Pulmonary Resection Patient

Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.

Risk-Adjusted Margin Positivity Rate as a Surgical Quality Metric for Non-Small Cell Lung Cancer

BACKGROUND

Incomplete lung cancer resection connotes poor prognosis; the incidence varies with patient demographic, clinical, and institutional factors. We sought to develop a valid, survival impactful, facility-based surgical quality metric that adjusts for related patient demographic and clinical characteristics.

METHODS

Facilities performing resections for patients diagnosed with stage I to IIIA non-small cell lung cancer in the National Cancer Data Base between 2004 and 2011 were identified. Multivariate logistic regression modeling was used to estimate the expected number of margin-positive cases by adjusting for patient risk mix and calculate the observed-to-expected ratio for each facility. Facilities were categorized as outperformers (observed-to-expected ratio less than 1, p < 0.05), nonoutliers (p > 0.05), and underperformers (observed-to-expected ratio greater than 1, p < 0.05); and their characteristics across performance categories were compared by χ² tests. Multivariate Cox proportional hazard analyses were conducted, adjusting for patient demographic and clinical characteristics.

RESULTS

A total of 96,324 patients underwent surgery at 809 facilities. The overall observed margin-positive rate was 4.4%. Sixty-one facilities (8%) were outperformers, 644 (80%) were nonoutliers, and 104 (13%) were underperformers. One third (36%) of National Cancer Institute-designated facilities, 13% of academic comprehensive cancer programs, 5% of comprehensive community cancer programs, and 13% of "other" facilities achieved outperforming status but no community cancer programs did. Interestingly, 9% of National Cancer Institute-designated facilities and 11% of academic comprehensive cancer program facilities were underperformers. Adjusting for patient demographic and clinical characteristics, outperformers had a 5-year all-cause hazard ratio of 0.88 (95% confidence interval: 0.85 to 0.91, p < 0.0001) compared with nonoutliers, and 0.80 (95% confidence interval: 0.77 to 0.84, p < 0.0001) compared with underperformers.

CONCLUSIONS

Facility performance in lung cancer surgery can be captured by the risk-adjusted margin-positivity rate, potentially providing a valid quality improvement metric.

Failure-to-Rescue in Thoracic Surgery

Variability in outcomes not attributable to case mix or chance is an indicator of low-quality care. Failure-to-rescue is an outcome measure defined as death during a hospitalization among patients who experience a complication. Researchers have used this measure to better understand the determinants of an untimely death-preventing complications, rescue, or both. Studies repeatedly find that complication rates vary little, if at all, across hospitals ranked by risk-adjusted mortality rates, suggesting that hospitals are equally capable (or incapable) of preventing complications. In contrast, variation in failure-to-rescue rates seems to explain much of the variation in risk-adjusted hospital-level mortality rates. These findings suggest that system-level interventions that allow for the early detection and treatment of complications (ie, rescue) may reduce variability in hospital-level outcomes and improve the quality of thoracic surgical care.

Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria

BACKGROUND

The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small cell lung cancer recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of three or more mediastinal nodal stations. We examined the survival impact of these criteria.

METHODS

A population-based observational study was done using patient-level data from all curative-intent, non-small cell lung cancer resections from 2004 to 2013 at 11 institutions in four contiguous Dartmouth Hospital referral regions in three US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines.

RESULTS

Of 2,429 eligible resections, 91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria; however, there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p < 0.001). Compared with patients whose surgery missed one or more criteria, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59 to 0.86, p < 0.001). Margin status and the nodal staging criteria were most strongly linked with survival.

CONCLUSIONS

Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the United States. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in non-small cell lung cancer care.

Colon cancer operations at high- and low-mortality hospitals

BACKGROUND

There is wide variation in mortality across hospitals for cancer operations. While higher rates of mortality are commonly ascribed to high-risk resections, the impact on more common operations is unclear. We sought to evaluate causes of mortality following colon cancer operations across hospitals.

METHODS

Forty-nine American College of Surgeons Commission on Cancer hospitals were selected for participation in a Commission on Cancer special study. We ranked hospitals using a composite measure of mortality and performed onsite chart reviews. We examined patient characteristics and mortality following colon resections at very high-mortality and very low- mortality hospitals (2006-2007).

RESULTS

We identified 3,025 patients who underwent an operation at 19 low-mortality (n = 1,006) and 30 high-mortality (n = 2,019) hospitals. There were wide differences in risk-adjusted mortality between high-mortality and low-mortality hospitals (9.3% vs 2.4%; P < .001). Compared with low-mortality hospitals, high-mortality hospitals had more patients who were black (11.2% vs 6.5%; P < .001), had ≥2 comorbidities (22.7% vs 18.9%; P < .05), were categorized American Society of Anesthesiologists class 4-5 (11.9% vs 5.3%; P < .001), and were functionally dependent (13.9% vs 8.8%; P < .001). Rates of complication were similar in high-mortality versus low-mortality hospitals (odds ratio 1.29, 95% confidence interval, 0.85-1.95). For those experiencing complications, though, case fatality rates were significantly higher in high-mortality versus low-mortality hospitals (odds ratio 3.74, 95% confidence interval, 1.59-8.82).

CONCLUSION

There is significant variation in mortality across hospitals for colon cancer operations, despite similar perioperative morbidity. This finding reflects a need for improved operative decision-making to enhance outcomes and quality of care at these hospitals.