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Kalata S, Reddy RM, Norton EC, Clark MJ, He C, Leyden T, Adams KN, Popoff AM, Lall SC, Lagisetty KH. Quality improvement mechanisms to improve lymph node staging for lung cancer: Trends from a statewide database. J Thorac Cardiovasc Surg 2024; 167:1469-1478.e3. [PMID: 37625618 DOI: 10.1016/j.jtcvs.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Our statewide thoracic quality collaborative has implemented multiple quality improvement initiatives to improve lung cancer nodal staging. We subsequently implemented a value-based reimbursement initiative to further incentivize quality improvement. We compare the impact of these programs to steer future quality improvement initiatives. METHODS Since 2016, our collaborative focused on improving lymph node staging for lung cancer by leveraging unblinded, hospital-level metrics and collaborative feedback. In 2021, a value-based reimbursement initiative was implemented with statewide yearly benchmark rates for (1) preoperative mediastinal staging for ≥T2N0 lung cancer, and (2) sampling ≥5 lymph node stations. Participating surgeons would receive additional reimbursement if either benchmark was met. We reviewed patients from January 2015 to March 2023 at the 21 participating hospitals to determine the differential effects on quality improvement. RESULTS We analyzed 6228 patients. In 2015, 212 (39%) patients had ≥5 nodal stations sampled, and 99 (51%) patients had appropriate preoperative mediastinal staging. During 2016 to 2020, this increased to 2253 (62%) patients and 739 (56%) patients, respectively. After 2020, 1602 (77%) patients had ≥5 nodal stations sampled, and 403 (73%) patients had appropriate preoperative mediastinal staging. Interrupted time-series analysis demonstrated significant increases in adequate nodal sampling and mediastinal staging before value-based reimbursement. Afterward, preoperative mediastinal staging rates briefly dropped but significantly increased while nodal sampling did not change. CONCLUSIONS Collaborative quality improvement made significant progress before value-based reimbursement, which reinforces the effectiveness of leveraging unblinded data to a collaborative group of thoracic surgeons. Value-based reimbursement may still play a role within a quality collaborative to maintain infrastructure and incentivize participation.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | | | - Edward C Norton
- Departments of Health Management and Policy and Economics, University of Michigan, Ann Arbor, Mich
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | | | - Kumari N Adams
- Department of Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, Mich
| | - Andrew M Popoff
- Department of Thoracic Surgery, Henry Ford Hospital, Detroit, Mich
| | - Shelly C Lall
- Department of Thoracic Surgery, Munson Medical Center, Traverse City, Mich
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Towe CW, Grau-Sepulveda MV, Hartwig MG, Kang L, Jiang B, Sinopoli J, Tapias Vargas L, Kosinski A, Linden PA. The Society of Thoracic Surgeons Database Analysis: Comparing Sublobar Techniques in Stage IA Lung Cancer. Ann Thorac Surg 2024:S0003-4975(24)00191-7. [PMID: 38493921 DOI: 10.1016/j.athoracsur.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/05/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND This study compares sublobar resections-wedge resection and segmentectomy-in clinical stage IA lung cancers. It tests the hypothesis that overall survival after wedge resection is similar to segmentectomy. METHODS Adults undergoing wedge resection or segmentectomy for clinical stage IA lung cancer were identified from The Society of Thoracic Surgeons General Thoracic Surgery Database. Eligible patients were linked to the Centers for Medicare and Medicaid Services database using a matching algorithm. The primary outcome was long-term overall survival. Propensity scores overlap weighting (PSOW) adjustment of wedge resection using validated covariates was used for group difference mitigation. Kaplan-Meier and Cox regression models analyzed survival. All-cause first readmission, and morbidity and mortality were examined using PSOW regression models. RESULTS Of 9756 patients, 6141 met inclusion criteria, comprising 2154 segmentectomies and 3987 wedge resections. PSOW reduced differences between the groups. Unadjusted perioperative mortality was comparable, but wedge resection showed lower major morbidity rates. Weighted regression analysis indicated reduced mortality and major morbidity risks in wedge resection. Kaplan-Meier analysis revealed no mortality difference between groups, which was confirmed by PSOW Cox regression models. The cumulative risk of readmission was also comparable for both groups, with Cox Fine-Gray models showing no difference in rehospitalization risks. CONCLUSIONS In clinical stage IA lung cancer, relative to segmentectomy, wedge resection has comparable overall survival and lower perioperative morbidity, suggesting it is an equally effective option for the broader population of patients with clinical stage IA lung cancer, not only those at highest risk of complications.
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Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | | | - Matthew G Hartwig
- Department of Surgery, Duke Health and Duke Clinical Research Institute, Durham, North Carolina
| | - Lillian Kang
- Division of Biostatistics, Duke Clinical Research Institute, Durham, North Carolina
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leonidas Tapias Vargas
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Andrzej Kosinski
- Division of Biostatistics, Duke Clinical Research Institute, Durham, North Carolina
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Potter AL, Spasojevic A, Raman V, Hurd JC, Senthil P, Mathey-Andrews C, Schumacher LY, Yang CFJ. The Increasing Adoption of Minimally Invasive Lobectomy in the United States. Ann Thorac Surg 2023; 116:222-229. [PMID: 36223806 DOI: 10.1016/j.athoracsur.2022.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 08/22/2022] [Accepted: 09/03/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The objective of this study is to evaluate the trends of and outcomes associated with the use of minimally invasive lobectomy for stage I and II non-small cell lung cancer (NSCLC) in the United States. METHODS The use of and outcomes associated with open and minimally invasive lobectomy for clinical stage I and stage II NSCLC from 2010 to 2017 in the National Cancer Database were assessed by multivariable logistic regression and propensity score matching. RESULTS From 2010 to 2017, use of minimally invasive lobectomies increased for stage I NSCLC (multivariable-adjusted odds ratio [aOR] 4.52; 95% CI, 3.95-5.18; P < .001) and stage II NSCLC (aOR 4.38; 95% CI, 3.38-5.68; P < .001). In 2015, for the first time, more lobectomies for stage I NSCLC were performed by minimally invasive techniques (52.2%, n = 5647) than by thoracotomy (47.8%, n = 5164); and in 2017, more lobectomies for stage II NSCLC were performed by minimally invasive techniques (54.7%, n = 1620) than by thoracotomy (45.3%, n = 1,342). From 2010 to 2017, the conversion rates from minimally invasive to open lobectomy for stage I NSCLC decreased from 19.6% (n = 466) to 7.2% (n = 521; aOR 0.32; 95% CI, 0.23-0.43; P < .001). Similarly, from 2010 to 2017, the conversion rates from minimally invasive to open lobectomy for stage II NSCLC decreased from 20% (n = 114) to 11.5% (n = 186; aOR 0.39; 95% CI, 0.21-0.72; P = .002). CONCLUSIONS In the United States, for stage I and stage II NSCLC from 2010 to 2017, the use of minimally invasive lobectomy significantly increased while the conversion rate significantly decreased. By 2017, the minimally invasive approach had become the predominant approach for both stage I and stage II NSCLC.
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Affiliation(s)
- Alexandra L Potter
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ana Spasojevic
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Vignesh Raman
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob C Hurd
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Priyanka Senthil
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Camille Mathey-Andrews
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Lana Y Schumacher
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Chi-Fu Jeffrey Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Division of Thoracic Surgery, Wentworth-Douglass Hospital, Dover, New Hampshire.
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Karush JM, Alex G, Geissen N, Wakefield C, Basu S, Liptay MJ, Seder CW. Predicting Non-home Discharge After Lung Surgery: Analysis of the General Thoracic Surgery Database. Ann Thorac Surg 2023; 115:687-692. [PMID: 35921862 DOI: 10.1016/j.athoracsur.2022.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/05/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Anticipating the need for non-home discharge (NHD) enables improved patient counseling and expedites placement, potentially reducing length of stay and hospital readmission. The objective of this study was to create a simple, preoperative, clinical prediction tool for NHD using The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD). METHODS The STS GTSD was queried for patients who underwent elective anatomic lung cancer resection between 2009 and 2019. Exclusion criteria included age <18 years, percentage predicted diffusion capacity of the lung for carbon monoxide <20% or >150%, N3 or M1 disease, incomplete datasets, and mortality. The primary outcome was defined as discharge to an extended care, transitional care, rehabilitation center, or another hospital. Multivariable logistic regression was used to select risk factors and a nomogram for predicting risk of NHD was developed. The approach was cross-validated in 100 replications of a training set consisting of randomly selected two-thirds of the cohort and a validation set of remaining patients. RESULTS A total of 35 948 patients from the STS GTSD met inclusion criteria. Final model variables used to derive the nomogram for NHD risk prediction included age (P < .001), percentage predicted diffusion capacity of the lung for carbon monoxide (P < .001), open surgery (P < .001), cerebrovascular history (P < .001), and Zubrod score (P < .001). The receiver operating characteristic curve, using sensitivities and specificities of the model, yielded area under the curve of 0.74. In 100 replicated cross-validations, out-of-sample area under the curve ranged from 0.72-0.76. CONCLUSIONS Using readily available preoperative variables, our nomogram prognosticates the risk of NHD after anatomic lung resection with good discriminatory ability. Such risk stratification can enable improved patient counseling and facilitate better planning of patients' postoperative needs.
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Affiliation(s)
- Justin M Karush
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois.
| | - Gillian Alex
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nicole Geissen
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Sanjib Basu
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael J Liptay
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
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Hadaya J, Verma A, Haro G, Richardson S, Sanaiha Y, Revels S, Benharash P. Cost Variation and Value of Care in Pulmonary Lobectomy Across the United States. Ann Thorac Surg 2023; 115:671-677. [PMID: 35526606 DOI: 10.1016/j.athoracsur.2022.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/27/2022] [Accepted: 04/18/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Optimization of value, or quality relative to costs, has garnered significant attention in the United States. We aimed to characterize center-level variation in costs and quality after pulmonary lobectomy using a national cohort. METHODS Adults undergoing elective pulmonary lobectomy were identified in the 2016 to 2018 Nationwide Readmissions Database. Quality was defined by the absence of major adverse outcomes including respiratory failure, acute kidney injury, reoperation, and death. Risk-adjusted adverse outcome rates and costs were studied for institutions performing greater than or equal to 10 operations annually. Using observed-to-expected (O/E) ratios, high-value hospitals were defined as those with an O/E ratio less than 1 for costs and O/E ratio less than 1 for quality, while low-value hospitals were defined by the converse. RESULTS Among 95 446 patients managed at 565 hospitals annually, the median center-level cost for lobectomy was $22 000 (interquartile range, $18 000-$27 000), while the median adverse outcome rate was 14.3% (interquartile range, 8.3%-23.1%). Centers with an O/E ratio less than 1 for adverse events exhibited a $2200/case reduction in risk-adjusted costs. Using O/E ratios, 35.2% of centers were classified as high value while 18.6% were low value. Compared with low-value centers, high-value centers treated older patients (67.1 years of age vs 65.5 years of age; P < .001) with greater comorbidities (Elixhauser Comorbidity Index 3.7 vs 2.9; P < .001) but had greater annual lobectomy volume (40 cases vs 30 cases; P = .001) and were more commonly teaching hospitals. CONCLUSIONS Significant variation in costs and quality persists for lobectomy at the national level. Although high-value programs operated on patients at greater surgical risk, they had reduced complications and costs. Our findings suggest the need for dissemination of quality improvement and cost reduction practices.
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Affiliation(s)
- Joseph Hadaya
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Arjun Verma
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Greg Haro
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Shannon Richardson
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Yas Sanaiha
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Sha'shonda Revels
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.
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Bonner SN, He C, Clark M, Adams K, Orelaru F, Popoff A, Chang A, Wakeam E, Lagisetty K. Understanding Racial Differences in Lung Cancer Surgery Through a Statewide Quality Collaborative. Ann Surg Oncol 2023; 30:517-526. [PMID: 36018516 DOI: 10.1245/s10434-022-12435-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Persistent racial disparities in lung cancer incidence, treatment, and survival are well documented. Given the importance of surgical resection for lung cancer treatment, racial disparities in surgical quality were investigated using a statewide quality collaborative. METHODS This retrospective study used data from the Michigan Society of Cardiothoracic Surgeons General Thoracic database, which includes data gathered for the Society of Thoracic Surgeons General Thoracic Surgery Database at 17 institutions in Michigan. Adult patients undergoing resection for lung cancer between 2015 and 2021 were included. Propensity score-weighting methodology was used to assess differences in surgical quality, including extent of resection, adequate lymph node evaluation, 30-day mortality, and 30-day readmission rate between white and black patients. RESULTS The cohort included 5073 patients comprising 357 (7%) black and 4716 (93%) white patients. The black patients had significantly higher unadjusted rates of wedge resection than the white patients, but after propensity score-weighting for clinical factors, wedge resection did not differ from lobectomy (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.78-1.49; P = 0.67). The black patients had fewer lymph nodes collected (incidence rate ratio [IRR], 0.77; 95% CI, 0.73-0.81; P < 0.0001) and lymph node stations sampled (IRR, 0.89; 95% CI, 0.84-0.94; P < 0.0001). The black patients did not differ from the white patients in terms of mortality (OR, 0.65; 95% CI, 0.19-2.34; P = 0.55) or readmission (OR, 0.79; 95 % CI, 0.49-1.27; P = 0.32). The black patients had longer hospital stays (OR, 1.08; 95% CI, 1.02-1.14; P = 0.01). CONCLUSION In a statewide quality collaborative that included high-volume centers, black patients received a less extensive lymph node evaluation, with fewer non-anatomic wedge resections performed, and a more limited lymph node evaluation with lobectomy.
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Affiliation(s)
- Sidra N Bonner
- Department of Surgery, Section of General Surgery, University of Michigan, Ann Arbor, MI, USA. .,Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. .,National Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA.
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Melissa Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Kumari Adams
- Department of Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Felix Orelaru
- Department of Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Andrew Popoff
- Department of Thoracic Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Andrew Chang
- Department of Surgery, Section of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Elliot Wakeam
- Department of Surgery, Section of General Surgery, University of Michigan, Ann Arbor, MI, USA.,Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Kiran Lagisetty
- Department of Surgery, Section of General Surgery, University of Michigan, Ann Arbor, MI, USA
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Impact of center volume on conversion to thoracotomy during minimally invasive pulmonary lobectomy. Surgery 2022; 172:1478-1483. [PMID: 36031450 DOI: 10.1016/j.surg.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/22/2022] [Accepted: 07/08/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Conversion to open is a potentially serious intraoperative event associated with minimally invasive pulmonary lobectomy. However, the impact of institutional expertise on conversion to open has not been studied on a large scale. We used a nationally representative database to evaluate the association between hospital pulmonary lobectomy caseload and rates of conversion to open. METHODS All adults who underwent minimally invasive pulmonary lobectomy were identified from the 2017 to 2019 Nationwide Readmissions Database. Annual institutional caseloads of open and minimally invasive lobectomy were independently tabulated. Restricted cubic splines were used to parametrize the relationship between conversion to open and hospital volumes. Furthermore, multivariable regression was used to examine the association of conversion to open with in-hospital mortality, length of stay, and hospitalization costs. RESULTS Of an estimated 52,886 patients who met study criteria, 4.9% required conversion to open. Compared to others, conversion to open patients were slightly younger (66 vs 67 years) and more commonly male (52.2 vs 42.3%, P < .001). After adjustment, male sex (adjusted odds ratio 1.42), history of tobacco use (adjusted odds ratio 1.35), and prior radiation therapy (adjusted odds ratio 1.35, P < .001) were associated with increased odds of conversion to open. Increasing minimally invasive lobectomy volume was linked to lower risk-adjusted rates of conversion to open, whereas greater open lobectomy caseload was associated with higher rates. Despite no impact on mortality (adjusted odds ratio 1.11, P = .73), conversion to open was associated with a 1.2-day increment in length of stay and $5,600 in attributable costs. CONCLUSION The present study found institutional minimally invasive pulmonary lobectomy caseload to be associated with decreased rates of conversion to thoracotomy, emphasizing the relevance of minimally invasive training among surgeons and perioperative staff.
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Mitchell KG, Bostock IC, Antonoff MB. Social Disparities in Thoracic Surgery Database Research: Implications and Impact. Thorac Surg Clin 2021; 32:83-90. [PMID: 34801199 DOI: 10.1016/j.thorsurg.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A complex relationship exists between health care disparities and large databases among the thoracic surgical patient population. Using the example of thoracic malignancies, the ability of investigations leveraging large databases and novel analytical approaches to highlight disparate access to care and discordant outcomes following treatment is illustrated. Large, widely used databases may not be representative of the thoracic surgical patient population as a whole, and caution must be used when interpreting and generalizing results gleaned from such database analyses. Ensuring appropriate representation of all relevant patient subgroups in research databases will improve external generalizability and scientific validity of future investigations.
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Affiliation(s)
- Kyle G Mitchell
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1489, Houston, TX 77030, USA
| | - Ian C Bostock
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1489, Houston, TX 77030, USA
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1489, Houston, TX 77030, USA.
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Karamlou T, Javorski MJ, Weiss A, Pasquali SK, Welke KF. Utility of administrative and clinical data for cardiac surgery research: A case-based approach to guide choice. J Thorac Cardiovasc Surg 2021; 162:1157-1165. [DOI: 10.1016/j.jtcvs.2020.09.135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/24/2022]
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Servais EL, Towe CW, Farjah F, Brown LM, Broderick SR, Block MI, Burfeind WR, Mitchell JD, Schipper PH, Raymond DP, David EA. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2021 Update on Outcomes and Research. Ann Thorac Surg 2021; 112:693-700. [PMID: 34237295 DOI: 10.1016/j.athoracsur.2021.06.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/26/2021] [Indexed: 10/20/2022]
Abstract
The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the largest and most robust thoracic surgical database in the world. Participating sites receive risk-adjusted performance reports for benchmarking and quality improvement initiatives. The GTSD also provides several mechanisms for high-quality clinical research using data from 271 participant sites and nearly 720,000 procedures since its inception in 2002. Participant sites are audited at random annually for completeness and accuracy. During the last year and a half, the GTSD Task Force continued to refine the data collection form, ensuring high-quality data while minimizing data entry burden. In addition, the STS Workforce on National Databases has supported robust GTSD-based research program, which led to 10 scholarly publications in 2020. This report provides an update on outcomes, volume trends, and database improvements as well as a summary of research productivity resulting from the GTSD over the preceding year.
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Affiliation(s)
- Elliot L Servais
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts; Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts.
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, Washington
| | - Lisa M Brown
- Section of General Thoracic Surgery, University of California Davis Health, Sacramento, California
| | - Stephen R Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark I Block
- Department of Surgery, Memorial Healthcare System, Hollywood, Florida
| | - William R Burfeind
- Department of Surgery, St. Luke's University Hospital, Bethlehem, Pennsylvania
| | - John D Mitchell
- Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, University of Colorado Denver, Aurora, Colorado
| | - Paul H Schipper
- Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth A David
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Factors Associated With Successful Postoperative Day One Discharge After Anatomic Lung Resection. Ann Thorac Surg 2021; 112:221-227. [DOI: 10.1016/j.athoracsur.2020.07.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/28/2020] [Accepted: 07/30/2020] [Indexed: 11/22/2022]
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Patel DC, Leipzig M, Jeffrey Yang CF, Wang Y, Shrager JB, Backhus LM, Lui NS, Liou DZ, Berry MF. Early Discharge after Lobectomy for Lung Cancer does not Equate to Early Readmission. Ann Thorac Surg 2021; 113:1634-1640. [PMID: 34126077 DOI: 10.1016/j.athoracsur.2021.05.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/11/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways in several specialties reduce length of stay, but accelerated discharge after thoracic surgery is not well characterized. This study tested the hypothesis that patients discharged on post-operative day 1 (POD1) after lobectomy for lung cancer have an increased risk of readmission. METHODS Patients who underwent a lobectomy for lung cancer between 2011-2019 in the American College of Surgeons National Surgical Quality Improvement Program database were identified. Readmission rates were compared between patients discharged on postoperative day 1 (POD1) and patients discharged POD 2-6. Early discharge and readmission predictors were evaluated using multivariable logistic regression analysis. RESULTS Only 854 (3.8%) of 22,585 patients that met inclusion criteria were discharged on POD1, though POD1 discharge rates increased from 2.3% to 8.1% (p< 0.001) from 2011 to 2019. Median hospitalization for POD2-6 patients was 4 days (IQR: 3-5). Patient characteristics associated with a lower likelihood of POD1 discharge were increasing age, smokers, or history of dyspnea, while a minimally invasive approach was the strongest predictor of early discharge (AOR 5.42, p<0.001). Readmission rates were not significantly different for POD1 and POD2-6 groups in univariate analysis (6.0% vs 7.0%, p=0.269). Further, POD1 discharge was not a risk factor for readmission in multivariable analysis (AOR 1.10, p=0.537). CONCLUSIONS Select patients can be discharged on POD1 after lobectomy for lung cancer without an increased readmission risk, supporting this accelerated discharge target inclusion in lobectomy ERAS protocols.
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Affiliation(s)
- Deven C Patel
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Matthew Leipzig
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Chi-Fu Jeffrey Yang
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Yoyo Wang
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Leah M Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA; VA Palo Alto Health Care System, Palo Alto, CA
| | - Natalie S Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Mark F Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA; VA Palo Alto Health Care System, Palo Alto, CA.
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Potter AL, Jeffrey Yang CF. Commentary: Beyond the scope of randomized controlled trials: Navigating the sea of big data. J Thorac Cardiovasc Surg 2021; 162:1155-1156. [PMID: 33941371 DOI: 10.1016/j.jtcvs.2021.03.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Alexandra L Potter
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Chi-Fu Jeffrey Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
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Tran Z, Chervu N, Williamson C, Verma A, Hadaya J, Gandjian M, Revels S, Benharash P. The Impact of Expedited Discharge on 30-Day Readmission Following Lung Resection: A National Study. Ann Thorac Surg 2021; 113:1274-1281. [PMID: 33882292 DOI: 10.1016/j.athoracsur.2021.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/01/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Expedited discharge (within 24 hours) following lung resection has received scrutiny due to concerns for higher readmissions and paradoxically increased costs. The present study examined the impact of expedited discharge on hospitalization costs and unplanned readmissions using a nationally-representative sample. In addition, we sought to determine inter-hospital practice variation. METHODS Adults undergoing elective lobar or sublobar resection were identified using the 2016-2018 Nationwide Readmissions Database, while those with postoperative duration of hospitalization >5 days or experienced any perioperative complication, were excluded. Patients were classified as Expedited if postoperative hospitalization was 0 or 1 day and otherwise as Routine. Inverse probability of treatment weighing was utilized to adjust for intergroup differences. Hospitals were ranked according to risk-adjusted early discharge rates. Multivariable regression models were developed to assess the association of expedited discharge on nonelective 30-day readmissions as well as associated mortality and costs. RESULTS Of an estimated 84,152 patients, 13,834 (16.4%) comprised the Expedited group. Compared to Routine, Expedited were younger, less likely to have chronic obstructive pulmonary disease and undergo open procedures. Following adjustment, early discharge was associated with lower incremental costs (β coefficient: -$3.6K, 95%CI: -4.4 - -2.8) as well as similar readmissions (odds ratio: 0.89, 95%CI: 0.70 - 1.13) and related-mortality. Nearly half (48.1%) of all hospitals performed zero early discharges. CONCLUSIONS Expedited discharge following lung resection is a feasible management strategy and is associated with decreased costs and similar readmission risk compared to the norm. Select individuals should be strongly considered for expedited discharge following lung resection.
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Affiliation(s)
- Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sha'Shonda Revels
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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McCarthy DP, DeCamp MM. Does the Punishment Fit the Crime?: Using Frozen Section Results to Guide Extent of Resection. Chest 2021; 159:915-916. [PMID: 33678277 DOI: 10.1016/j.chest.2020.12.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/30/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Daniel P McCarthy
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine, Madison, WI
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine, Madison, WI.
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The influence of tobacco load versus smoking status on outcomes following lobectomy for lung cancer in a statewide quality collaborative. J Thorac Cardiovasc Surg 2020; 162:1375-1385.e1. [PMID: 33558118 DOI: 10.1016/j.jtcvs.2020.10.162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Collaborative quality consortia can facilitate implementation of quality measures arising from clinical databases. Our statewide general thoracic surgery (GTS) collaborative investigated the influences of cigarette smoking status on mortality and major morbidity following lobectomy for lung cancer. METHODS Society of Thoracic Surgeons General Thoracic Surgery Database records were identified from 14 institutions participating in a statewide thoracic surgical quality collaborative between 2012 and 2017. We excluded patients with nonelective procedures, stage 0 tumors, American Society of Anesthesiologists class VI disease, and missing clinical characteristics. Outcomes analysis included the combined mortality and major postoperative morbidity rates and the influence of patient characteristics, including smoking status, on composite rate and on postoperative complications. RESULTS The study cohort included 2267 patient records for analysis. Overall combined mortality and major morbidity rate was 10.2% (n = 231). Postoperative 30-day mortality was 1.5%, and major morbidity 9.6%. Significant predictors of the combined outcome included male sex (P = .004), body mass index (P < .001), Zubrod score (P = .02), smoking pack-years (P = .03), and thoracotomy (P < .001). Higher American Society of Anesthesiologists disease class and advanced tumor stage were marginally associated with worse combined outcome (P = .06). Smoking status; that is, current, past (no smoking within 30 days), or never smoked, was not associated with worse combined outcome (P = .56) and had no significant influence on major complications. CONCLUSIONS Smoking status was not associated with worse outcomes; however, smoking dose (pack-years) was associated with worse combined mortality and major morbidity. A statewide quality collaborative provides constructive feedback for participating institutions and surgeons, promoting quality improvement in perioperative patient care strategies and improved outcomes.
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Embun R, Royo-Crespo I, Recuero Díaz JL, Bolufer S, Call S, Congregado M, Gómez-de Antonio D, Jimenez MF, Moreno-Mata N, Aguinagalde B, Amor-Alonso S, Arrarás MJ, Blanco Orozco AI, Boada M, Cabañero Sánchez A, Cal Vázquez I, Cilleruelo Ramos Á, Crowley Carrasco S, Fernández-Martín E, García-Barajas S, García-Jiménez MD, García-Prim JM, Garcia-Salcedo JA, Gelbenzu-Zazpe JJ, Giraldo-Ospina CF, Gómez Hernández MT, Hernández J, Wolf JDI, Jauregui Abularach A, Jiménez U, López Sanz I, Martínez-Hernández NJ, Martínez-Téllez E, Milla Collado L, Mongil Poce R, Moradiellos-Díez FJ, Moreno-Balsalobre R, Moreno Merino SB, Obiols C, Quero-Valenzuela F, Ramírez-Gil ME, Ramos-Izquierdo R, Rivo E, Rodríguez-Fuster A, Rojo-Marcos R, Sanchez-Lorente D, Sanchez Moreno L, Simón C, Trujillo-Reyes JC, Hernando Trancho F. Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections. Arch Bronconeumol 2020; 56:718-724. [PMID: 35579917 DOI: 10.1016/j.arbr.2020.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/05/2020] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). METHODS We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". RESULTS The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR=0.61 (p=0.081), 90-day mortality OR=0.46 (p=0.051). CONCLUSIONS More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.
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Affiliation(s)
- Raul Embun
- Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet y Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain.
| | - Iñigo Royo-Crespo
- Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet y Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain
| | - José Luis Recuero Díaz
- Servicio de Cirugía Torácica, Hospital Universitario Miguel Servet y Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain
| | - Sergio Bolufer
- Servicio de Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, Spain
| | - Sergi Call
- Servicio de Cirugía Torácica, Hospital Universitari Mútua Terrasa, Universidad de Barcelona, Terrasa, Barcelona, Spain
| | - Miguel Congregado
- Servicio de Cirugía Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - David Gómez-de Antonio
- Servicio de Cirugía Torácica, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Marcelo F Jimenez
- Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Universidad de Salamanca, IBSAL, Salamanca, Spain
| | - Nicolas Moreno-Mata
- Servicio de Cirugía Torácica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Borja Aguinagalde
- Servicio de Cirugía Torácica, Hospital Universitario de Donostia, San Sebastián-Donostia, Spain
| | - Sergio Amor-Alonso
- Servicio de Cirugía Torácica, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Miguel Jesús Arrarás
- Servicio de Cirugía Torácica, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | | | - Marc Boada
- Servicio de Cirugía Torácica, Hospital Clinic de Barcelona, Instituto Respiratorio, Universidad de Barcelona, Barcelona, Spain
| | | | - Isabel Cal Vázquez
- Servicio de Cirugía Torácica, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Silvana Crowley Carrasco
- Servicio de Cirugía Torácica, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | | | | | - Jose María García-Prim
- Servicio de Cirugía Torácica, Hospital Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | | | - María Teresa Gómez Hernández
- Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Universidad de Salamanca, IBSAL, Salamanca, Spain
| | - Jorge Hernández
- Servicio de Cirugía Torácica, Hospital Universitario Sagrat Cor, Barcelona, Spain
| | | | | | - Unai Jiménez
- Servicio de Cirugía Torácica, Hospital Universitario Cruces, Bilbao, Spain
| | - Iker López Sanz
- Servicio de Cirugía Torácica, Hospital Universitario de Donostia, San Sebastián-Donostia, Spain
| | | | - Elisabeth Martínez-Téllez
- Servicio de Cirugía Torácica, Hospital Santa Creu y Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Roberto Mongil Poce
- Servicio de Cirugía Torácica, Hospital Regional Universitario, Málaga, Spain
| | | | | | | | - Carme Obiols
- Servicio de Cirugía Torácica, Hospital Universitari Mútua Terrasa, Universidad de Barcelona, Terrasa, Barcelona, Spain
| | | | | | - Ricard Ramos-Izquierdo
- Servicio de Cirugía Torácica, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Eduardo Rivo
- Servicio de Cirugía Torácica, Hospital Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Alberto Rodríguez-Fuster
- Servicio de Cirugía Torácica, Hospital del Mar, Barcelona, Spain; IMIM (Instituto de Investigación Médica Hospital del Mar), Barcelona, Spain
| | - Rafael Rojo-Marcos
- Servicio de Cirugía Torácica, Hospital Universitario Cruces, Bilbao, Spain
| | - David Sanchez-Lorente
- Servicio de Cirugía Torácica, Hospital Clinic de Barcelona, Instituto Respiratorio, Universidad de Barcelona, Barcelona, Spain
| | - Laura Sanchez Moreno
- Servicio de Cirugía Torácica, Hospital Universitario Marqués de Valdecilla, Santader, Spain
| | - Carlos Simón
- Servicio de Cirugía Torácica, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Juan Carlos Trujillo-Reyes
- Servicio de Cirugía Torácica, Hospital Santa Creu y Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
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Embun R, Royo-Crespo I, Recuero Díaz JL, Bolufer S, Call S, Congregado M, Gómez-de Antonio D, Jimenez MF, Moreno-Mata N, Aguinagalde B, Amor-Alonso S, Arrarás MJ, Blanco Orozco AI, Boada M, Cabañero Sánchez A, Cal Vázquez I, Cilleruelo Ramos Á, Crowley Carrasco S, Fernández-Martín E, García-Barajas S, García-Jiménez MD, García-Prim JM, Garcia-Salcedo JA, Gelbenzu-Zazpe JJ, Giraldo-Ospina CF, Gómez Hernández MT, Hernández J, Wolf JDI, Jauregui Abularach A, Jiménez U, López Sanz I, Martínez-Hernández NJ, Martínez-Téllez E, Milla Collado L, Mongil Poce R, Moradiellos-Díez FJ, Moreno-Balsalobre R, Moreno Merino SB, Obiols C, Quero-Valenzuela F, Ramírez-Gil ME, Ramos-Izquierdo R, Rivo E, Rodríguez-Fuster A, Rojo-Marcos R, Sanchez-Lorente D, Sanchez Moreno L, Simón C, Trujillo-Reyes JC, Hernando Trancho F. Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections. Arch Bronconeumol 2020. [DOI: 10.1016/j.arbres.2020.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Cowper PA, Feng L, Kosinski AS, Tong BC, Habib RH, Putnam JB, Onaitis MW, Furnary AP, Wright CD, Jacobs JP, Fernandez FG. Initial and Longitudinal Cost of Surgical Resection for Lung Cancer. Ann Thorac Surg 2020; 111:1827-1833. [PMID: 33031776 DOI: 10.1016/j.athoracsur.2020.07.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/18/2020] [Accepted: 07/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The longitudinal cost of treating patients with non-small cell lung cancer (NSCLC) undergoing surgical resection has not been evaluated. We describe initial and 4-year resource use and cost for NSCLC patients aged 65 years of age or greater who were treated surgically between 2008 and 2013. METHODS Using clinical data for NSCLC resections from The Society of Thoracic Surgeons General Thoracic Surgery Database linked to Medicare claims, resource use and cost of preoperative staging, surgery, and subsequent care through 4 years were examined ($2017). Cost of hospital-based care was estimated using cost-to-charge ratios; professional services and care in other settings were valued using reimbursements. Inverse probability weighting was used to account for administrative censoring. Outcomes were stratified by pathologic stage and by surgical approach for stage I lobectomy patients. RESULTS Resection hospitalizations averaged 6 days and cost $31,900. In the first 90 days, costs increased with stage ($12,430 for stage I to $26,350 for stage IV). Costs then declined toward quarterly means more similar among stages. Cumulative costs ranged from $131,032 (stage I) to $205,368 (stage IV). In the stage I lobectomy cohort, patients selected for minimally invasive procedures had lower 4-year costs than did thoracotomy patients ($120,346 versus $136,250). CONCLUSIONS The 4-year cost of surgical resection for NSCLC was substantial and increased with pathologic stage. Among stage I lobectomy patients, those selected for minimally invasive surgery had lower costs, particularly through 90 days. Potential avenues for improving the value of surgical resection include judicious use of postoperative intensive care and earlier detection and treatment of disease.
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Affiliation(s)
| | | | | | - Betty C Tong
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Joe B Putnam
- Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Mark W Onaitis
- Division of Cardiothoracic Surgery, University of California, San Diego, La Jolla, California
| | | | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Felix G Fernandez
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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The Society of Thoracic Surgeons General Thoracic Surgery Database: 2020 Update on Outcomes and Research. Ann Thorac Surg 2020; 110:768-775. [DOI: 10.1016/j.athoracsur.2020.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/07/2020] [Indexed: 11/22/2022]
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Vossler JD, Abdul-Ghani A, Tsai PI, Morris PT. Outcomes of Anatomic Lung Resection for Cancer Are Better When Performed by Cardiothoracic Surgeons. Ann Thorac Surg 2020; 111:1004-1011. [PMID: 32800788 DOI: 10.1016/j.athoracsur.2020.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 05/01/2020] [Accepted: 06/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anatomic lung resection (ALR) outcomes are superior for cardiothoracic surgeons (CTSs) by analysis of Medicare; National Inpatient Sample; South Carolina Office of Research and Statistics; and Surveillance, Epidemiology, and End Results databases. Similar findings have been reported for all noncardiac thoracic procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Our aim was to further delineate outcome differences between CTSs and general surgeons (GSs) specifically for ALR. METHODS A retrospective analysis of 15,574 nonemergent, nonpediatric ALR for lung cancer was conducted using the ACS-NSQIP 2013 to 2017 database. Included procedures were all ALR for lung cancer. Surgeons were classified as CTSs or GSs. Other specialties were excluded. Preoperative characteristics and 30-day outcomes were compared by bivariate (chi-square test) and multivariate analysis. Multivariate analysis was conducted by multiple logistic regression. RESULTS CTSs performed 14,172 (91.0%) of included procedures, and GSs performed 1402 (9.0%). A thoracoscopic approach was utilized at a similar rate (49.08% for CTSs vs 49.71% for GSs; P = .747). The extent of resection differed in a statistically, but not clinically, significant fashion. CTS patients had a higher rate of preoperative dyspnea (22.66% for CTSs vs 17.62% for GSs; P < .001). Procedures performed by CTSs had a lower risk-adjusted odds ratio of overall morbidity, pulmonary morbidity, sepsis or septic shock, bleeding requiring transfusion, and length of stay greater than the median (5 days). CONCLUSIONS ALR outcomes are superior for CTSs when compared with GSs. This is consistent with prior studies looking at this specific subset of patients and studies looking at a different subset of patients using the ACS-NSQIP database.
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Affiliation(s)
- John D Vossler
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Ayman Abdul-Ghani
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Peter I Tsai
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Paul T Morris
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii.
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Farjah F, Grau-Sepulveda MV, Gaissert H, Block M, Grogan E, Brown LM, Kosinski AS, Kozower BD. Volume Pledge is Not Associated with Better Short-Term Outcomes After Lung Cancer Resection. J Clin Oncol 2020; 38:3518-3527. [PMID: 32762615 DOI: 10.1200/jco.20.00329] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We examined the relationship between short-term outcomes and hospitals and surgeons who met minimum volume thresholds for lung cancer resection based on definitions provided by the Volume Pledge. A secondary aim was to evaluate the volume-outcome relationship to determine alternative thresholds in the event the Volume Pledge was not associated with outcomes. PATIENTS AND METHODS We conducted a retrospective study (2015-2017) using the Society of Thoracic Surgeons General Thoracic Surgery Database. We used generalized estimating equations that accounted for confounding and clustering to compare outcomes across hospitals and surgeons who did and did not meet the Volume Pledge criteria: ≥ 40 patients per year for hospitals and ≥ 20 patients per year for surgeons. Our secondary aim was to model volume by using restricted cubic splines to determine the association between volume and short-term outcomes. RESULTS Among 32,183 patients, 465 surgeons, and 209 hospitals, 16,630 patients (52%) received care from both a hospital and surgeon meeting the Volume Pledge criteria. After adjustment, there was no relationship with operative mortality, complications, major morbidity, a major morbidity-mortality composite end point, or failure to rescue. The Volume Pledge group had a 0.5 day (95% CI, 0.2 to 0.7 day) shorter length of stay. Our secondary aim revealed a nonlinear relationship between hospital volume and complications in which intermediate-volume hospitals had the highest risk of complications. Surgeon volume was associated with major morbidity, a major morbidity-mortality composite end point, and length of stay in an inverse linear fashion. Only 8% of surgeons had volumes associated with better outcomes. CONCLUSION The Volume Pledge was not associated with better outcomes except for a marginally shorter length of stay. A re-examination of volume-outcome relationships for hospitals and surgeons yielded mixed results that did not reveal a practical alternative for volume-based quality improvement efforts.
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Affiliation(s)
- Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA
| | | | - Henning Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark Block
- Division of Thoracic Surgery, Memorial Healthcare System, Hollywood, FL
| | - Eric Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California Davis Health, Sacramento, CA
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Benjamin D Kozower
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
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Resio BJ, Canavan M, Mase V, Dhanasopon AP, Blasberg JD, Boffa DJ. Invasive Staging Procedures Do Not Prevent Nodal Metastases From Being Missed in Stage I Lung Cancer. Ann Thorac Surg 2020; 110:390-397. [PMID: 32283084 DOI: 10.1016/j.athoracsur.2020.03.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/21/2020] [Accepted: 03/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Up to 20% of clinical stage I lung cancer patients harbor lymph node metastases that go undetected (missed) during the clinical staging evaluation. We investigated to what degree the addition of invasive nodal staging procedures to imaging, as currently practiced, prevents radiographically occult nodal metastases from being missed during the clinical staging evaluation. METHODS Treatment-naive patients, imaged by positron emission tomography and computed tomography, who underwent lobectomy for clinical stage I lung cancer from 2012 to 2017 in The Society of Thoracic Surgeons General Thoracic Surgery Database were studied. Rates of missed nodal metastases (MNM) (ie, nodal metastases in lobectomy specimens undetected during clinical staging evaluation) were determined. Risk factors were assessed with multivariable modeling. RESULTS Of the 30,685 clinical stage I patients identified, 3895 (12.7%) underwent preoperative endobronchial ultrasound and 3341 (10.9%) underwent mediastinoscopy. Invasive staging was more common with tumors > 2 cm (66.4% vs 50.2%, P < .001) and squamous histology (26.9% vs 16.9%, P < .001). MNM were discovered in 14.7% of patients, including 20.1% of patients (95% confidence interval, 18.8%-21.5%) who had undergone endobronchial ultrasound and 18.2% (95% confidence interval, 16.7%-19.6%) who had undergone mediastinoscopy. Hilar nodes were most often "missed" (9.5%). Using cut-points in tumor size, histology, laterality, and age, patients could be stratified into particularly high-risk (25% MNM) and low-risk (6% MNM) cohorts. CONCLUSIONS Substantial risk of occult lymph node metastases persists in patients with clinical stage I lung cancer despite negative invasive nodal staging, positron emission tomography, and computed tomography. In the absence of a thorough surgical nodal evaluation, early-stage lung cancer patients are at risk of under-treatment.
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Affiliation(s)
- Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Maureen Canavan
- Department of Internal Medicine, Cancer Outcomes and Public Policy and Effectiveness Research (COPPER), Yale School of Medicine, New Haven, Connecticut
| | - Vincent Mase
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Andrew P Dhanasopon
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Justin D Blasberg
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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Groth SS, Habermann EB, Massarweh NN. United States Administrative Databases and Cancer Registries for Thoracic Surgery Health Services Research. Ann Thorac Surg 2020; 109:636-644. [DOI: 10.1016/j.athoracsur.2019.08.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/18/2019] [Indexed: 12/20/2022]
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Abbas AE. Commentary: Winning the race after lung surgery: The tortoise or the hare? J Thorac Cardiovasc Surg 2019; 159:679-680. [PMID: 31679708 DOI: 10.1016/j.jtcvs.2019.08.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pa.
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Zhang H, Rueckert JC. Advocate the implementation of video-assisted thoracoscopic surgery lobectomy program for early stage lung cancer treatment: time to transfer from why to how. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S202. [PMID: 31656781 DOI: 10.21037/atm.2019.07.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hongbin Zhang
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, Berlin, Germany
| | - Jens Carsten Rueckert
- Department of Surgery, Competence Center of Thoracic Surgery, Charite University Hospital Berlin, Berlin, Germany
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Fernandez FG, Shahian DM, Kormos R, Jacobs JP, D'Agostino RS, Mayer JE, Kozower BD, Higgins RSD, Badhwar V. The Society of Thoracic Surgeons National Database 2019 Annual Report. Ann Thorac Surg 2019; 108:1625-1632. [PMID: 31654621 DOI: 10.1016/j.athoracsur.2019.09.034] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 02/07/2023]
Abstract
The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety for cardiothoracic surgery. The STS National Database has 4 components, each focusing on a distinct discipline-Adult Cardiac Surgery, General Thoracic Surgery, Congenital Heart Surgery, and mechanical circulatory support with the STS Interagency Registry for Mechanical Circulatory Support (Intermacs)/Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides the fourth annual summary of the status of the STS National Database.
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Affiliation(s)
- Felix G Fernandez
- Department of General Thoracic Surgery, Emory University, Atlanta, Georgia.
| | - David M Shahian
- Division of Cardiac Surgery and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Richard S D'Agostino
- Lahey Hospital and Medical Center, Burlington, Massachusetts and Tufts University School of Medicine, Boston, Massachusetts
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Robert S D Higgins
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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Linden PA, Perry Y, Worrell S, Wallace A, Argote-Greene L, Ho VP, Towe CW. Postoperative day 1 discharge after anatomic lung resection: A Society of Thoracic Surgeons database analysis. J Thorac Cardiovasc Surg 2019; 159:667-678.e2. [PMID: 31606175 DOI: 10.1016/j.jtcvs.2019.08.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/22/2019] [Accepted: 08/24/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and that there might be significant variation in day 1 discharge rates between hospitals. METHODS We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission. RESULTS A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges. CONCLUSIONS Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.
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Affiliation(s)
- Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Stephanie Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | | | - Luis Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, and Acute Care Surgery, Department of Surgery, MetroHealth Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio.
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Seder CW, Magee MJ, Broderick SR, Brown LM, Blasberg JD, Kozower BD, Fernandez FG, Welsh RJ, Gaissert HA, Burfeind WR, Becker S, Raymond DP. The Society of Thoracic Surgeons General Thoracic Surgery Database 2019 Update on Outcomes and Quality. Ann Thorac Surg 2019; 107:1302-1306. [DOI: 10.1016/j.athoracsur.2019.02.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 11/25/2022]
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30
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Jacobs JP, Shahian DM, D'Agostino RS, Mayer JE, Kozower BD, Badhwar V, Thourani VH, Jacobs ML, Gaissert HA, Fernandez FG, Naunheim KS. The Society of Thoracic Surgeons National Database 2018 Annual Report. Ann Thorac Surg 2018; 106:1603-1611. [DOI: 10.1016/j.athoracsur.2018.10.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 11/15/2022]
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