1
|
Grogan RS, Wieser AP, Bennie BA, Fischer CL, Paramesh V, Jarman BT. Effect of General Surgery Resident Participation in Thoracic Surgery on Oncologic Outcomes: An Observational Cohort Study. Am Surg 2024:31348241269407. [PMID: 39058406 DOI: 10.1177/00031348241269407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Background: Despite increasing sub-specialization, general surgeons continue to perform oncologic thoracic surgeries. Our objective was to determine whether general surgery resident participation in thoracic surgery affects surgical quality or oncologic outcomes. We hypothesized that patient outcomes with and without resident participation would be similar. Methods: We retrospectively reviewed the electronic health records of patients with stage 0-IV lung cancer undergoing oncologic pulmonary resection at BLINDED FOR REVIEW during an 11-year period (2012-2022). Patients younger than 18 years or older than 85 years were excluded, as were those who had incomplete follow-up data or were unregistered in our institutional cancer registry. Patients were divided into groups based on whether residents or staff surgeons completed >50% of the critical portions of the operation. We compared 30-day morbidity outcomes, overall survival (OS), and disease-free survival (DFS). Results: Three hundred thirteen patients met inclusion criteria. Demographic and clinical characteristics were similar between groups, as were types of surgical resection and median operative times. A statistical difference was found in the distribution of surgical approach. The odds of morbidity were 65% higher in the Staff group (OR=1.65; 95% CI, 1.007-2.71). Resident participation was not significantly associated with OS or DFS (P =.32 and P =.54, respectively). Discussion: General surgery resident involvement in lung cancer operations is not associated with longer operative times but is associated with a higher likelihood of a thoracotomy. General surgery resident involvement was associated with decreased postoperative morbidity and did not significantly affect OS or DFS.
Collapse
Affiliation(s)
- Riley S Grogan
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Alex P Wieser
- Department of Research Navigation, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Barbara A Bennie
- Department of Research Navigation, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Cathy L Fischer
- Department of Research Navigation, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Venki Paramesh
- Department of Cardiothoracic Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Benjamin T Jarman
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
| |
Collapse
|
2
|
Gómez-Hernández MT, Rivas C, Novoa N, Jiménez MF. Failure to rescue following anatomical lung resection. Analysis of a prospective nationwide database. Front Surg 2023; 10:1077046. [PMID: 36896264 PMCID: PMC9989191 DOI: 10.3389/fsurg.2023.1077046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/19/2023] [Indexed: 02/25/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- María Teresa Gómez-Hernández
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain.,Salamanca Institute of Biomedical Research, Salamanca, Spain.,University of Salamanca, Salamanca, Spain
| | - Cristina Rivas
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Nuria Novoa
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain.,Salamanca Institute of Biomedical Research, Salamanca, Spain.,University of Salamanca, Salamanca, Spain
| | - Marcelo F Jiménez
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain.,Salamanca Institute of Biomedical Research, Salamanca, Spain.,University of Salamanca, Salamanca, Spain
| | | |
Collapse
|
3
|
Gómez Hernández MT, Novoa Valentín N, Fuentes Gago M, Aranda Alcaide JL, Varela Simó G, Jiménez López MF. Mortality predictors in complicated patients after anatomical lung resection. Arch Bronconeumol 2021; 57:625-629. [PMID: 35702903 DOI: 10.1016/j.arbr.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/03/2020] [Indexed: 06/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- M Teresa Gómez Hernández
- Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.
| | - Nuria Novoa Valentín
- Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Marta Fuentes Gago
- Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - José Luis Aranda Alcaide
- Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | | | - Marcelo F Jiménez López
- Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| |
Collapse
|
4
|
Nguyen AB, Selevany M, Turner AL, Langan RC, Sesti J, Paul S. Effect of On-Site Cardiac Surgery Program on General Thoracic Surgery Outcomes. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:142-147. [PMID: 33533671 DOI: 10.1177/1556984520976572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Limited data exist exploring the relationship between multispecialty surgical collaboration and outcomes in general thoracic surgery. To address this, the Nationwide Inpatient Sample (NIS) was analyzed to determine whether the presence of an on-site cardiac surgery program is associated with improved general thoracic surgery outcomes. METHODS The NIS (1999-2008) was utilized to identify 389,959 patients who had a lobectomy, pneumonectomy, or esophagectomy. Short-term outcomes of patients undergoing these procedures were compared between hospitals with and without an on-site cardiac surgery program. Univariate and multivariate analyses were performed to determine patient and hospital predictors of mortality and morbidity. RESULTS During the study period, patients undergoing lobectomy (n = 314,130), pneumonectomy (n = 34,860), or esophagectomy (n = 40,969) were identified. Univariate analysis demonstrated lower mortality for lobectomy (P < 0.001) and esophagectomy (P < 0.001) but not pneumonectomy (P = 0.344) in hospitals with a cardiac surgery program. All-cause morbidity was significantly lower for all 3 procedures in hospitals with a cardiac surgery program. However, multivariate analysis demonstrated that a cardiac surgery program was not an independent predictor when adjusted for known confounders, particularly procedure volume and hospital academic teaching status. CONCLUSIONS The presence of an on-site cardiac surgery program is not in and of itself associated with improved general thoracic surgery outcomes. The presence of a cardiac surgery program is likely a surrogate for other known predictors of improved outcomes such as hospital teaching status and procedure volume.
Collapse
Affiliation(s)
- Andrew B Nguyen
- 240544598 Thoracic Surgical Services, RWJ Barnabas Health, West Orange, NJ, USA
| | - Mariam Selevany
- 240544598 Thoracic Surgical Services, RWJ Barnabas Health, West Orange, NJ, USA
| | - Amber L Turner
- 24056 Department of Surgery, Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ, USA
| | - Russell C Langan
- 24056 Department of Surgery, Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ, USA
| | - Joanna Sesti
- 240544598 Thoracic Surgical Services, RWJ Barnabas Health, West Orange, NJ, USA
| | - Subroto Paul
- 240544598 Thoracic Surgical Services, RWJ Barnabas Health, West Orange, NJ, USA
| |
Collapse
|
5
|
Gómez Hernández MAT, Novoa Valentín N, Fuentes Gago M, Aranda Alcaide JL, Varela Simó G, Jiménez López MF. Mortality Predictors In Complicated Patients After Anatomical Lung Resection. Arch Bronconeumol 2020; 57:S0300-2896(20)30132-0. [PMID: 32493640 DOI: 10.1016/j.arbres.2020.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Nuria Novoa Valentín
- Departamento de Cirugía Torácica. Hospital Universitario de Salamanca, Salamanca, España
| | - Marta Fuentes Gago
- Departamento de Cirugía Torácica. Hospital Universitario de Salamanca, Salamanca, España
| | | | - Gonzalo Varela Simó
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, España
| | | |
Collapse
|
6
|
[Evaluation of surgical practice in the treatment of lung cancer in France from the PMSI national database]. Rev Mal Respir 2018; 36:31-38. [PMID: 30287109 DOI: 10.1016/j.rmr.2018.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 01/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND In recent years, improving the quality of care has been a concern for health professionals in France, through the certification of institutions, accreditation and continuous professional development. Evaluation of these different measures has rarely been carried out. The objective of the study was to evaluate the quality of surgical management of lung cancer in different regions using hospital mortality as an indicator. METHOD From the national database of the Program of Medical Information Systems (PMSI), data on all patients who had undergone surgery for lung cancer were extracted as well as the characteristics of the centers. The main outcome criterion was hospital mortality. Logistic models allowed an estimation of the risk standardized mortality rate for each center. RESULTS From January 1, 2015 to December 31, 2015, 10,675 patients underwent surgery for lung cancer in 158 French centers. The hospital mortality rate was 3.43% (n=366). Thirty-nine facilities (25%) performed fewer than 15 pulmonary resections. The minimum activity volume was a single pulmonary resection during the year and the maximum was 300 interventions with a coefficient of variation estimated at 147%. Hospital mortality ranged from 0 % to 50% depending on the entries with a coefficient of variation of 112%. For some regions, it is possible to count up to 5 centers per million inhabitants (Languedoc-Roussillon) or 4 centers per million inhabitants (Limousin, Pays-de-Loire). The majority of regions had 3 centers per million inhabitants. Eleven regions have no centers with a standardized mortality rate below 3%. Five regions (Languedoc-Roussillon, Pays-de-Loire, Aquitaine, Brittany and Provence Alpes Côte d'Azur) have at least two centers with a risk standardized rate of mortality above 4%. Among the academic centers, 20% have a risk standardized mortality rate of less than 3%. Among the centers with a risk standardized rate of mortality<3%, 20% performed more than 39 pulmonary resections, 7% between 39 and 15 procedures and 0% for centers with<15 interventions. CONCLUSION This work confirms that hospital volume is one of the components of quality of care. The number of centers should be adapted to the actual needs of the population in order to enable patients to access effective services.
Collapse
|
7
|
Liou DZ, Serna-Gallegos D, Mirocha J, Bairamian V, Alban RF, Soukiasian HJ. Predictors of Failure to Rescue After Esophagectomy. Ann Thorac Surg 2018; 105:871-878. [PMID: 29397102 DOI: 10.1016/j.athoracsur.2017.10.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/17/2017] [Accepted: 10/10/2017] [Indexed: 12/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Douglas Z Liou
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Derek Serna-Gallegos
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vahak Bairamian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F Alban
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harmik J Soukiasian
- Department of Surgery, Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
| |
Collapse
|
8
|
Abstract
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.
Collapse
Affiliation(s)
- Farhood Farjah
- Division of Cardiothoracic Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356310, Seattle, WA 98195, USA.
| |
Collapse
|
9
|
Magee MJ, Herbert MA, Tumey L, Prince SL. Establishing a Dedicated General Thoracic Surgery Subspecialty Program Improves Lung Cancer Outcomes. Ann Thorac Surg 2017; 103:1063-1069. [PMID: 27938908 DOI: 10.1016/j.athoracsur.2016.09.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 08/29/2016] [Accepted: 09/08/2016] [Indexed: 11/24/2022]
|
10
|
Pagès PB, Cottenet J, Mariet AS, Bernard A, Quantin C. In-hospital mortality following lung cancer resection: nationwide administrative database. Eur Respir J 2016; 47:1809-17. [PMID: 26965293 DOI: 10.1183/13993003.00052-2016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/08/2016] [Indexed: 02/06/2023]
Abstract
Our aim was to determine the effect of a national strategy for quality improvement in cancer management (the "Plan Cancer") according to time period and to assess the influence of type and volume of hospital activity on in-hospital mortality (IHM) within a large national cohort of patients operated on for lung cancer.From January 2005 to December 2013, 76 235 patients were included in the French Administrative Database. Patient characteristics, hospital volume of activity and hospital type were analysed over three periods: 2005-2007, 2008-2010 and 2011-2013.Global crude IHM was 3.9%: 4.3% during 2005-2007, 4% during 2008-2010 and 3.5% during 2011-2013 (p<0.01). 296, 259 and 209 centres performed pulmonary resections in 2005-2007, 2008-2010 and 2011-2013, respectively (p<0.01). The risk of death was higher in centres performing <13 resections per year than in centres performing >43 resections per year (adjusted (a)OR 1.48, 95% CI 1.197-1.834). The risk of death was lower in the period 2011-2013 than in the period 2008-2010 (aOR 0.841, 95% CI 0.764-0.926). Adjustment variables (age, sex, Charlson score and type of resection) were significantly linked to IHM, whereas the type of hospital was not.The French national strategy for quality improvement seems to have induced a significant decrease in IHM.
Collapse
Affiliation(s)
- Pierre-Benoit Pagès
- Dept of Thoracic Surgery, Centre Hospitalier Universitaire Dijon, Bocage Central, Dijon, France INSERM UMR 866, Centre Hospitalier Universitaire Bocage, University of Burgundy, Dijon, France
| | - Jonathan Cottenet
- Department of Biostatistics and Medical Informatics, Centre Hospitalier Universitaire Dijon, Bocage Central, Dijon, France
| | - Anne-Sophie Mariet
- Department of Biostatistics and Medical Informatics, Centre Hospitalier Universitaire Dijon, Bocage Central, Dijon, France
| | - Alain Bernard
- Dept of Thoracic Surgery, Centre Hospitalier Universitaire Dijon, Bocage Central, Dijon, France
| | - Catherine Quantin
- Department of Biostatistics and Medical Informatics, Centre Hospitalier Universitaire Dijon, Bocage Central, Dijon, France INSERM, CIC 1432, Clinical Investigation Centre, Clinical Epidemiology/Clinical Trials Unit, Centre Hospitalier Universitaire Bocage, University of Burgundy, Dijon, France INSERM UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases, Centre Hospitalier Universitaire Bocage, University of Burgundy, Dijon, France
| |
Collapse
|
11
|
Nagayasu T, Sato S, Yamamoto H, Yamasaki N, Tsuchiya T, Matsumoto K, Miyazaki T, Endo S, Tanaka F, Yokomise H, Okumura M. The impact of certification of general thoracic surgeons on lung cancer mortality: a survey by The Japanese Association for Thoracic Surgery. Eur J Cardiothorac Surg 2016; 49:e134-40. [PMID: 26834236 DOI: 10.1093/ejcts/ezw006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/22/2015] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The Japanese Board of General Thoracic Surgery and the annual survey by the Japanese Association for Thoracic Surgery (JATS) of certified hospitals began in 2005; since then, over 1300 specialists and 650 hospitals have been certified by this system. To evaluate how this system contributes to improving the outcomes of general thoracic surgery, the effects of the number of certified general thoracic surgeons (GTSs) and hospital volume on 30-day mortality or hospital mortality were evaluated. METHODS Using data from the annual survey of JATS from 2005 to 2012, the outcomes of 211 619 patients who underwent lung resection for lung cancer were evaluated. The patients were divided into four groups by the level of surgery: first level, partial resection; second level, segmentectomy and lobectomy; third level, sleeve segmentectomy and lobectomy; and fourth level, pneumonectomy, sleeve pneumonectomy and pleuro-pneumonectomy. Multiple logistic regression analysis was used to examine the associations between operative mortality and the number of GTSs, hospital volume and level of surgical procedure. RESULTS Overall 30-day and hospital mortality rates were 0.40 and 0.77%, respectively. The 30-day and hospital mortality rates for each surgical level were 0.20 and 0.35% for the first level, 0.36 and 0.73% for the second level, 1.02 and 1.81% for the third level and 2.42 and 4.26% for the fourth level, respectively. The number of GTSs was associated with lower 30-day and hospital mortality rates (P < 0.0001). On logistic analysis, number of GTSs (<3 vs ≥3), hospital volume (<50 vs ≥50) and level of procedure (1 vs 2, 3 vs 2, 4 vs 2) were significantly associated with 30-day and hospital mortality rates. For 30-day mortality, the odds ratios were 0.688 (P < 0.0001) for higher number of GTSs and 0.856 (P = 0.0510) for higher volume hospitals. In the subgroup analysis by surgical level, low 30-day and hospital mortality rates in the second and fourth surgical levels were correlated with a higher number of GTSs. CONCLUSIONS The current decrease in overall 30-day mortality rates from the JATS data showed greater dependence on the number of GTSs than on the hospital volume. We believe that the certification system in Japan is useful for the establishment of GTS status.
Collapse
Affiliation(s)
- Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroshi Yamamoto
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Naoya Yamasaki
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoshi Tsuchiya
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Keitaro Matsumoto
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takuro Miyazaki
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shunsuke Endo
- Department of Thoracic Surgery, Jichi Medical University, Tochigi, Japan Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Tokyo, Japan
| | - Fumihiro Tanaka
- Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Tokyo, Japan Second Department of Surgery, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Hiroyasu Yokomise
- Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Tokyo, Japan Faculty of Medicine, Department of General Thoracic Surgery, Kagawa University, Kagawa, Japan
| | - Meinoshin Okumura
- Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Tokyo, Japan Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
12
|
Falcoz PE. Editorial comment on: "Major morbidity after video-assisted thoracic surgery lung resections: a comparison between the European Society of Thoracic Surgeons definition and the Thoracic Morbidity and Mortality system" by Sandri A, et al. J Thorac Dis 2015; 7:E329-31. [PMID: 26543622 DOI: 10.3978/j.issn.2072-1439.2015.09.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
13
|
Van Schil PE, Balduyck B, De Waele M, Hendriks JM, Hertoghs M, Lauwers P. Surgical treatment of early-stage non-small-cell lung cancer. EJC Suppl 2015. [PMID: 26217120 PMCID: PMC4041566 DOI: 10.1016/j.ejcsup.2013.07.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Surgical resection remains the standard of care for functionally operable early-stage non-small-cell lung cancer (NSCLC) and resectable stage IIIA disease. The role of invasive staging and restaging techniques is currently being debated, but they provide the largest biopsy samples which allow for precise mediastinal staging. Different types of operative procedures are currently available to the thoracic surgeon, and some of these interventions can be performed by video-assisted thoracic surgery (VATS) with the same oncological results as those by open thoracotomy. The principal aim of surgical treatment for NSCLC is to obtain a complete resection which has been precisely defined by a working group of the International Association for the Study of Lung Cancer (IASLC). Intraoperative staging of lung cancer is of utmost importance to decide on the extent of resection according to the intraoperative tumour (T) and nodal (N) status. Systematic nodal dissection is generally advocated to evaluate the hilar and mediastinal lymph nodes which are subdivided into seven zones according to the most recent 7th tumour-node-metastasis (TNM) classification. Lymph-node involvement not only determines prognosis but also the administration of adjuvant therapy. In 2011, a new multidisciplinary adenocarcinoma classification was published introducing the concepts of adenocarcinoma in situ and minimally invasive adenocarcinoma. This classification has profound surgical implications. The role of limited or sublobar resection, comprising anatomical segmentectomy and wide wedge resection, is reconsidered for early-stage lesions which are more frequently encountered with the recently introduced large screening programmes. Numerous retrospective non-randomised studies suggest that sublobar resection may be an acceptable surgical treatment for early lung cancers, also when performed by VATS. More tailored, personalised therapy has recently been introduced. Quality-of-life parameters and surgical quality indicators become increasingly important to determine the short-term and long-term impact of a surgical procedure. International databases currently collect extensive surgical data, allowing more precise calculation of mortality and morbidity according to predefined risk factors. Centralisation of care has been shown to improve results. Evidence-based guidelines should be further developed to provide optimal staging and therapeutic algorithms.
Collapse
Affiliation(s)
- Paul E Van Schil
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Bram Balduyck
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Michèle De Waele
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Jeroen M Hendriks
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Marjan Hertoghs
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| | - Patrick Lauwers
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Edegem, Antwerp, Belgium
| |
Collapse
|
14
|
Wakeam E, Hyder JA, Lipsitz SR, Darling GE, Finlayson SRG. Outcomes and Costs for Major Lung Resection in the United States: Which Patients Benefit Most From High-Volume Referral? Ann Thorac Surg 2015; 100:939-46. [PMID: 26116480 DOI: 10.1016/j.athoracsur.2015.03.076] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 03/14/2015] [Accepted: 03/23/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Accountable care organizations are designed to improve value by decreasing costs and maintaining quality. Strategies to maximize value are needed for high-risk surgery. We wanted to understand whether certain patient groups were differentially associated with better outcomes at high-volume hospitals in terms of quality and cost. METHODS In all, 37,746 patients underwent elective major lung resection in 1,273 hospitals in the Nationwide Inpatient Sample from 2007 to 2011. Patients were stratified by hospital volume quartile and substratified by preoperative mortality risk, age, and chronic obstructive pulmonary disease status. Mortality was evaluated using clustered multivariable hierarchical logistic regression controlling for patient comorbidity, demographics, and procedure. Adjusted cost was evaluated using generalized linear models fit to a gamma distribution. RESULTS Patients were grouped into volume quartiles based on cases per year (less than 21, 21 to 40, 40 to 78, and more than 78). Patient characteristics and procedure mix differed across quartiles. Overall, mortality decreased across volume quartiles (lowest 1.9% versus highest 1.1%, p < 0.0001). Patients aged more than 80 years were associated with greater absolute and relative mortality rates than patients less than 60 years old in highest volume versus lowest volume hospitals (age more than 80 years, 4.2% versus 1.3%, p < 0.0001, odds ratio 3.31, 95% confidence interval: 1.89 to 5.80; age less than 60 years, 1.0% versus 0.8%, p = 0.19, odds ratio 1.38, 95% confidence interval: 0.74 to 2.56). Patients with high preoperative risk (more than 75th percentile) were also associated with lower absolute mortality in high-volume hospitals. Adjusted costs were not significantly different across quartiles or patient strata. CONCLUSIONS Older patients show a significantly stronger volume-outcome relationship than patients less than 60 years of age. Costs were equivalent across volume quartile and patient strata. Selective patient referral may be a strategy to improve outcomes for elderly patients undergoing lung resection.
Collapse
Affiliation(s)
- Elliot Wakeam
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Joseph A Hyder
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gail E Darling
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Samuel R G Finlayson
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
15
|
Al-Sahaf M, Lim E. The association between surgical volume, survival and quality of care. J Thorac Dis 2015; 7:S152-5. [PMID: 25984361 DOI: 10.3978/j.issn.2072-1439.2015.04.08] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 03/13/2015] [Indexed: 12/16/2022]
Abstract
Improving surgical outcomes is important to the thoracic surgical community and operative mortality is often used as a benchmark to gauge the quality of lung resection. In lung cancer surgery, increasing hospital volume is associated with better survival although the categorisation of procedure volume is arbitrary. When US and UK data are scrutinised, the association holds true for increasingly higher volumes up to 150 resection per year and more. The reason may be due to better infrastructure, better-staffed units, more resources and wider specialist and technology-based services in higher volume centers. For individual surgeon volume, reports are not consistent. However, studies suggest that surgeon sub-specialty is an important consideration. The results of general thoracic surgeons and cardiac surgeons are reported to be better than general surgeons for lung resection surgery, and the effects of specialty training was also associated with an increase in the number of patients undergoing lung resection. We conclude that the current evidence strongly supports the association between increasing hospital volume with lower mortality and improved long-term survival following lung resection. Whilst the data presented supports centralization of lung cancer surgery in high volume hospitals, patient choice and the threshold of quality of improvement required to overcome travel and closure of local services need to be considered.
Collapse
Affiliation(s)
- May Al-Sahaf
- The Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
| | - Eric Lim
- The Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
| |
Collapse
|
16
|
Farjah F, Backhus L, Cheng A, Englum B, Kim S, Saha-Chaudhuri P, Wood DE, Mulligan MS, Varghese TK. Failure to rescue and pulmonary resection for lung cancer. J Thorac Cardiovasc Surg 2015; 149:1365-71; discussion 1371-3.e3. [DOI: 10.1016/j.jtcvs.2015.01.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 12/16/2014] [Accepted: 01/24/2015] [Indexed: 10/24/2022]
|
17
|
Failure to rescue trends in elective abdominal aortic aneurysm repair between 1995 and 2011. J Vasc Surg 2014; 60:1473-80. [DOI: 10.1016/j.jvs.2014.08.106] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/26/2014] [Indexed: 11/19/2022]
|
18
|
The impact of hospital and surgeon volume on the 30-day mortality of lung cancer surgery: A nation-based reappraisal. J Thorac Cardiovasc Surg 2014; 148:841-8; discussion 848. [PMID: 24534677 DOI: 10.1016/j.jtcvs.2014.01.030] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 12/10/2013] [Accepted: 01/21/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Our objective was to analyze the time trend variation of 30-day mortality after lung cancer surgery, and to quantify the impact of surgeon and hospital volumes over a 5-year period in France. METHODS We used Epithor, the French national thoracic database and benchmark tool, which catalogues more than 180,000 procedures of 89 private and public hospitals in France. From January 2005 to December 2010, 19,556 patients who underwent major lung resection (lobectomy, bilobectomy, pneumonectomy) were included in our study. Multilevel logistic models were designed to investigate the relationship between 30-day mortality and surgeon (model 1) or hospital (model 2) volumes. The 3 levels considered were the patient, the surgeon, and the hospital. RESULTS From 2005 to 2007, the 30-day mortality of patients who underwent major lung resection averaged 10%, and then decreased until it reached 3.8% in 2010 (P < .0001). A significant decrease in 30-day mortality was observed over time (P = .0046). During the study period, the mean annual number of procedures per surgeon was 46.1 (standard deviation [SD] = 23.6) and per hospital was 97.9 (SD = 50.8). Model 1 showed that surgeon volume had a significant impact on 30-day mortality (P = .03), whereas model 2 failed to show that hospital volume influenced 30-day mortality (P = .75). CONCLUSIONS Since 2007, when France's first National Cancer Plan became effective, 30-day mortality of primary lung cancer surgery has decreased and currently measures 3.8%. Low mortality was correlated with higher surgeon volume but was not influenced by hospital volume, which cannot be considered a proxy measure for determining the safety of lung cancer surgery.
Collapse
|