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McLeod M, Leung K, Pramesh CS, Kingham P, Mutebi M, Torode J, Ilbawi A, Chakowa J, Sullivan R, Aggarwal A. Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals. BJS Open 2024; 8:zrae009. [PMID: 38513280 PMCID: PMC10957165 DOI: 10.1093/bjsopen/zrae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups. METHODS A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level. RESULTS A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data. CONCLUSION Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.
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Affiliation(s)
- Megan McLeod
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Otolaryngology—Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kari Leung
- Department of Oncology, Guy’s & St Thomas’ NHS Trust, London, UK
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Julie Torode
- Institute of Cancer Policy, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Andre Ilbawi
- Department of Universal Health Coverage, World Health Organization, Geneva, Switzerland
| | | | - Richard Sullivan
- Institute of Cancer Policy, Global Oncology Group, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Bernard A, Cottenet J, Quantin C. Is the Validity of Logistic Regression Models Developed with a National Hospital Database Inferior to Models Developed from Clinical Databases to Analyze Surgical Lung Cancers? Cancers (Basel) 2024; 16:734. [PMID: 38398124 PMCID: PMC10886576 DOI: 10.3390/cancers16040734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/11/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
In national hospital databases, certain prognostic factors cannot be taken into account. The main objective was to estimate the performance of two models based on two databases: the Epithor clinical database and the French hospital database. For each of the two databases, we randomly sampled a training dataset with 70% of the data and a validation dataset with 30%. The performance of the models was assessed with the Brier score, the area under the receiver operating characteristic (AUC ROC) curve and the calibration of the model. For Epithor and the hospital database, the training dataset included 10,516 patients (with resp. 227 (2.16%) and 283 (2.7%) deaths) and the validation dataset included 4507 patients (with resp. 93 (2%) and 119 (2.64%) deaths). A total of 15 predictors were selected in the models (including FEV1, body mass index, ASA score and TNM stage for Epithor). The Brier score values were similar in the models of the two databases. For validation data, the AUC ROC curve was 0.73 [0.68-0.78] for Epithor and 0.8 [0.76-0.84] for the hospital database. The slope of the calibration plot was less than 1 for the two databases. This work showed that the performance of a model developed from a national hospital database is nearly as good as a performance obtained with Epithor, but it lacks crucial clinical variables such as FEV1, ASA score, or TNM stage.
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Affiliation(s)
- Alain Bernard
- Department of Thoracic and Cardiovascular Surgery, Dijon University Hospital, 21000 Dijon, France;
| | - Jonathan Cottenet
- Service de Biostatistiques et d’Information Médicale (DIM), CHU Dijon Bourgogne, Inserm, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, 21000 Dijon, France;
| | - Catherine Quantin
- Service de Biostatistiques et d’Information Médicale (DIM), CHU Dijon Bourgogne, Inserm, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, 21000 Dijon, France;
- CESP, Inserm, UVSQ, Université Paris-Saclay, 94807 Villejuif, France
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Linhardt FC, Santer P, Xu X, Gangadharan SP, Gaissert HA, Kiyatkin M, Schaefer MS, Vidal Melo MF, Eikermann M, Nagrebetsky A. Reintubation After Lung Cancer Resection: Development and External Validation of a Predictive Score. Ann Thorac Surg 2024; 117:173-180. [PMID: 35690135 DOI: 10.1016/j.athoracsur.2022.05.035] [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: 01/16/2022] [Revised: 04/15/2022] [Accepted: 05/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Reintubation after lung cancer resection is an important quality metric because of increased disability, mortality and cost. However, no validated predictive instrument is in use to reduce reintubation after lung resection. This study aimed to create and validate the PRediction Of REintubation After Lung cancer resection (PROREAL) score. METHODS The study analyzed lung resection cases from 2 university hospitals. The primary end point was reintubation within 7 days after surgery. Predictors were selected through backward stepwise logistic regression and bootstrap resampling. The investigators used reclassification and receiver-operating characteristic (ROC) curve analyses to assess score performance and compare it with an established score for all surgical patients (Score for Prediction of Postoperative Respiratory Complications [SPORC]). RESULTS The study included 2672 patients who underwent resection for lung cancer (1754, development cohort; 918, validation cohort) between 2008 and 2020, of whom 71 (2.7%) were reintubated within 7 days after surgery. Identified score variables were surgical extent and approach, American Society of Anesthesiologists physical status, heart failure, renal disease, and diffusing capacity of the lung for carbon monoxide. The score achieved excellent discrimination in the development cohort (ROC AUC, 0.90; 95% CI, 0.87-0.94) and good discrimination in the validation cohort (ROC AUC, 0.74, 95% CI; 0.66-0.82), thus outperforming the SPORC in both cohorts (P < .001 and P = .018, respectively; validation cohort net reclassification improvement, 0.39; 95% CI, 0.18-0.60; P = .001). The score cutoff of ≥5 yielded a sensitivity of 88% (95% CI, 72-95) and a specificity of 81% (95% CI,79-83) in the development cohort. CONCLUSIONS A simple score (PROREAL) specific to lung cancer predicts postoperative reintubation more accurately than the nonspecific SPORC score. Operative candidates at risk may be identified for preventive intervention or alternative oncologic therapy.
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Affiliation(s)
- Felix C Linhardt
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Anaesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Peter Santer
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Xinling Xu
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Kiyatkin
- Department of Anaesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Maximilian S Schaefer
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marcos F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Anaesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Alexander Nagrebetsky
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Wang Y, Kapula N, Yang CFJ, Manapat P, Elliott IA, Guenthart BA, Lui NS, Backhus LM, Berry MF, Shrager JB, Liou DZ. Comparison of failure to rescue in younger versus elderly patients following lung cancer resection. JTCVS OPEN 2023; 16:855-872. [PMID: 38204720 PMCID: PMC10774945 DOI: 10.1016/j.xjon.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/14/2023] [Accepted: 08/02/2023] [Indexed: 01/12/2024]
Abstract
Objective Failure to rescue (FTR), defined as in-hospital death following a major complication, has been increasingly studied in patients who undergo cardiothoracic surgery. This study tested the hypothesis that elderly patients undergoing lung cancer resection have greater rates of FTR compared with younger patients. Methods Patients who underwent surgery for primary lung cancer between 2011 and 2020 and had at least 1 major postoperative complication were identified using the National Surgical Quality Improvement Program database. Patients who died following complications (FTR) were compared with those who survived in an elderly (80+ years) and younger (<80 years) cohort. Results Of the 2823 study patients, the younger cohort comprised 2497 patients (FTR: n = 139 [5.6%]), whereas the elderly cohort comprised 326 patients (FTR: n = 39 [12.0%]). Pneumonia was the most common complication in younger (877/2497, 35.1%) and elderly patients (118/326, 36.2%) but was not associated with FTR on adjusted analysis. Increasing age was associated with FTR (adjusted odds ratio [AOR], 1.55 per decade, P < .001), whereas unplanned reoperation was associated with reduced risk (AOR, 0.55, P = .01). Within the elderly cohort, surgery conducted by a thoracic surgeon was associated with lower FTR risk (AOR, 0.29, P = .028). Conclusions FTR following lung cancer resection was more frequent with increasing age. Pneumonia was the most common complication but not a predictor of FTR. Unplanned reoperation was associated with reduced FTR, as was treatment by a thoracic surgeon for elderly patients. Surgical therapy for complications after lung cancer resection and elderly patients managed by a thoracic specialist may mitigate the risk of death following an adverse postoperative event.
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Affiliation(s)
- Yoyo Wang
- University of Michigan Medical School, Ann Arbor, Mich
| | - Ntemena Kapula
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Chi-Fu J. Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Pooja Manapat
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Irmina A. Elliott
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Brandon A. Guenthart
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Natalie S. Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Leah M. Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Mark F. Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Joseph B. Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Douglas Z. Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
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Bernard A, Cottenet J, Pagès PB, Quantin C. Mortality and failure-to-rescue major complication trends after lung cancer surgery between 2005 and 2020: a nationwide population-based study. BMJ Open 2023; 13:e075463. [PMID: 37699626 PMCID: PMC10503350 DOI: 10.1136/bmjopen-2023-075463] [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: 05/09/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVES To estimate the evolution of quality indicators (30-day mortality and failure-to-rescue) inpatients who underwent lung cancer surgery in France over the past 15 years and to study the potential influencing factors. DESIGN Retrospective cohort study using data from the French hospital database (PMSI). SETTING Nationwide population-based study. PARTICIPANTS All patients who underwent pulmonary resection for lung cancer in France (2005-2020) were included (N=1 57 566). Characteristics of patients (age, gender, comorbidities), surgery (surgical approach, type of resection, extent of resection) and hospital (type of hospital, hospital volume for pulmonary resections) were retrieved. PRIMARY AND SECONDARY OUTCOME MEASURES We studied two outcome indicators: 30-day mortality and failure-to-rescue. We used regression-based techniques (including interrupted time-series) to assess the effects of patient and hospital characteristics on 30-day mortality and failure-to-rescue (number of deaths among patients with at least one major postoperative complication within the 30 days after surgery), adjusting for case mix. RESULTS The 30-day mortality rate increased from 3.8% in 2005 to 4.9% in 2010 and then decreased to 2.9% in 2020. The failure-to-rescue rate decreased from 12.2% in 2005 to 7.1% in 2020. The pneumonectomy rate decreased significantly over time (18.1% in 2005 to 4.8% in 2020) and had the greatest contribution on the reduction of mortality between two periods (2005-2010/2015-2020). The use of video-assisted thoracoscopic surgery or robot-assisted surgery had a great influence on the reduction of mortality (16% of the observed difference in mortality) between the two periods, as did hospital volume. CONCLUSIONS The change in surgical practices, particularly the reduction in pneumonectomies, could be one of the main reasons for reduction in postoperative mortality and failure-to-rescue in France since 2011. Hospital volume is another important factor in reducing postoperative mortality. Our study should encourage the use of technological or organisational innovation, such as changes in surgical practice and cancer surgery authorisations, to improve quality of care.
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Affiliation(s)
| | - Jonathan Cottenet
- Service de Biostatistiques et d'Information Médicale (DIM) ; INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, CHU Dijon, Dijon, France
| | | | - Catherine Quantin
- Service de Biostatistiques et d'Information Médicale (DIM) ; INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, CHU Dijon, Dijon, France
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
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Ray MA, Akinbobola O, Fehnel C, Saulsberry A, Dortch K, Wolf B, Valaulikar G, Patel HD, Ng T, Robbins T, Smeltzer MP, Faris NR, Osarogiagbon RU. Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer. J Clin Oncol 2023; 41:3616-3628. [PMID: 37267506 PMCID: PMC10325770 DOI: 10.1200/jco.22.01971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/06/2023] [Accepted: 04/12/2023] [Indexed: 06/04/2023] Open
Abstract
PURPOSE The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care. PATIENTS AND METHODS Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes. RESULTS From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively. CONCLUSION Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.
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Affiliation(s)
| | | | - Carrie Fehnel
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
| | - Andrea Saulsberry
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
| | - Kourtney Dortch
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
| | | | | | | | - Thomas Ng
- Methodist University Hospital, Memphis, TN
| | - Todd Robbins
- Baptist Memorial Hospital—Memphis, Memphis TN
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
| | | | - Nicholas R. Faris
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
| | - Raymond U. Osarogiagbon
- Thoracic Oncology Research Group, Baptist Cancer Center, Memphis, TN
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
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Pienta MJ, Cascino TM, Likosky DS, Ghaferi AA, Aaronson KD, Pagani FD, Thompson MP. Failure to rescue: A candidate quality metric for durable left ventricular assist device implantation. J Thorac Cardiovasc Surg 2023; 165:2114-2123.e5. [PMID: 34887093 PMCID: PMC9081291 DOI: 10.1016/j.jtcvs.2021.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 10/21/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Failure to rescue (FTR), defined as death after a complication, is recognized as a principal driver of variation in mortality among hospitals. We evaluated FTR as a quality metric in patients who received durable left ventricular assist devices (LVADs) using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support. METHODS Data on 13,617 patients who received primary durable LVADs from April 2012 to October 2017 at 131 hospitals that performed at least 20 implants were analyzed from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support. Rates of major complications and FTR were compared across risk-adjusted in-hospital mortality terciles (low, medium, high) and hospital volume. Logistic regression was used to estimate expected FTR rates on the basis of patient factors for each major complication. RESULTS The overall unadjusted in-hospital mortality rate was 6.96%. Risk-adjusted in-hospital mortality rates varied 3.1-fold across terciles (low, 3.3%; high, 10.3%; P trend <.001). Rates of major complications varied 1.1-fold (low, 34.0%; high, 38.8%; P < .0001). Among patients with a major complication, 854 died in-hospital for an FTR rate of 17.7%, with 2.8-fold variation across mortality terciles (low, 8.5%; high, 23.9%; P < .0001). FTR rates were highest for renal dysfunction requiring dialysis (45.3%) and stroke (36.5%). Higher average annual LVAD volume was associated with higher rates of major complications (<10 per year, 26.7%; 10-20 per year, 34.0%; 20-30 per year, 34.0%; >30 per year, 40.1%; P trend <.0001) whereas hospitals implanting <10 per year had the highest FTR rate (<10 per year, 23.5%; 10-20 per year, 16.5%; 20-30 per year, 17.0%; >30 per year, 17.9%; P = .03). CONCLUSIONS FTR might serve as an important quality metric for durable LVAD implant procedures, and identifying strategies for successful rescue after complications might reduce hospital variations in mortality.
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Affiliation(s)
- Michael J Pienta
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Mich
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Amir A Ghaferi
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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Implementation of a Surgical Critical Care Service Reduces Failure to Rescue in Emergency Gastrointestinal Surgery in Rural Kenya. Ann Surg 2023; 277:e719-e724. [PMID: 34520427 DOI: 10.1097/sla.0000000000005215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. SUMMARY BACKGROUND DATA FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. METHODS All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score. RESULTS A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%-47.8%) to 21.8% (95% CI: 13.2%-32.6%) ( P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1-14.9) to 15.2 (95% CI, 14.7-15.7) ( P =0.03). CONCLUSIONS The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.
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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.
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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
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Cameron RB. Commentary: Thoracic intensive care unit readmissions—glass half full or half empty? JTCVS OPEN 2022; 9:291-292. [PMID: 36003425 PMCID: PMC9390598 DOI: 10.1016/j.xjon.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 10/24/2022]
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Qu WW, Wei JW, Binongo JN, Keeling WB. Gender Differences in Failure-to-Rescue After Coronary Artery Bypass Grafting. Ann Thorac Surg 2021; 114:1596-1602. [PMID: 34774815 DOI: 10.1016/j.athoracsur.2021.09.070] [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: 02/05/2021] [Revised: 08/23/2021] [Accepted: 09/27/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Female patients experience worse outcomes following coronary artery bypass grafting (CABG). We investigated whether rates of failure-to-rescue (FTR), a systems-based quality indicator, were greater in women who underwent CABG. METHODS A retrospective review was conducted on 20,045 patients who underwent isolated, non-emergent CABG between January 2002 and August 2019 at a single academic center. FTR was defined as postoperative death within 30 days after stroke, renal failure, reoperation, and prolonged ventilation. Propensity-score matching was performed utilizing preoperative variables, excluding gender. RESULTS 4,980 propensity-score matched pairs were identified. In the matched analysis, women experienced higher rates of postoperative stroke (1.9% vs. 1.2%; p = 0.008), prolonged ventilation (13.3% vs. 10.0%, p < 0.001), and 30-day mortality (2.6% vs. 1.8%; p = 0.01). Rates of FTR following stroke (p = 0.36), renal failure (p = 0.11), reoperation (p = 0.86), and prolonged ventilation (p = 0.48) were not statistically significant between female and male patients. CONCLUSIONS Women who underwent isolated, non-emergent CABG had statistically similar frequencies of FTR compared to their male counterparts despite experiencing greater rates of morbidity and mortality. Further efforts to narrow the gender outcome gap after CABG should focus on preoperative and intraoperative phases of care instead of postoperative management.
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Affiliation(s)
- William W Qu
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine.
| | - Jane W Wei
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health
| | - Jose N Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health
| | - William B Keeling
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine
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12
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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.
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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
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Chiew KL, Sundaresan P, Jalaludin B, Chong S, Vinod SK. Quality indicators in lung cancer: a review and analysis. BMJ Open Qual 2021; 10:bmjoq-2020-001268. [PMID: 34344690 PMCID: PMC8336169 DOI: 10.1136/bmjoq-2020-001268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 07/25/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Kim-Lin Chiew
- Macarthur Cancer Therapy Centre, South Western Sydney Cancer Service, Campbelltown, New South Wales, Australia .,South Western Sydney Clinical School, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
| | - Puma Sundaresan
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Bin Jalaludin
- Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District, Liverpool, New South Wales, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Shanley Chong
- Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District, Liverpool, New South Wales, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Shalini K Vinod
- South Western Sydney Clinical School, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia.,Liverpool Cancer Therapy Centre, South Western Sydney Cancer Service, Liverpool, New South Wales, Australia
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Yao L, Luo J, Liu L, Wu Q, Zhou R, Li L, Zhang C. Risk factors for postoperative pneumonia and prognosis in lung cancer patients after surgery: A retrospective study. Medicine (Baltimore) 2021; 100:e25295. [PMID: 33787617 PMCID: PMC8021381 DOI: 10.1097/md.0000000000025295] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 03/07/2021] [Indexed: 01/04/2023] Open
Abstract
Postoperative pneumonia (POP) is one of the most frequent complications following lung surgery. The aim of this study was to identify the risk factors for developing POP and the prognostic factors in lung cancer patients after lung resection.We performed a retrospective review of 726 patients who underwent surgery for stages I-III lung cancer at a single institution between August 2017 and July 2018 by conducting logistic regression analysis of the risk factors for POP. The Cox risk model was used to analyze the factors influencing the survival of patients with lung cancer.We identified 112 patients with POP. Important risk factors for POP included smoking (odds ratio [OR], 2.672; 95% confidence interval [CI], 1.586-4.503; P < .001), diffusing capacity for carbon monoxide (DLCO) (40-59 vs ≥80%, 4.328; 95% CI, 1.976-9.481; P < .001, <40 vs ≥80%, 4.725; 95% CI, 1.352-16.514; P = .015), and the acute physiology and chronic health evaluation (APACHE) II score (OR, 2.304; 95% CI, 1.382-3.842; P = .001). In the Cox risk model, we observed that age (hazard ratios (HR), 1.633; 95% CI, 1.062-2.513; P = .026), smoking (HR, 1.670; 95% CI, 1.027-2.716; P = .039), POP (HR, 1.637; 95% CI, 1.030-2.600; P = .037), etc were predictor variables for patient survival among the factors examined in this study.The risk factors for POP and the predictive factors affecting overall survival (OS) should be taken into account for effective management of patients with lung cancer undergoing surgery.
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Lin DQ, Zhu JG, Xu XH, Xiao K, Wen XQ, Zheng QF, Zhou YH, Cai XY. Chronic Progression of Lung Cancer Recurrence After Surgery: Warning Role of Postoperative Pneumonia. Cancer Manag Res 2021; 13:7387-7398. [PMID: 34602824 PMCID: PMC8481098 DOI: 10.2147/cmar.s327646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/11/2021] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The association between the process of postoperative pneumonia and lung cancer recurrence remains elusive in lung cancer surgery. Herein, the association between postoperative pneumonia and lung cancer recurrence was investigated, emphasizing the warning role of postoperative specific pneumonia in primary lung cancer resection patients. METHODS The occurrence of postoperative pneumonia was assessed in 4-6 months (PPFS), 7-12 months (PPST), and lung cancer recurrence within 1 year (LRO) in 332 patients. The primary outcome was the development of PPST and LRO according to PPFS occurrence. The relevant risk factors of PPFS, PPST, and LRO were identified through multivariable regression analysis. RESULTS During follow-up, 151 (45.48%) participants experienced PPFS. Irrespective of the existing postoperative pneumonia in 1-3 months (PPOT), PPFS significantly increased the risk of PPST (P < 0.01) and LRO (P < 0.01), and persistent PPST further increased the risk of LRO (P < 0.001). The generalized estimating equation identified chemotherapy as an independent risk factor for PPFS and PPST. CONCLUSION PPFS was associated with the increased risk of PPST and LRO. Postoperative pulmonary inflammation assessed 4 months post-surgery also significantly influenced LRO development, indicating a need for close follow-up of lung inflammatory conditions to improve patient outcomes.
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Affiliation(s)
- Dong-qi Lin
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Jin-guo Zhu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Xiao-hua Xu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Ke Xiao
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Xu-qing Wen
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Qi-fa Zheng
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, People’s Republic of China
| | - Yu-hua Zhou
- Nursing Department, Shantou Central Hospital, Shantou, Guangdong, People’s Republic of China
| | - Xin-ying Cai
- Clinical Research Center, Shantou Central Hospital, Shantou, Guangdong, People’s Republic of China
- Correspondence: Xin-ying Cai Clinical Research Center, Shantou Central Hospital, Wai-ma Road 114, Shantou, Guangdong, People’s Republic of ChinaTel +86 754-88903584Fax +86 754-88548117 Email
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Kim S, Balmert L, Raval MV, Johnson EK, Abdullah F, Chu DI. Association of number and type of serious complications with failure to rescue in children undergoing surgery: A NSQIP-Pediatric analysis. J Pediatr Surg 2020; 55:2584-2590. [PMID: 32430105 DOI: 10.1016/j.jpedsurg.2020.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/23/2020] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Failure to rescue (FTR) represents death after a serious complication. This study aims to determine the FTR rate in a pediatric surgical population, and if number (1 or 2+) and type of serious complications are associated with FTR. METHODS A secondary analysis was performed using the National Surgical Quality Improvement Program Pediatric database from 2012 to 2016. Primary and secondary exposures of interest were number (1 or 2+) and type of serious complications, respectively. Propensity score analysis adjusted for baseline covariates. Primary outcome was FTR. RESULTS Of 36,167 children with ≥1 serious complication, there were 851 deaths resulting in a FTR rate of 2.4%. Having 2+ serious complications was associated with higher adjusted odds of FTR (OR 1.77, 95% CI 1.52-2.08, p < 0.0001). Among those who had one complication, the type of serious complication was significantly associated with FTR. When type of initial serious complication was adjusted, number of serious complications continued to be strongly associated with FTR (OR 2.00, 95% CI 1.67-2.38, p < 0.0001). CONCLUSIONS FTR rate within a large, diverse, multi-specialty pediatric surgical population was 2.4%. Both number and type of postoperative complications were associated with FTR. These findings may facilitate early recognition of high-risk patients and identify quality targets for pediatric surgical centers. LEVEL OF EVIDENCE Retrospective study (secondary analysis), Level II.
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Affiliation(s)
- Soojin Kim
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada; Department of Urologic Sciences, British Columbia Children's Hospital, Vancouver, BC, Canada.
| | - Lauren Balmert
- Biostatistics Collaboration Center, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mehul V Raval
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Fizan Abdullah
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David I Chu
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Surgery, Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Donington JS, Paulus R, Edelman MJ, Krasna MJ, Le QT, Suntharalingam M, Loo BW, Hu C, Bradley JD. Resection following concurrent chemotherapy and high-dose radiation for stage IIIA non-small cell lung cancer. J Thorac Cardiovasc Surg 2020; 160:1331-1345.e1. [PMID: 32798022 PMCID: PMC7702021 DOI: 10.1016/j.jtcvs.2020.03.171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Concern exists regarding surgery after thoracic radiation. We aimed to assess early results of anatomic resection following induction therapy with platinum-based chemotherapy and full-dose thoracic radiation for resectable N2+ stage IIIA non-small cell lung cancer. METHODS Two prospective trials were recently conducted by NRG Oncology in patients with resectable N2+ stage IIIA non-small cell lung cancer with the primary end point of mediastinal node sterilization following concurrent full-dose chemoradiotherapy (Radiation Therapy Oncology Group trials 0229 and 0839). All surgeons demonstrated postinduction resection expertise. Induction consisted of weekly carboplatin (area under the curve, 2.0) and paclitaxel (50 mg/m2) and concurrent thoracic radiation 60 Gy (0839)/61.2 Gy (0229) in 30 fractions. Patients in study 0839 were randomized 2:1 to weekly panitumumab + chemoradiotherapy or chemoradiotherapy alone during induction. Primary results were similar in all treatment arms and reported previously. Short-term surgical outcomes are reported here. RESULTS One hundred twenty-six patients enrolled; 93 (74%) had anatomic resection, 77 underwent lobectomy, and 16 underwent extended resection. Microscopically margin-negative resections occurred in 85 (91%). Fourteen (15%) resections were attempted minimally invasively, including 2 converted without event. Grade 3 or 4 surgical adverse events were reported in 26 (28%), 30-day mortality in 4 (4%) and 90-day mortality in 5 (5%). Patients undergoing extended resection experienced similar rates of grade 3 or 4 adverse events (odds ratio, 0.95; 95% confidence interval, 0.42-3.8) but higher 30-day (1.3% vs 18.8%) (odds ratio, 17.54; 95% confidence interval, 1.75-181.8) and 90-day mortality (2.6% vs 18.8%) (odds ratio, 8.65; 95% confidence interval, 1.3-56.9). CONCLUSIONS Lobectomy was performed safely following full-dose concurrent chemoradiotherapy in these multi-institutional prospective trials; however, increased mortality was noted with extended resections.
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Affiliation(s)
- Jessica S Donington
- Department of Department of Surgery, University of Chicago Medicine and Biologic Sciences, Chicago, Ill.
| | - Rebecca Paulus
- Department of Department of Surgery, University of Chicago Medicine and Biologic Sciences, Chicago, Ill
| | - Martin J Edelman
- Division of Medical Oncology, Department of Medicine, University of Maryland Medical Center, Baltimore, Md
| | - Mark J Krasna
- Department of Surgery, Jersey Shore University Medical Center, Neptune City, NJ
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, Calif
| | - Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Md
| | - Billy W Loo
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, Calif
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pa; Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Ga
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Ma LW, Kaufman EJ, Hatchimonji JS, Xiong R, Scantling DR, Stoecker JB, Holena DN. The Impact of Socially Stigmatized Preexisting Conditions on Outcomes After Injury. J Surg Res 2020; 257:511-518. [PMID: 32916504 DOI: 10.1016/j.jss.2020.08.005] [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: 02/28/2020] [Revised: 07/16/2020] [Accepted: 08/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Socially stigmatized preexisting conditions (SSPECs), including alcohol use disorder (AUD), drug use disorder (DUD), and major psychiatric illness, may lead to provider minimization of patient symptoms and have been associated with negative outcomes. However, the impact of SSPECs on failure to rescue (FTR) has not been evaluated. We hypothesized that SSPEC patients would have increased probability of complications, mortality, and FTR. MATERIALS AND METHODS We performed a retrospective analysis of the 2015 National Trauma Data Bank, including patients aged ≥18 y and excluding burn victims, patients with Injury Severity Score <9, and non-SSPEC patients with drug or alcohol withdrawal. We defined SSPECs using the National Trauma Data Bank's comorbidity recording codes for AUD, DUD, and major psychiatric illnesses. We built multivariable logistic regression models to determine the relationships between SSPECs and complications, mortality, and FTR. RESULTS We included 365,801 patients (62% male, 76% White, median age 56 y [interquartile range 35-74], median Injury Severity Score 10 [interquartile range 9-17]). After adjusting for patient and injury characteristics, SSPEC patients were more likely to have complications (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.70-1.79), less likely to die (OR 0.43, CI 0.38-0.48), and less likely to have FTR (OR 0.34, CI 0.26-0.43). SSPEC patients had a significantly higher complication rate (12.4% versus 7.2%; P < 0.001). After excluding drug or alcohol withdrawal, the complication rate remained significantly higher for SSPEC patients (9.3% versus 7.2%; P < 0.001). CONCLUSIONS Although SSPEC patients have lower odds of mortality and FTR, they are at higher probability of complications after injury. Further investigation into the causality behind the higher complications despite lower mortality and FTR is warranted.
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Affiliation(s)
- Lucy W Ma
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Elinore J Kaufman
- The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruiying Xiong
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dane R Scantling
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordan B Stoecker
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel N Holena
- The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Baum P, Diers J, Haag J, Klotz L, Eichhorn F, Eichhorn M, Wiegering A, Winter H. Nationwide effect of high procedure volume in lung cancer surgery on in-house mortality in Germany. Lung Cancer 2020; 149:78-83. [PMID: 32980612 DOI: 10.1016/j.lungcan.2020.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The literature reports that hospital caseload volume is associated with survival for lung cancer resection. The aim of this study is to explore this association in a nationwide setting according to individual hospital caseload volume of every inpatient case in Germany. METHODS This retrospective analysis of nationwide hospital discharge data in Germany between 2014 and 2017 comprises 121,837 patients of whom 36,051 (29.6 %) underwent surgical anatomic resection. Hospital volumes were defined according to the number of patient resections for lung cancer in each hospital, and patients were categorized into 5 quintiles based on hospital caseload volume. A logistic regression model accounting for death according to sex, age, comorbidity, and resection volume was calculated, and effect modification was evaluated using the Mantel-Haenszel method. RESULTS In-house mortality ranged from 2.1 % in very high-volume centers to 4.0 % in very low-volume hospitals (p < 0.01). In multivariable logistic regression analysis, lower in-house mortality in very high-volume centers performing > 140 anatomic lung resections per year was observed compared with very low-volume centers performing < 27 resections (OR, 0.58; CI, 0.46 to 0.72; p < 0.01). This relationship also held for failure to rescue rates (12.9 vs 16.7 %, p = 0.01), although a greater number of extended resections were performed (23.1 vs. 14.8 %, p < 0.01). CONCLUSIONS Hospitals with high volumes of lung cancer resections performed surgery with a higher ratio of complex procedures and achieved reduced in-house mortality, fewer complications, and lower failure to rescue rates.
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Affiliation(s)
- Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany.
| | - Johannes Diers
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Straße 6, 97080 Wuerzburg, Germany.
| | - Johannes Haag
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany.
| | - Laura Klotz
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
| | - Florian Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
| | - Martin Eichhorn
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Straße 6, 97080 Wuerzburg, Germany.
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany.
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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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Surgical results and prognosis of lung cancer in elderly Japanese patients aged over 85 years: comparison with patients aged 80-84 years. Gen Thorac Cardiovasc Surg 2020; 69:67-75. [PMID: 32627148 DOI: 10.1007/s11748-020-01426-y] [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: 05/12/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE With the increase in lung cancer patients over 80 years of age, lobectomy with mediastinal lymph node dissection is often performed in patients in a good general condition. However, the age limit for this procedure has not yet been determined. In this study, we examined the safety, therapeutic results, and prognosis of surgical treatment for lung cancer patients over 85 years of age. METHODS Among the 4446 lung cancer patients who underwent surgery at our hospital from January 1997 to March 2019, we assessed 320 patients (7.2%, Group A, aged 80-84 years) and 74 patients (1.7%, Group B, aged over 85 years). RESULTS The median age of the patients in Group B was 86 years. Compared to Group A, Group B had significantly more patients with a history of ischemic heart disease, lower pack-year smoking, and lobectomy and lobectomy less resection (reduced surgery), and a shorter operation time (P < 0.05). There was no significant difference between the two groups in terms of postoperative complications. There was no significant difference in survival rate and prognosis between the two groups, and the 2-, 3-, and 5-year survival rates were 79.0%, 74.7%, and 53.6%, respectively, in Group B. In Group B sex (female) and early stage of cancer were independent prognostic factors of non-small cell lung cancer (stage I). CONCLUSIONS In a limited number of patients, surgical resection in patients aged over 85 years was safely performed, and the survival of these patients was comparable to those aged 80-84 years.
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Hadaya J, Dobaria V, Aguayo E, Mandelbaum A, Sanaiha Y, Revels SL, Benharash P. Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States. Ann Thorac Surg 2020; 110:1874-1881. [PMID: 32553767 DOI: 10.1016/j.athoracsur.2020.04.115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/06/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. METHODS We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. RESULTS During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. CONCLUSIONS High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.
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Affiliation(s)
- Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ava Mandelbaum
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sha'Shonda L Revels
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California.
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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.
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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
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Failure to rescue in surgical patients: A review for acute care surgeons. J Trauma Acute Care Surg 2020; 87:699-706. [PMID: 31090684 DOI: 10.1097/ta.0000000000002365] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Gómez-Hernández MT, Novoa NM, Varela G, Jiménez MF. Quality Control in Anatomical Lung Resection. Major Postoperative Complications vs Failure to Rescue. Arch Bronconeumol 2020; 57:251-255. [PMID: 31982251 DOI: 10.1016/j.arbres.2019.12.009] [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: 08/22/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Failure to rescue (FTR) is defined by the number of deaths among patients experiencing major complications after surgery. In this report we analyze FTR and apply a cumulative sum control chart (CUSUM) methodology for monitoring performance in a large series of operated lung carcinoma patients. METHODS Prospectively stored records of cases undergoing anatomical lung resection in one center were reviewed. Postoperative adverse events were coded and included as a binary variable (major, or minor complications). The occurrence of 30-day mortality was also recorded. Patients dying after suffering major complications were considered as FTR. Risk-adjusted CUSUM graphs using EuroLung1 and 2 variables were constructed for major complications and FTR. Points of plateauing or trend inversion were checked to detect intentional or non-adverted changes in the process of care. RESULTS 2237 cases included. 9.1% cases suffered major complications. The number of cases considered as failures to rescuing was 46 (2.1% of the total series and 22.5% of cases having major complications). The predictive performance of EuroLung1 and 2 models was as follows: EuroLung1 (major morbidity) C-index 0.70 (95%CI: 0.66-0.73); EuroLung2 (applied to FTR) C-index 0.81 (95%CI: 0.750.87). CUSUM graphs depicted improvement in rescuing complicated patients after case 330 but no improvement in the rate of non-complicated cases until case 720. CONCLUSIONS FTR offers a complementary view to classical outcomes for quality assessment in Thoracic Surgery. Our study also shows how the analysis of FTR on time series can be applied to evaluate changes in team performance along time.
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Affiliation(s)
| | - Nuria M Novoa
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Gonzalo Varela
- Salamanca Institute of Biomedical Research (IBSAL), Spain.
| | - Marcelo F Jiménez
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
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Smeltzer MP, Faris NR, Ray MA, Osarogiagbon RU. Association of Pathologic Nodal Staging Quality With Survival Among Patients With Non-Small Cell Lung Cancer After Resection With Curative Intent. JAMA Oncol 2019; 4:80-87. [PMID: 28973110 DOI: 10.1001/jamaoncol.2017.2993] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Pathologic nodal stage is the most significant prognostic factor in resectable non-small cell lung cancer (NSCLC). The International Association for the Study of Lung Cancer NSCLC staging project revealed intercontinental differences in N category-stratified survival. These differences may indicate differences not only in cancer biology but also in the thoroughness of the nodal examination. Objective To determine whether survival was affected by sequentially more stringent definitions of pN staging quality in a cohort of patients with NSCLC after resection with curative intent. Design This observational study used the Mid-South Quality of Surgical Resection cohort, a population-based database of lung cancer resections with curative intent. A total of 2047 consecutive patients who underwent surgical resection at 11 hospitals with at least 5 annual lung cancer resections in 4 contiguous US Dartmouth hospital referral regions in northern Mississippi, eastern Arkansas, and western Tennessee (>90% of the eligible population) were included. Resections were performed from January 1, 2009, through January 25, 2016. Survival was evaluated with the Kaplan-Meier method and Cox proportional hazards models. Exposures Eight sequentially more stringent pN staging quality strata included the following: all patients (group 1); those with complete resections only (group 2); those with examination of at least 1 mediastinal lymph node (group 3); those with examination of at least 10 lymph nodes (group 4); those with examination of at least 3 hilar or intrapulmonary and at least 3 mediastinal lymph nodes (group 5); those with examination of at least 10 lymph nodes, including at least 1 mediastinal lymph node (group 6); those with examination of at least 1 hilar or intrapulmonary and at least 3 mediastinal nodal stations (group 7); and those with examination of at least 1 hilar or intrapulmonary lymph node, at least 10 total lymph nodes, and at least 3 mediastinal nodal stations (group 8). Main Outcomes and Measures N category-stratified overall survival. Results Of the total 2047 patients (1046 men [51.1%] and 1001 women [48.9%]; mean [SD] age, 67.0 [9.6] years) included in the analysis, the eligible analysis population ranged from 541 to 2047, depending on stringency. Sequential improvement in the N category-stratified 5-year survival of pN0 and pN1 tumors was found from the least stringent group (0.63 [95% CI, 0.59-0.66] for pN0 vs 0.46 [95% CI, 0.38-0.54] for pN1) to the most stringent group (0.71 [95% CI, 0.60-0.79] for pN0 vs 0.60 [95% CI, 0.43-0.73] for pN1). The pN1 cohorts with 3 or more mediastinal nodal stations examined had the most striking survival improvements. More stringently defined mediastinal nodal examination was associated with better separation in survival curves between patients with pN1 and pN2 tumors. Conclusions and Relevance The prognostic value of pN stratification depends on the thoroughness of examination. Differences in thoroughness of nodal staging may explain a large proportion of intercontinental survival differences. More thorough nodal examination practice must be disseminated to improve the prognostic value of the TNM staging system. Future updates of the TNM staging system should incorporate more quality restraints.
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Affiliation(s)
- Matthew P Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Nicholas R Faris
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Meredith A Ray
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
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Failure to rescue as a center-level metric in pediatric trauma. Surgery 2019; 165:1116-1121. [PMID: 31072669 DOI: 10.1016/j.surg.2019.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/25/2019] [Accepted: 03/06/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Failure to rescue is defined as death after a complication and has been used to evaluate quality of care in adult trauma patients, but there are no published studies on failure to rescue in pediatric trauma. The aim of this study was to define the relationship among rates of mortality, complications, and failure to rescue at centers caring for pediatric (<18 years of age) trauma patients in a nationally representative database. METHODS We performed a retrospective cohort study of the 2015 and 2016 National Trauma Data Bank. We included patients <18 years of age with an Injury Severity Score of ≥9. We excluded centers with <50 pediatric patients or that reported no complications. We calculated the complication, failure to rescue, mortality, and precedence rates by center and divided centers into tertiles of mortality. We compared complication and failure-to-rescue rates between high and low tertiles of mortality using the Kruskal-Wallis test. RESULTS Of 62,190 patients from 284 centers, 2,204 patients had at least 1 complication for an overall complication rate of 4% (center level 0%-15%), and 120 patients died after a complication for an overall failure-to-rescue rate of 5% (center level 0%-67%). High-mortality centers had both higher failure-to-rescue rates (10% vs 0.6%, P < .001) and higher complication rates (5% vs 4%, P = .001) than lower-mortality hospitals. The overall precedence rate was 15% with a median rate of 0% (interquartile range 0%-25%). CONCLUSION Both complication and failure-to-rescue rates are low in the pediatric injury population, but both complication and failure-to-rescue rates are higher at higher-mortality centers. The low overall complication rates and precedence rates likely limit the utility of failure to rescue as a valid center-level metric in this population, but further investigation into individual failure-to-rescue cases may reveal important opportunities for improvement.
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Shinohara S, Kobayashi K, Kasahara C, Onitsuka T, Matsuo M, Nakagawa M, Sugaya M. Long-term impact of complications after lung resections in non-small cell lung cancer. J Thorac Dis 2019; 11:2024-2033. [PMID: 31285895 DOI: 10.21037/jtd.2019.04.91] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Postoperative complications after lung resection are common and fatal. The immediate effects of postoperative complications are related to poor prognosis; however, the long-term effects have not been assessed. Thus, this investigation aimed to clarify the long-term effects of postoperative complications among patients with resected non-small cell lung cancer (NSCLC). Methods This retrospective cohort study included 345 patients with resected NSCLC from a single institution. We used the Clavien-Dindo classification to classify postoperative complications. Postoperative complications were defined as complications with a Clavien-Dindo grade of ≥2. The Kaplan-Meier method was used to evaluate survival. Prognostic factors were analyzed using a Cox proportional hazard model. Results There were 110 patients with postoperative complications (31.9%). The 5-year overall survival (OS), recurrence-free survival (RFS), and cause-specific survival (CSS) rates were significantly lower in patients with complications than in those without complications [OS: 66.1%, 95% confidence interval (CI): 55.4-74.8% vs. 78.0%, 95% CI: 71.8-83.1%, P=0.001; RFS: 48.8%, 95% CI: 38.1-58.7% vs. 70.8%, 95% CI: 64.2-76.4%, P<0.001; CSS: 82.7%, 95% CI: 72.8-89.3% vs. 88.2%, 95% CI: 82.8-92.0%, P=0.005]. The 5-year OS was lower in the pulmonary complication group than in the other complication group (58.1%, 95% CI: 40.0-72.4% vs. 70.5%, 95% CI: 56.6-80.6%, P=0.033). Postoperative complications were indicated as a poor prognostic factor for OS (hazard ratio, 1.67; 95% CI: 1.11-2.53; P=0.002). Conclusions Postoperative complications were associated with unfavorable OS because of the worse prognosis of postoperative pulmonary complications.
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Affiliation(s)
- Shuichi Shinohara
- Department of Thoracic Surgery, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Kenichi Kobayashi
- Department of Thoracic Surgery, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Chinatsu Kasahara
- Department of Pulmonary and Respiratory Medicine, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Takamitsu Onitsuka
- Department of Thoracic Surgery, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Masaki Matsuo
- Department of Pulmonary and Respiratory Medicine, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Makoto Nakagawa
- Department of Thoracic Surgery, Chubu Rosai Hospital, Nagoya, Aichi, Japan
| | - Masakazu Sugaya
- Department of Thoracic Surgery, Chubu Rosai Hospital, Nagoya, Aichi, Japan
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Impact of Postoperative Pneumonia Developing After Discharge on Long-Term Follow-up for Resected Lung Cancer. World J Surg 2019; 42:3979-3987. [PMID: 29946786 DOI: 10.1007/s00268-018-4727-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postoperative nosocomial pneumonia is a common immediate complication following lung resection. However, the incidence and mortality of pneumonia developing after discharge (PDAD) for lung-resected patients during long-term observation remain unclear. The aim of this study was to investigate the clinical features of PDAD in patients with resected lung cancer. METHODS We conducted a retrospective cohort study of 357 consecutive patients with lung cancer who had undergone lung resection at a single institution, between April 2007 and December 2016. The clinical characteristics, pathological features, and overall survival were analyzed. Propensity score matched analysis was used for the evaluation of overall survival between PDAD and non-PDAD groups with adjusted relevant confounding factors. RESULTS PDAD was observed in 66 patients (18.5%). The cumulative incidence of PDAD was 14.9% at 3 years and 21.6% at 5 years. Mortality of PDAD was 30.3%. Multivariate analysis demonstrated that the risk factors for PDAD were age (OR 1.07; P = 0.005), oral steroid use (OR 5.62; P = 0.046), and lower-lobe resection (OR 1.87; P = 0.034). After propensity score matching, 52 patients with PDAD and 52 patients without it were compared. The incidence of PDAD resulted in a worse 5-year overall survival (56.1 vs. 69.3%; P = 0.024). The Cox proportional hazards model indicated that PDAD was associated with poor overall survival (HR 1.99, P = 0.027). CONCLUSIONS Our findings revealed a high incidence and mortality of PDAD among patients who had undergone lung resection with long-term follow-up. Therefore, PDAD could be associated with poorer overall survival.
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Ulrich CM, Himbert C, Boucher K, Wetter DW, Hess R, Kim J, Lundberg K, Ligibel JA, Barnes CA, Rushton B, Marcus R, Finlayson SRG, LaStayo PC, Varghese TK. Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: rationale and design of the PEP study trial. BMJ Open 2018; 8:e024672. [PMID: 30559162 PMCID: PMC6303592 DOI: 10.1136/bmjopen-2018-024672] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/05/2018] [Accepted: 09/26/2018] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Lung cancer is a significant burden on societies worldwide, and the most common cause of death in patients with cancer overall. Exercise intervention studies in patients with lung cancer have consistently shown benefits with respect to physical and emotional functioning. However, to date, exercise training has not been consistently implemented into clinical practice given that interventions have been costly and not aligned with clinical care. METHODS/DESIGN The Precision-Exercise-Prescription (PEP) study is a prospective randomised controlled trial comparing the effectiveness and feasibility of a personalised intervention exercise programme among patients with lung cancer undergoing surgery. Two-hundred patients who are diagnosed with stage primary or secondary lung cancer and are eligible to undergo surgical treatment at Huntsman Cancer Institute comprise the target population. Patients are randomised to either the (1) outpatient precision-exercise intervention group or (2) delayed intervention group. The intervention approach uses Motivation and Problem Solving, a hybrid behavioural treatment based on motivational interviewing and practical problem solving. The dosage of the exercise intervention is personalised based on the individual's Activity Measure for Post-Acute-Care outpatient basic mobility score, and incorporates four exercise modes: mobility, callisthenics, aerobic and resistance. Exercise is implemented by physical therapists at study visits from presurgery until 6 months postsurgery. The primary endpoint is the level of physical function assessed by 6 min walk distance at 2 months postsurgery. Secondary outcomes include patient-reported outcomes (eg, quality of life, fatigue and self-efficacy) and other clinical outcomes, including length of stay, complications, readmission, pulmonary function and treatment-related costs up to 6 months postsurgery. ETHICS/DISSEMINATION The PEP study will test the clinical effectiveness and feasibility of a personalised exercise intervention in patients with lung cancer undergoing surgery. Outcomes of this clinical trial will be presented at national and international conferences and symposia and will be published in international, peer-reviewed journals. Ethics approval was obtained at the University of Utah (IRB 00104671). TRIAL REGISTRATION NUMBER NCT03306992.
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Affiliation(s)
- Cornelia M Ulrich
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Caroline Himbert
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Kenneth Boucher
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - David W Wetter
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Rachel Hess
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
- Division of General Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jaewhan Kim
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Health and Kinesiology, University of Utah, Salt Lake City, Utah, USA
| | - Kelly Lundberg
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, USA
| | - Jennifer A Ligibel
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Barnes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | | | - Robin Marcus
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | | | - Paul C LaStayo
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah, USA
| | - Thomas K Varghese
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah, USA
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Smith ME, Wells EE, Friese CR, Krein SL, Ghaferi AA. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood) 2018; 37:1870-1876. [PMID: 30395494 PMCID: PMC7033741 DOI: 10.1377/hlthaff.2018.0704] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Failure to rescue-mortality following a major surgical complication-is a key driver of variation in postoperative mortality. However, little is known about the impact of interpersonal and organizational dynamics, or microsystem factors, on failure to rescue. In a qualitative study of providers from hospitals with high and low rescue rates, we identified five key factors that providers believe influence the successful rescue of surgical patients: teamwork, action taking, psychological safety, recognition of complications, and communication. Near-uniform agreement existed on two targets for improvement: delayed recognition of developing complications and poor interprofessional communication and inability to express clinical concerns. To improve perioperative outcomes, hospitals and payers should shift their attention to improving early detection and effective communication of major complications.
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Affiliation(s)
- Margaret E Smith
- Margaret E. Smith ( ) is a general surgery resident in the Department of Surgery, University of Michigan Medical School, in Ann Arbor
| | - Emily E Wells
- Emily E. Wells is a clinical research coordinator in the Department of Surgery, University of Michigan Medical School
| | - Christopher R Friese
- Christopher R. Friese is the Elizabeth Tone Hosmer Professor of Nursing in the University of Michigan School of Nursing and a professor of health management and policy in the University of Michigan School of Public Health
| | - Sarah L Krein
- Sarah L. Krein is a research career scientist in the Center for Clinical Management Research, Veterans Affairs (VA) Ann Arbor Healthcare System, and a research professor in the Department of Internal Medicine, University of Michigan Medical School
| | - Amir A Ghaferi
- Amir A. Ghaferi is an associate professor in the Department of Surgery, University of Michigan Medical School, and an associate professor in the University of Michigan Stephen M. Ross School of Business
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Differential effects of operative complications on survival after surgery for primary lung cancer. J Thorac Cardiovasc Surg 2018; 155:1254-1264.e1. [DOI: 10.1016/j.jtcvs.2017.09.149] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/30/2017] [Accepted: 09/09/2017] [Indexed: 02/04/2023]
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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.
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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.
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Pompili C, Shargall Y, Decaluwe H, Moons J, Chari M, Brunelli A. Risk-adjusted performance evaluation in three academic thoracic surgery units using the Eurolung risk models†. Eur J Cardiothorac Surg 2018; 54:122-126. [DOI: 10.1093/ejcts/ezx483] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/08/2017] [Indexed: 12/25/2022] Open
Affiliation(s)
- Cecilia Pompili
- Section of Patient Centred Outcomes Research, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Yaron Shargall
- Department of Surgery, St. Joseph’s Healthcare, McMaster University, Hamilton, CA, USA
| | - Herbert Decaluwe
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Madhu Chari
- Department of Surgery, St. Joseph’s Healthcare, McMaster University, Hamilton, CA, USA
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Kuckelman J, Cuadrado DG. Care of the Postoperative Pulmonary Resection Patient. SURGICAL CRITICAL CARE THERAPY 2018. [PMCID: PMC7120963 DOI: 10.1007/978-3-319-71712-8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.
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Brandt WS, Isbell JM, Jones DR. Defining quality in the surgical care of lung cancer patients. J Thorac Cardiovasc Surg 2017; 154:1397-1403. [PMID: 28676186 DOI: 10.1016/j.jtcvs.2017.05.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 05/17/2017] [Accepted: 05/28/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Whitney S Brandt
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James M Isbell
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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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.
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Affiliation(s)
- Farhood Farjah
- Division of Cardiothoracic Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356310, Seattle, WA 98195, USA.
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Osarogiagbon RU, Ray MA, Faris NR, Smeltzer MP, Fehnel C, Houston-Harris C, Signore RS, McHugh LM, Levy P, Wiggins L, Sachdev V, Robbins ET. Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria. Ann Thorac Surg 2017; 103:1557-1565. [PMID: 28366464 DOI: 10.1016/j.athoracsur.2017.01.098] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/23/2017] [Accepted: 01/30/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small cell lung cancer recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of three or more mediastinal nodal stations. We examined the survival impact of these criteria. METHODS A population-based observational study was done using patient-level data from all curative-intent, non-small cell lung cancer resections from 2004 to 2013 at 11 institutions in four contiguous Dartmouth Hospital referral regions in three US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines. RESULTS Of 2,429 eligible resections, 91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria; however, there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p < 0.001). Compared with patients whose surgery missed one or more criteria, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59 to 0.86, p < 0.001). Margin status and the nodal staging criteria were most strongly linked with survival. CONCLUSIONS Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the United States. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in non-small cell lung cancer care.
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Affiliation(s)
| | - Meredith A Ray
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Nicholas R Faris
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Matthew P Smeltzer
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee; Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Carrie Fehnel
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Cheryl Houston-Harris
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Raymond S Signore
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Laura M McHugh
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Paul Levy
- North East Arkansas Baptist Memorial Hospital, Jonesboro, Arkansas
| | - Lynn Wiggins
- St. Bernard's Regional Medical Center, Jonesboro, Arkansas
| | | | - Edward T Robbins
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
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Gaissert HA, Fernandez FG, Allen MS, Burfeind WR, Block MI, Donahue JM, Mitchell JD, Schipper PH, Onaitis MW, Kosinski AS, Jacobs JP, Shahian DM, Kozower BD, Edwards FH, Conrad EA, Patterson GA. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2016 Update on Research. Ann Thorac Surg 2016; 102:1444-1451. [DOI: 10.1016/j.athoracsur.2016.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/01/2016] [Accepted: 09/08/2016] [Indexed: 11/17/2022]
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Failure-to-rescue after injury is associated with preventability: The results of mortality panel review of failure-to-rescue cases in trauma. Surgery 2016; 161:782-790. [PMID: 27788924 DOI: 10.1016/j.surg.2016.08.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/02/2016] [Accepted: 08/05/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Failure-to-rescue is defined as the conditional probability of death after a complication, and the failure-to-rescue rate reflects a center's ability to successfully "rescue" patients after complications. The validity of the failure-to-rescue rate as a quality measure is dependent on the preventability of death and the appropriateness of this measure for use in the trauma population is untested. We sought to evaluate the relationship between preventability and failure-to-rescue in trauma. METHODS All adjudications from a mortality review panel at an academic level I trauma center from 2005-2015 were merged with registry data for the same time period. The preventability of each death was determined by panel consensus as part of peer review. Failure-to-rescue deaths were defined as those occurring after any registry-defined complication. Univariate and multivariate logistic regression models between failure-to-rescue status and preventability were constructed and time to death was examined using survival time analyses. RESULTS Of 26,557 patients, 2,735 (10.5%) had a complication, of whom 359 died for a failure-to-rescue rate of 13.2%. Of failure-to-rescue deaths, 272 (75.6%) were judged to be non-preventable, 65 (18.1%) were judged potentially preventable, and 22 (6.1%) were judged to be preventable by peer review. After adjusting for other patient factors, there remained a strong association between failure-to-rescue status and potentially preventable (odds ratio 2.32, 95% confidence interval, 1.47-3.66) and preventable (odds ratio 14.84, 95% confidence interval, 3.30-66.71) judgment. CONCLUSION Despite a strong association between failure-to-rescue status and preventability adjudication, only a minority of deaths meeting the definition of failure to rescue were judged to be preventable or potentially preventable. Revision of the failure-to-rescue metric before use in trauma care benchmarking is warranted.
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Edwards FH, Ferraris VA, Kurlansky PA, Lobdell KW, He X, O’Brien SM, Furnary AP, Rankin JS, Vassileva CM, Fazzalari FL, Magee MJ, Badhwar V, Xian Y, Jacobs JP, Wyler von Ballmoos MC, Shahian DM. Failure to Rescue Rates After Coronary Artery Bypass Grafting: An Analysis From The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2016; 102:458-64. [DOI: 10.1016/j.athoracsur.2016.04.051] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/17/2016] [Accepted: 04/18/2016] [Indexed: 12/21/2022]
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Age and preexisting conditions as risk factors for severe adverse events and failure to rescue after injury. J Surg Res 2016; 205:368-377. [PMID: 27664885 DOI: 10.1016/j.jss.2016.06.082] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/01/2016] [Accepted: 06/26/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Failure to rescue (FTR: the conditional probability of death after complication) has been studied in trauma cohorts, but the impact of age and preexisting conditions (PECs) on risk of FTR is not well known. We assessed the relationship between age and PECs on the risk of experiencing serious adverse events (SAEs) subsequent FTR in trauma patients with the hypothesis that increased comorbidity burden and age would be associated with increased FTR. MATERIALS AND METHODS We performed a retrospective cohort analysis at an urban level 1 trauma center in Pennsylvania. All patients aged ≥16 y with minimum Abbreviated Injury Scale score ≥2 from 2009 to 2013 were included. Univariate logistic regression models for SAE and FTR were developed using age, PECs, demographics, and injury physiology. Variables found to be associated with the end point of interest (P ≤ 0.2) in univariate analysis were included in separate multivariable logistic regression models for each outcome. RESULTS SAE occurred in 1136 of 7533 (15.1 %) patients meeting inclusion criteria (median age 42 [interquartile range 26-59], 53% African-American, 72% male, 79% blunt, median ISS 10 [interquartile range 5-17]). Of those who experienced an SAE, 129 of 1136 patients subsequently died (FTR = 11.4%). Development of SAE and FTR was associated with age ≥ 70 y (odds ratio 1.58-1.78, 95% confidence interval 1.13-2.82). Renal disease was the only preexisting condition associated with both SAE and FTR. CONCLUSIONS Trauma patients with renal disease are mostly at increased risk for both SAE and FTR, but other PECs associated with SAE are not necessarily those associated with FTR. Future interventions designed to reduce FTR events should target this high-risk cohort.
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Failure-to-rescue: An evolving quality metric. J Thorac Cardiovasc Surg 2015; 149:1247-8. [DOI: 10.1016/j.jtcvs.2015.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/02/2015] [Indexed: 12/21/2022]
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