A clinical audit in a multidisciplinary care path for thoracic surgery: An instrument for continuous quality improvement

Impact of a standardized protocol for chest tube management after VATS pulmonary resections on post-operative outcomes and complications

Chest tube management represents a major issue after lung surgery as no protocol is widely accepted and tube management is generally based on local or personal habits. Aim of this study is to evaluate the impact of a standardized protocol for chest tube management after pulmonary resections on the post-operative outcomes. We performed a single center retrospective analysis of all adult patients undergoing thoracoscopic pulmonary resection from January 2020 to December 2021. Starting from January 2021 a standardized protocol of chest tube management was applied after all procedures. Patients were divided into two groups according to the chest tube management strategy. he two groups had similar pre-operative characteristics and the extent of lung resection was comparable. Intervention group had significantly shorter time to chest tube removal (median 1 vs 3 days, p < 0.001) and post-operative length of stay (median 3 vs 4 days, p < 0.001). Despite earlier chest tube removal, there was not an increased incidence of post-removal complications. On multivariable analysis, the new chest drain management strategy was an independent predictor of earlier chest tube removal. A standardized protocol of chest tube management allows for an earlier chest tube removal and a shorter hospital stay, without an increase in post-operative complications.

Efficacy and safety of early chest tube removal after selective pulmonary resection with high-output drainage: A systematic review and meta-analysis

BACKGROUND

There is controversy over the drainage threshold for removal of chest tubes in the absence of significant air leakage after selective pulmonary resection.

METHODS

A comprehensive search of online databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, Ovid, Elsevier, Ebsco, and Wiley) and clinical trial registries (WHO-ICTRP and ClinicalTrials.gov) was performed to investigate the efficacy and safety of early chest tube removal with high-output drainage. Primary outcome (postoperative hospital day) and secondary outcomes (30-day complications, rate of thoracentesis, and chest tube placement) were extracted and synthesized. Subgroup analysis, meta-regression, and sensitivity analysis were used to explore the potential heterogeneity. Study quality was assessed with the Newcastle-Ottawa Scale, and evidence was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment by the online GRADEpro Guideline Development Tool.

RESULTS

Six cohort studies with a total of 1262 patients were included in the final analysis. The postoperative hospital stay in the high-output group was significantly shorter than in the conventional treatment group (weighted mean difference: -1.34 [-2.34 to -0.34] day, P = .009). While there was no significant difference between 2 groups in 30-day complications (relative ratio [RR]: 0.92 [0.77-1.11], P = .38), the rate of thoracentesis (RR: 1.93 [0.63-5.88], P = .25) and the rate of chest tube placement (RR: 1.00 [0.37-2.70], P = .99). According to the sensitivity analysis, the relative impacts of the 2 groups had already stabilized. Subgroup analysis revealed that postoperative hospital stay was modified by Newcastle-Ottawa Scale score. The online GRADEpro Guideline Development Tool presented very low quality of evidence for the available data.

CONCLUSIONS

This meta-analysis revealed that it is feasible and safe to remove a chest tube with high-output drainage after pulmonary resection for selected patients.

The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme

OBJECTIVES

Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL).

METHODS

We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores.

RESULTS

The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores.

CONCLUSIONS

ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.

Enhanced recovery after thoracic surgery: Systematic review and meta-analysis

ERATS decreased length of stay, postoperative complications, and readmission.

Feasibility, safety and outcomes of ambulation within 2 h postoperatively in patients with lung cancer undergoing thoracoscopic surgery

AIMS

The aims of this study were to evaluate the safety, feasibility and outcomes of ambulation within 2 h after thoracoscopic surgery in patients with lung cancer.

BACKGROUND

There are no consensus guidelines on the ideal time for early ambulation following thoracic surgery, although enhanced recovery programmes have been proposed since years.

METHODS

This non-randomized, concurrent-control study was conducted on patients who underwent thoracoscopic surgery between October 2020 and February 2021. Participants were assigned to either the observation group (ambulation within 2 h of extubation) or the control group (ambulation on the first postoperative day).

RESULTS

Of the 325 patients who were eligible, 227 were included in the study. Eighty-three per cent of patients were able to walk any distance within 2 h of extubation, and no adverse events occurred in patients. The length of hospital stay and time to first postoperative flatus were significantly shorter in the observation group than in the control group. There were no differences in the occurrence of postoperative complications and orthostatic hypotension, readmission rate and 6-min walk distance at discharge.

CONCLUSION

Ambulation within 2 h of extubation was safe and feasible and could lead to better recovery in patients with lung cancer undergoing thoracoscopic surgery.

The effect of the enhanced recovery after surgery program on lung cancer surgery: a systematic review and meta-analysis

BACKGROUND

Lung cancer is one of the most common causes of cancer-related death worldwide. The enhanced recovery after surgery (ERAS) program is an effective evidence-based multidisciplinary protocol of perioperative care. However, the roles of ERAS in lung cancer surgery remain unclear. This systematic review and meta-analysis aimed to investigate the short-term impact of the ERAS program on lung resection surgery, especially in relation to postoperative complications.

METHODS

A systematic literature search of PubMed, EMBASE, and the Cochrane Library databases until October 2020 was performed to identify the studies that implemented an ERAS program in lung cancer surgery. The studies were selected and subjected to data extraction by 2 reviewers independently, which was followed by quality assessment. A random effects model was used to calculate overall effect sizes. Risk ratio (RR), risk difference (RD), and standardized mean difference (SMD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. Subgroup analysis and sensitivity analysis were subsequently performed.

RESULTS

A total of 21 studies with 6,480 patients were included. The meta-analysis indicated that patients in the ERAS group had a significantly reduced risk of postoperative complications (RR =0.64; 95% CI: 0.52 to 0.78) and shortened postoperative length of stay (SMD=-1.58; 95% CI: -2.38 to -0.79) with a significant heterogeneity. Subgroup analysis showed that the risks of pulmonary (RR =0.58; 95% CI: 0.45 to 0.75), cardiovascular (RR =0.73; 95% CI: 0.59 to 0.89), urinary (RR =0.53; 95% CI: 0.32 to 0.88), and surgical complications (RR =0.64; 95% CI: 0.42 to 0.97) were significantly lower in the ERAS group. No significant reduction was found in the in-hospital mortality (RD =0.00; 95% CI: -0.01 to 0.00) and readmission rate (RR =1.00; 95% CI: 0.76 to 1.32). In the qualitative review, most of the evidence reported significantly decreased hospitalization costs in the ERAS group.

CONCLUSIONS

The implementation of an ERAS program for surgery of lung cancer can effectively reduce risks of postoperative complications, length of stay, and costs of patients who have undergone lung cancer surgery without compromising their safety.

Understanding how and why audits work in improving the quality of hospital care: A systematic realist review

BACKGROUND

Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care.

METHODS

A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context-mechanism-outcome configurations (CMOcs).

RESULTS

From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration.

CONCLUSIONS

This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts.

PROSPERO REGISTRATION

CRD42016039882.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Enhanced recovery after elective surgery for lung cancer patients: analysis of current pathways and perspectives

The concept of enhanced recovery after surgery (ERAS), initially introduced in the field of colorectal surgery, has been developed in order to optimize the postoperative course. In recent years the number of authors analyzing the role of ERAS in lung cancer surgery is increasing, highlighting several interventions with positive effects on the postoperative course. Yet it is still difficult to draw definite conclusions and specific guidelines, as most of these studies largely differ for their methodological aspects and study populations. Herein we focus on the key elements of each single intervention, trying to identify what we can apply in a common pathway, and which aspects are still to be evaluated for the validation of an ERAS program.

Enhancing the study of enhanced recovery after thoracic surgery: methodology and population-based approaches for the future

Achieving optimal outcomes following thoracic surgery requires a complex multidisciplinary effort spanning the entire peri-operative period. Enhanced recovery after surgery (ERAS) protocols aim to codify essential elements in care across all perioperative settings. As thoracic surgeons have begun to embrace ERAS, identification of optimal protocol elements and novel study endpoints is necessary. In this review we will briefly review the current available evidence for ERAS in thoracic surgery, while focusing on study methods and design. We will discuss methodology for future studies and how a population-based approach can improve the current level of evidence supporting broad implementation of ERAS to thoracic surgery.

Implementing a thoracic enhanced recovery with ambulation after surgery program: key aspects and challenges

Enhanced recovery after surgery (ERAS) protocols aim to improve operative outcomes by focusing on perioperative care, including early mobilization, limitation of narcotics, and maintenance of fluid balance. We implemented a T-ERA^AS (Thoracic-Early Recovery with Ambulation After Surgery) protocol which focused on early ambulation, with the rationale that a patient's mobility may be a reproducible and measurable metric for their overall status-pain control, respiratory function, cardiac function, and patient satisfaction. We set a benchmark distance of 250 feet for our early ambulation goal and redefined "early" as within the first hour post extubation. We describe some of the major aspects to our program as well as some of the challenges and successes during our 8-year experience following the implementation of this program.

Enhanced recovery for thoracic surgery in the elderly

PURPOSE OF REVIEW

Both surgical workload and the age of those patients being considered for radial pulmonary resection are increasing. Enhanced recovery programmes are now well established in most surgical disciplines and are increasingly reported in thoracic procedures. This review will discuss the relevant principles of these programmes as applied to an increasing elderly population.

RECENT FINDINGS

Elderly patients undergoing less radial surgical resections without lymphadenectomy have comparable outcomes to those undergoing classical curative treatment. Patients require careful assessment and self-reported quality of life metrics or function may be a better marker of outcome than static measures such as lung function. Hypotension, low values for bispectral index and low anaesthetic gas mean alveolar concentration values are common and independent predictors of mortality in the elderly. Paravertebral blockade is preferred to epidural anaesthesia because of a more favourable side-effect profile and comparable efficacy. As yet no robust work has examined the efficacy of an integrated enhanced recovery programme in thoracic surgery.

SUMMARY

Elderly patients are suitable for enhanced recovery programmes but these must be tailored to individual circumstance. Further work is required to comprehensively assess their value in a modern healthcare setting.

A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video-assisted thoracoscopic surgery lobectomy

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS.

Methods

The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database.

Discussion

Pre- and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients' experience. The mainstays of a physiokinesis therapy ERAS protocol are patients' education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.

INTEGRATED CARE PATHWAYS IN LUNG CANCER: A QUALITY IMPROVEMENT PROJECT

BACKGROUND

Non small cell lung cancer (NSCLC) diagnosis and treatment is a highly complex process, requiring managerial skills merged with clinical knowledge and experience. Integrated care pathways (ICPs) might be a good strategy to overview and improve patient's management. The aim of this study was to review the ICPs of NSCLC patients in a University Hospital and to identify areas of quality improvement.

MATERIALS AND METHODS

The electronic medical records of 169 NSCLC patients visited at the University Hospital were retrospectively reviewed. Quality of care (QoC) has been measured trough fifteen indicators, selected according main international Guidelines and approved by the multi-disciplinary team for thoracic malignancies. Results have been compared with those of a similar retrospective study conducted at the same hospital in 2008.

RESULTS

A total of 146 patients were considered eligible. Eight of fifteen indicators were not in line with the benchmarks. We compared the results obtained in the two separate periods. Moreover, we process some proposal to be discussed with the general management of the hospital, aimed to redesign NSCLC care pathways.

CONCLUSIONS

ICPs confirm to be feasible and to be an effective tool in real life. The periodic measurement of QoC indicators is necessary to ensure clinical governance of patients pathways.

Peri- and postoperative management of stage I-III Non Small Cell Lung Cancer: Which quality of care indicators are evidence-based?

Quality of care (QoC) has a central role in our health care system. The aim of this review is to present a set of evidence-based quality indicators for the surgical treatment and postoperative management of lung cancer. A search was performed through PubMed, Embase and the Cochrane library database, including English literature, published between 1980 and 2012. Search terms regarding 'lung neoplasms', 'surgical treatment' and 'quality of care' were used. Potential QoC indicators were divided into structure, process or outcome measures and a final selection was made based upon the level of evidence. High hospital volume and surgery performed by a thoracic surgeon, were identified as important structure indicators. Sleeve resection instead of pneumonectomy and the importance of treatment within a clinical care path setting were identified as evidence-based process indicators. A symptom-based follow-up regime was identified as a new QoC indicator. These indicators can be used for registration, benchmarking and ultimately quality improvement in lung cancer surgery.

Narcissus, the Beam, and lung cancer

In the management of lung cancer, the rules of engagement of stereotactic ablative radiotherapy (SABR) are not clearly defined. The potential for SABR to affect to an unprecedented level current protocols and in all disease stages emerges vehemently from the literature. However, in a time when the role of surgery is being reassessed, surgeons need to take a closer look at the evidence for the use of SABR in lung cancer patients and clearly define their indisputable role within the context of multidisciplinary teams. The myth of Narcissus exemplified in the absolute masterpiece by Caravaggio seems to represent an ideal metaphor to explain the ever-evolving interaction between surgery and SABR in lung cancer management.

A 10 years audit of cardiothoracic referrals from a pulmonology service in a developing country: impact of patient human immunodeficiency virus status

BACKGROUND

There are few studies that have documented the clinical presentation, complication rate and outcome of cardiothoracic referrals from a Pulmonology Service, particularly in developing countries. Furthermore, the impact of human immunodeficiency virus (HIV) status on such referrals and their outcomes is not well documented.

METHODS

This was a retrospective audit of combined pulmonologist/cardiothoracic consultations, undertaken among the tertiary academic hospitals attached to the University of the Witwatersrand, Johannesburg, South Africa, over a 10 years period (2001-2010) in order to document the clinical features of these referrals and to determine any impact of HIV status on trends in disease presentations, complications and outcome.

RESULTS

A total of 847 patients were evaluated on whom a variety of surgical procedures was performed, 50.4% being therapeutic, 32.8% diagnostic and 16.9% both therapeutic and diagnostic. HIV status was known in 488 cases. Of these 229 (46.9%) were HIV-seropositive and 259 (53.1%) -seronegative. The main reasons for referral were for infective conditions, including tuberculosis (TB), pleural disease/effusion/empyema, and other bacterial infections, with significantly more of the TB patients being HIV-seropositive (P<0.0001).There was a trend for increasing presentations for TB and pleural conditions, particularly during the last 4-5 years of the audit, coinciding with an increase in the numbers of HIV-positive referrals. HIV status had no impact on the frequency of surgical complications or mortality.

CONCLUSIONS

The audit indicates an increasing referral rate of HIV-seropositive patients to cardiothoracic services in Johannesburg, particularly in association with TB and pleural diseases. However with careful cardiothoracic/pulmonologist evaluation of the cases the frequency of complications and mortality appear to be no different from that of HIV-seronegative cases.

Innovative health systems projects

BACKGROUND

Residency programmes struggle with the systems-based practice and improvement competency promoted by the Accreditation Council for Graduate Medical Education. The development of Innovative Health Systems Projects (IHelP) was driven by the need for better systems-based initiatives at an institutional level. Our objective was to develop a novel approach that successfully incorporates systems-based practice in our Graduate Medical Education (GME) programmes, while tracking our impact on health care delivery as an academic medical centre.

METHODS

We started the IHelP programme as a 'volunteer initiative' in 2010. A detailed description of the definition, development and implementation of the IHelP programme, along with our experience of the first year, is described. Residents, fellows and faculty mentors all played an important role in establishing the foundation of this initiative. Following the positive response, we have now incorporated IHelP into all curricula as a graduating requirement. IHelP has promoted scholarly activity and faculty mentorship, [and] has improved aspects of patient care and safety

RESULTS

A total of 123 residents and fellows, representing 26 specialties, participated. We reviewed 145 projects that addressed topics ranging from administrative and departmental improvements to clinical care algorithms. The projects by area of focus were: patient care - clinical care, 38 per cent; patient care - quality, 27 per cent; resident education, 21 per cent; and a cumulative 16 per cent among pharmacy, department activities, patient education, medical records and clinical facility.

DISCUSSION

We are pleased with the results of our first year of incorporating a systems-based improvement programme into the GME programmes. This initiative has promoted scholarly activity and faculty mentorship, has improved aspects of patient care and safety, and has led to the development of many practical innovations.

Optimal surgical management of pulmonary metastases: VATS versus thoracotomy

Survival benefit after pulmonary metastasectomy is under question and knowledge of functional recovery after pulmonary metastasectomy by thoracotomy and video-assisted thoracoscopic surgery (VATS) is of great importance. We analysed prospective data of 100 patients operated for pulmonary metastasis by either VATS or thoracotomy. VATS yielded a better physical performance 1 month postoperative, shorter hospital stay, a shorter duration of chest tube drainage and epidural analgesia. We concluded that VATS is the preferable approach due to superior functional outcome.

An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy

BACKGROUND

Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions.

METHODS

Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions.

RESULTS

We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P < .05), total complications (40 [37%] vs 64 [50%]; P < .05), urinary tract infections (3 [3%] vs 15 [12%]; P < .05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P < .05), with no difference in readmissions (7 [7%] vs 6 [5%]; P < .05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P < .05).

CONCLUSION

Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.

Nationwide quality improvement in lung cancer care: the role of the Danish Lung Cancer Group and Registry

INTRODUCTION

To improve prognosis and quality of lung cancer care the Danish Lung Cancer Group has developed a strategy consisting of national clinical guidelines and a clinical quality and research database. The first edition of our guidelines was published in 1998 and our national lung cancer registry was opened for registrations in 2000. This article describes methods and results obtained by multidisciplinary collaboration and illustrates how quality of lung cancer care can be improved by establishing and monitoring result and process indicators.

METHODS

A wide range of indicators was established, validated, and monitored. By registration of all lung cancer patients since the year 2000, data on more than 40,000 patients have been included in the database. Results are reported periodically/quarterly and submitted to formal auditing on an annual basis.

RESULTS

Improvements in all outcome indicators are documented and statistically significant. Thus the 1-year overall survival rate has increased between 2003 and 2011 from 36.6% to 42.7%, the 2-year survival rate from 19.8% to 24.3%, and the 5-year survival rate from 9.8% to 12.1%. Five-year survival after surgical resection has increased from 39.5% to 48.1%. Improvements of waiting times, accordance between cTNM and pTNM, and resection rates are documented.

CONCLUSION

The Danish experience shows that a national quality management system including national guidelines, a database with high data quality, frequent reports, audit and commitment from all stakeholders can contribute to improve clinical practice, improve core results, and reduce regional differences.

Effects of sertraline on executive function and quality of life in patients with advanced cancer

Background

The aim of this study was to investigate effects of the antidepressant sertraline on executive function and quality of life in patients with advanced cancer.

Material/Methods

We assigned 122 patients with stage III or IV cancer to the depressed group (DG, n=86) or the non-depressed group (NG, n=36). All subjects were given supportive treatment and patients in the DG received additional antidepressant treatment.

Results

There were significant differences in total scores of the Hamilton anxiety scale (HAMA) and the Hamilton depression scale (HAMD), performance in the Wisconsin card sorting test, and SF-36 domains. After antidepressant treatment, the level of depression and anxiety decreased significantly in the DG, but was still significantly higher than in the NG. Low executive function was enhanced in the DG, but a worsening executive function was found in total errors in the NG (−2.3±3.8) (P<0.05). The dimensions of SF-36 in physical functioning (PF), role limitations-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations-emotional (RE), and mental health (MH) were decreased significantly at baseline in the DG compared to the NG (P<0.01). After 12-week Sertraline treatment, improvement in the DG in factors VT, SF, RE, and MH were more powerful than in the NG (P<0.05). HAMA, HAMD, and VAS scores and tumor stage were significantly correlated to any one dimension of quality of life.

Conclusions

Depression is an important cause of decreased quality of life and executive function in patients with advanced cancer. The antidepressant sertraline can improve the executive function and quality of life, which may be helpful in the clinical practice of cancer treatment.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2012

Cardiothoracic and vascular critical care has emerged as a subspecialty due to procedural breakthroughs, an aging population, and a multidisciplinary collaboration. This subspecialty now has a dedicated professional society, recently published guidelines, and plans for standardized certification. This paradigm shift represents a major collaboration opportunity for our specialty. The rise of evidence-based perioperative practice has produced a culture of large trials in our specialty to search for solutions to the challenging outcome questions. Besides the growth in the development of evidence, the consensus conference format and postpublication peer review have both emerged as effective processes for identifying the most relevant high-quality evidence. The quest for best perioperative practice has highlighted the importance of teamwork at all phases of care with respect to transitions in care, blood component transfusion, and research misconduct. The emergence of ultrasound as a standard for central vascular access also has been emphasized in recent multisociety guidelines. There also has been a paradigm shift in the management of patients with coronary artery disease. Recent guidelines have emphasized the roles of the cardiac anesthesiologist and the interventional cardiologist as part of the heart team approach. Major recent trials in comparative effectiveness have challenged the advantages of percutaneous coronary intervention, off-pump coronary artery bypass surgery, and intra-aortic balloon counterpulsation. The year 2012 has witnessed the emergence of new paradigms of care in our specialty with the emphasis on teamwork, safety, and quality. These processes will further improve perioperative outcome.