Specialists achieve better outcomes than generalists for lung cancer surgery

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

Evaluating the implementation of robotic thoracic surgery on a Veterans Administration Hospital

Robotic thoracic surgery has demonstrated benefits. We aimed to evaluate implementation of a robotic thoracic surgery program on postoperative outcomes at our Veteran’s Administration Medical Center (VAMC). We retrospectively reviewed our VAMC database from 2015 to 2021. Patients who underwent surgery with intention to treat lung nodules were included. Primary outcome was patient length of stay (LOS). Patients were grouped by surgical approach and stratified to before and after adoption of robotic surgery. Univariate comparison of postoperative outcomes was performed using Wilcoxon rank sums and chi-squared tests. Multivariate regression was performed to control for ASA class. P values < 0.05 were considered significant. Outcomes of 108 patients were assessed. 63 operations (58%) occurred before and 45 (42%) after robotic surgery implementation. There were no differences in patient preoperative characteristics. More patients underwent minimally invasive surgery (MIS) in the post-implementation era than pre-implementation (85% vs. 42%, p < 0.001). Robotic operations comprised 53% of operations post-implementation. On univariate analysis, patients in the post-implementation era had a shorter LOS vs. pre-implementation, regardless of surgical approach (mean 4.7 vs. 6.0 days, p = 0.04). On multivariate analysis, patients who underwent MIS had a shorter LOS [median 4 days (IQR 2–6 days) vs. 7 days (6–9 days), p < 0.001] and were more likely to be discharged home than to inpatient facilities [OR (95% CI) 13.00 (1.61–104.70), p = 0.02]. Robotic thoracic surgery program implementation at a VAMC decreased patient LOS and increased the likelihood of discharging home. Implementation at other VAMCs may be associated with improvement in some patient outcomes.

Racial Disparities in Overall Survival and Surgical Treatment for Early Stage Lung Cancer by Facility Type

BACKGROUND

Early stage Non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. There are persistent racial disparities for the receipt of surgery and overall survival rate for early stage NSCLC. The facility type where patients receive NSCLC treatment may directly impact racial disparities.

METHODS

A total of 111,009 patients with the American Joint Committee on Cancer TNM clinical stage I and II NSCLC that were reported to the National Cancer Data Base were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. A multivariate adjusted multinomial logistic regression was used to evaluate differences in the probability of undergoing surgery based on race and facility type. Kaplan Meier 3 and 5-year overall survival estimates were calculated for black and white patients based on treatment and the facility type where patients received care.

RESULTS

We identified 99,767 white (89.87%) and 11,242 (10.12%) black patients with early stage NSCLC. Black patients were more likely to undergo surgery at academic facilities (OR: 1.12; 95% CI: 1.01-1.24; P-value = .04) compared to community facilities. Black patients treated at academic facility types demonstrated significantly better 3 and 5-year overall survival compared to black patients treated at community facilities (Log Rank P-value < .0001).

CONCLUSION

Black patients with early stage NSCLC who were treated at academic facility types had a significantly higher overall survival compared black patients treated at community facility types. The odds of black patients undergoing surgery were higher at academic facilities compared to community facilities.

Performance of Risk Factor-Based Guidelines and Model-Based Chest CT Lung Cancer Screening in World Trade Center-Exposed Fire Department Rescue/Recovery Workers

BACKGROUND

Lung cancer is a leading cause of cancer incidence and death in the United States. Risk factor-based guidelines and risk model-based strategies are used to identify patients who could benefit from low-dose chest CT (LDCT) screening. Few studies compare guidelines or models within the same cohort. We evaluate lung cancer screening performance of two risk factor-based guidelines (US Preventive Services Task Force 2014 recommendations [USPSTF-2014] and National Comprehensive Cancer Network Group 2 [NCCN-2]) and two risk model-based strategies, Prostate Lung Colorectal and Ovarian Cancer Screening (PLCOm2012) and the Bach model) in the same occupational cohort.

RESEARCH QUESTION

Which risk factor-based guideline or model-based strategy is most accurate in detecting lung cancers in a highly exposed occupational cohort?

STUDY DESIGN AND METHODS

Fire Department of City of New York (FDNY) rescue/recovery workers exposed to the September 11, 2001 attacks underwent LDCT lung cancer screening based on smoking history and age. The USPSTF-2014, NCCN-2, PLCOm2012 model, and Bach model were retrospectively applied to determine how many lung cancers were diagnosed using each approach.

RESULTS

Among the study population (N = 3,953), 930 underwent a baseline scan that met at least one risk factor or model-based LDCT screening strategy; 73% received annual follow-up scans. Among the 3,953, 63 lung cancers were diagnosed, of which 50 were detected by at least one LDCT screening strategy. The NCCN-2 guideline was the most sensitive (79.4%; 50/63). When compared with NCCN-2, stricter age and smoking criteria reduced sensitivity of the other guidelines/models (USPSTF-2014 [44%], PLCOm2012 [51%], and Bach[46%]). The 13 missed lung cancers were mainly attributable to smoking less and quitting longer than guideline/model eligibility criteria. False-positive rates were similar across all four guidelines/models.

INTERPRETATION

In this cohort, our findings support expanding eligibility for LDCT lung cancer screening by lowering smoking history from ≥30 to ≥20 pack-years and age from 55 years to 50 years old. Additional studies are needed to determine its generalizability to other occupational/environmental exposed cohorts.

A mixed methods analysis of access barriers to dermatology care in a rural state

AIMS

To identify significant patient and system access barriers and facilitators to dermatology care in one rural health system with limited dermatology appointment availability.

DESIGN

Mixed methods study using data from electronic medical records, patient surveys, stakeholder semi-structured interviews, and service area dermatologist demographics. Retrospective data were collected between 1 January 2017-1 March 2018, and interviews and surveys were conducted between June 1-August 31, 2018. Participants were recruited from two primary care practices in one rural Maine regional health system.

METHODS

Findings from thematic analyses, descriptive statistics, and statistical modelling were integrated using Chi-square tests for homogeneity to develop a unified understanding. Statistical modelling using odd-ratio logistic and linear regression were performed for each outcome variable of interest.

RESULTS

Urgent referrals by primary care increased the likelihood of dermatology care overall (OR: 6.771; p = .007) and at nearby sites with limited availability (OR: 4.024; p = .024), but not at geographically further sites with higher capacities (p = .844). Referral under-diagnosis occurred in 20.8% of those biopsied. Older (p = .041) or non-working (p = .021) patients were more likely to remain unevaluated than seek more available but geographically further care.

CONCLUSIONS

In rural areas with scarce appointment availability, primary care provider diagnostic accuracy may be an important barrier of dermatology care receipt and health outcomes, especially among at-risk populations.

IMPACT

Although melanoma mortality rates are decreasing throughout the US, little is known about why rates in Maine continue to rise. This study applied a comprehensive approach to identify several patient and system access barriers to dermatology care in one underserved rural regional health system. While specific to this population and large service area, these findings will inform improvement efforts here and support broader future research efforts aimed at understanding and improving health outcomes in this rural state.

[Surgical Therapy for Lung Cancer: Why it Should be Performed in High Volume Centres]

Data on surgical lung cancer cases were extracted from the German Federal Statistics on Diagnosis-related groups (DRG) and a possible association between hospital volume and surgical mortality was explored. All treatment cases documented between 2005 and 2015 with the main diagnosis of lung cancer (International Classification of Disease code C34) and the German Operations and Procedure Key (OPS) codes 5-323 to 5-328 for anatomical lung resections were analysed. The treatment cases were assigned to hospital groups, defined according to the number of procedures performed per year. The total number of anatomical lung resections for the diagnosis of lung cancer increased by 24 % from 9376 resections in 2005 to 11,614 resections in 2015. In 2015, 57 % of anatomical lung resections in patients with lung cancer were performed in 47 high volume centres (hospitals with ≥ 75 resections/year); the remaining 43 % of the resections were distributed among 271 hospitals performing fewer than 75 resections per year. In hospitals performing fewer than 25 procedures/year, hospital mortality was almost twice as high as in large centres with ≥ 75 resections per year (5.7 vs. 3.0 %, mean value 2005 to 2015). In summary, our data indicate that a small number of high-volume hospitals perform the major part of lung resections of lung cancer in Germany with better survival as compared to low-volume hospitals. Based on current nationwide data a clear association between hospital volume and surgical mortality could be demonstrated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of Anatomic Lung Resection for Cancer Are Better When Performed by Cardiothoracic Surgeons

BACKGROUND

Anatomic lung resection (ALR) outcomes are superior for cardiothoracic surgeons (CTSs) by analysis of Medicare; National Inpatient Sample; South Carolina Office of Research and Statistics; and Surveillance, Epidemiology, and End Results databases. Similar findings have been reported for all noncardiac thoracic procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Our aim was to further delineate outcome differences between CTSs and general surgeons (GSs) specifically for ALR.

METHODS

A retrospective analysis of 15,574 nonemergent, nonpediatric ALR for lung cancer was conducted using the ACS-NSQIP 2013 to 2017 database. Included procedures were all ALR for lung cancer. Surgeons were classified as CTSs or GSs. Other specialties were excluded. Preoperative characteristics and 30-day outcomes were compared by bivariate (chi-square test) and multivariate analysis. Multivariate analysis was conducted by multiple logistic regression.

RESULTS

CTSs performed 14,172 (91.0%) of included procedures, and GSs performed 1402 (9.0%). A thoracoscopic approach was utilized at a similar rate (49.08% for CTSs vs 49.71% for GSs; P = .747). The extent of resection differed in a statistically, but not clinically, significant fashion. CTS patients had a higher rate of preoperative dyspnea (22.66% for CTSs vs 17.62% for GSs; P < .001). Procedures performed by CTSs had a lower risk-adjusted odds ratio of overall morbidity, pulmonary morbidity, sepsis or septic shock, bleeding requiring transfusion, and length of stay greater than the median (5 days).

CONCLUSIONS

ALR outcomes are superior for CTSs when compared with GSs. This is consistent with prior studies looking at this specific subset of patients and studies looking at a different subset of patients using the ACS-NSQIP database.

The Academic Facility Type Is Associated With Improved Overall Survival for Early-Stage Lung Cancer

BACKGROUND

Early-stage non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. The overall survival rate for early-stage NSCLC may be determined by the healthcare facility type where patients receive their lung cancer treatment.

METHODS

A total of 103,748 cases with the American Joint Committee on Cancer clinical stage I and II NSCLC that were reported to the National Cancer Database at over 1150 facilities were analyzed in this study. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazards models were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting was used to adjust for facility volume and patient-related baseline differences between facility types.

RESULTS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly better median overall survival (63.2 months) compared with patients who received care at community healthcare facilities (54.2 months) (hazard ratio, 0.86; 95% confidence interval, 0.82-0.91; P < .0001). The surgical quality outcomes for NSCLC surgery, including 30-day mortality, 90-day mortality, and the median number of lymph nodes removed were significantly better for patients treated at the academic facility types.

CONCLUSIONS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly higher overall median survival compared with patients treated at community facility types. The short-term surgical quality outcomes were significantly better for patients who underwent surgery for early-stage NSCLC at academic facility types.

Survival After Mediastinal Node Dissection, Systematic Sampling, or Neither for Early Stage NSCLC

INTRODUCTION

The American College of Surgeons Oncology Group Z0030 found no survival difference between patients with early stage NSCLC who had mediastinal nodal dissection or systematic sampling. However, a meta-analysis of 1980 patients in five randomized controlled trials from 1989 to 2007 associated better survival with nodal dissection. We tested the survival impact of the extent of nodal dissection in curative-intent resections for early stage NSCLC in a population-based observational cohort.

METHODS

Resections for clinical T1 or T2, N0 or nonhilar N1, M0 NSCLC in four contiguous United States Hospital Referral Regions from 2009 to 2019 were categorized into mediastinal nodal dissection, systematic sampling, and "neither" on the basis of of the evaluation of lymph node stations. We compared demographic and clinical characteristics, perioperative complication rates, and survival after assessing statistical interactions and confounding.

RESULTS

Of the 1942 eligible patients, 18% had nodal dissection, 6% had systematic sampling, and 75% had an intraoperative nodal evaluation that met neither standard. In teaching hospitals, nodal dissection was associated with a lower hazard of death than "neither" resections (0.57 [95% confidence interval: 0.41-0.79]) but not systematic sampling (0.74 [0.40-1.37]) after adjusting for multiple comparisons. There was no significant difference in hazard ratios at nonteaching institutions (p > 0.3 for all comparisons). Perioperative complication rates were not significantly worse after mediastinal nodal dissection or systematic sampling, compared with "neither," (p > 0.1 for all comparisons).

CONCLUSIONS

In teaching institutions, mediastinal nodal dissection was associated with superior survival over less-comprehensive pathologic nodal staging. There was no survival difference between teaching and nonteaching institutions, a finding that warrants further investigation.

Does institutional patient accrual volume impact overall survival in patients with inoperable non-small-cell lung cancer receiving radical (chemo)radiation? A secondary analysis of TROG 99.05

INTRODUCTION

Increased hospital patient volume, reflecting greater experience, has been shown to be associated with improved survival for some cancers. However, there is no evidence to support the volume-outcome hypothesis for inoperable non-small-cell lung cancer (NSCLC) patients within the Australasian setting. We examined the relationship between overall survival (OS) and institutional patient accrual volume (IPAV) in a large prospective Australasian NSCLC database (TROG 99.05).

METHODS

TROG 99.05 was an observational study which accrued patients from 1999 to 2007 to examine the relationship between primary lung cancer volume and survival. To be eligible for inclusion, patients had to have inoperable, biopsy-proven NSCLC planned for radiotherapy to a minimum dose of 50Gy in 20 fractions, with or without chemotherapy. Participating institutions were de-identified and grouped according to whether accrual was low, medium or high. OS was compared between groups and adjusted for prognostic factors using Cox regression.

RESULTS

About 509 patients were accrued from 16 centres. Median potential follow-up time was 60 months. Median survival for all groups was 20 months (95% CI 18.3-21.8 months). There were no statistically significant differences in OS with increasing patient accrual across the three groups after adjustment for prognostic factors (P = 0.84, 2 df). The hazard ratios (HR) for group accrual volumes, relative to that for high-accrual volume, were as follows: low, 1.18; medium, 1.14. Test for trend: HR = 0.91 per group (95% CI 0.76-1.09, P = 0.31).

CONCLUSION

In the setting of a clinical trial with rigorous quality assurance, we found no evidence for an association between institutional accrual and survival.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

Outcomes of laparoscopic hiatal hernia repair based on surgical specialty: thoracic versus general surgeons

BACKGROUND

Hiatal Hernia Repairs (HHR) are performed by both general surgeons (GS) and thoracic surgeons (TS). However, there are limited literature with respect to outcomes of HHR based on specialty training. The objective of this study was to compare the utilization, perioperative outcomes, and cost for HHR performed by GS versus TS.

METHODS

The Vizient database was used to identify patients who underwent elective laparoscopic HHR between October 2014 and June 2018. Patients were grouped according to surgeon's specialty (GS vs. TS). Patient demographics and outcomes including in-hospital mortality were compared between groups.

RESULTS

During the study period 13,764 patients underwent HHR by either GS or TS. GS performed 9930 (72%) cases while TS performed 3834 (28%) cases. There was no significant difference between GS versus TS with regard to serious morbidity (1.28% vs. 1.30%, p = 0.97) or mortality (0.10% vs. 0.21%, p = 0.19). The mortality index was 0.24 for GS versus 0.45 for TS. Compared to TS, laparoscopic HHR performed by GS was associated with a shorter LOS (2.57 days vs. 2.72 days, p < 0.001) and lower mean hospital costs ($7139 vs. $8032, p < 0.0001).

CONCLUSIONS

Within the context of academic centers, laparoscopic HHRs are mostly performed by GS with comparable outcome between general versus thoracic surgeons.

Making the Evidentiary Case for Universal Multidisciplinary Thoracic Oncologic Care

The goal of this article is to provide an overview of the state of the evidence for, and challenges to, sustainable implementation of multidisciplinary thoracic oncology programs. Multidisciplinary care is much advocated by professional groups and makers of clinical guidelines, but little practiced. The gap between universal recommendation and scant evidence of practice suggests the existence of major barriers to program implementation. We examine 2 articles published in this issue of Clinical Lung Cancer to illustrate problems with the evidence base for multidisciplinary care. The inherent complexity of care delivery for the lung cancer patient drives near-universal advocacy for multidisciplinary care as a means of overcoming the heterogeneous quality and outcomes of patient care. However, the evidence to support this model of care delivery is poor. Challenges include the absence of a clear definition of "multidisciplinary care" in the literature, a consequent hodge-podge of poorly-defined examples of tested models, methodologically flawed studies, exemplified by the near-total absence of prospective studies examining this model of care delivery, and absence of scientifically sound dissemination and implementation studies, as well as cost-effectiveness studies. Against this background, we examined the results of a recent large single-institutional retrospective study suggesting the survival benefit of care within a colocated multidisciplinary lung cancer clinic, and an ambitious systematic review of existing literature on multidisciplinary cancer clinics. Better-quality evidence is still needed to establish the value of the multidisciplinary care concept. Such studies need to be prospective, use standardized definitions of multidisciplinary care, and provide clear information about program structure.

Evaluation of Appropriate Mediastinal Staging among Endobronchial Ultrasound Bronchoscopists

RATIONALE

Endobronchial ultrasound (EBUS) has transformed mediastinal staging in lung cancer. A systematic approach, beginning with lymph nodes contralateral to the primary tumor (N3), is considered superior to selective sampling of radiographically abnormal nodes. However, the extent to which this recommendation is followed in practice remains unknown.

OBJECTIVES

To assess the frequency with which pulmonologists, pulmonary fellows, and interventional pulmonologists endoscopically stage lung cancer appropriately.

METHODS

Bronchoscopists currently performing EBUS were surveyed about their practice patterns, procedural volume, and self-confidence in EBUS skills; they then performed a proctored simulated staging EBUS. The primary outcome was the proportion of participants who appropriately initiated ultrasonographic evaluation with the N3 nodal stations in a simulated patient undergoing EBUS for mediastinal staging.

RESULTS

Sixty physicians (22 interventional pulmonologists, 18 general pulmonologists, and 20 pulmonary fellows) participated in the study. The rates of appropriate staging by study group were 95.5% (21 of 22) for interventional pulmonologists, 44.4% (8 of 18) for general pulmonologists, and 30.0% (6 of 20) for pulmonary fellows (P < 0.001). Increased procedural volume correlated with appropriate staging practices (P < 0.001). Within each group, we assessed the concordance between self-confidence in EBUS and simulation performance. Among interventional pulmonologists, the concordance was 95.4%, followed by 61.1% for general pulmonologists and 40.0% for pulmonary fellows.

CONCLUSIONS

General pulmonologists and pulmonary fellows were less likely than interventional pulmonologists to perform appropriate EBUS staging. In addition, the lack of concordance between self-confidence and appropriate staging performance among noninterventionists signals a need for improved dissemination of guidelines for EBUS-guided mediastinal staging.

Lung Cancer Stage is an Independent Risk Factor for Surgical Mortality

Aims and Background

To study surgical mortality and evaluate major risk factors, with specific focus on the role of pathological stage in patients undergoing lung cancer resection.

Methods and Study Design

Age, gender, comorbidity, resection volume, experience of the hospital and surgical team have been reported as variables related to postoperative morbidity and mortality in lung cancer. The role of pathological tumor stage on postoperative mortality has never been fully evaluated. The study included 1418 consecutive lung cancer resections performed from 1998 to 2002 in two institutions. The effect of age, gender, comorbidity, resection volume, pathological stage and induction therapies on postoperative mortality was assessed by univariable and multivariable logistic regression analysis.

Results

Postoperative mortality was 1.8% overall, 3.7% (9/243) for pneumonectomy, 1.7% (17/1016) for lobectomy, and null (0/159) for sublobar resections (P = 0.020). At multivariable analysis, cardiovascular comorbidity (P = 0.008), resection volume (P = 0.036) and pathological stage (P = 0.027) emerged as significant predictors of surgical mortality.

Conclusions

Early stage lung cancer resection has a favorable effect on surgical mortality, not only by preventing the need for pneumonectomy, but also by reducing mortality after lobectomy.

Lung cancer screening

PURPOSE OF REVIEW

Lung cancer screening with low-dose chest computed tomography is now recommended for high-risk individuals by the US Preventive Services Task Force. This recommendation was informed by several randomized controlled trials, the largest of which, the National Lung Screening Trial, demonstrated a 20% relative reduction in lung cancer mortality with annual low-dose chest computed tomography compared with chest radiography.

RECENT FINDINGS

The benefit of lung cancer screening must be balanced against potential harms, including a high false-positive rate with consequent further evaluative studies and invasive testing. It is critical that harms be minimized as screening generalizes to the broad community. Informed decision making between providers and patients should include individualized risk assessment, a discussion of both potential benefit and harm, and tobacco treatment. Given the multiple components required for high quality, screening should ideally occur in the context of a multidisciplinary program.

SUMMARY

We are in the early days of lung cancer screening, still with much to learn. Ongoing studies are necessary to refine the definition of a positive screen and develop better methods of distinguishing between true positive and false-positive results. Novel approaches, including the development of multicomponent lung cancer biomarkers, will likely inform and improve our future screening practice.

Assessing the Generalizability of the National Lung Screening Trial: Comparison of Patients with Stage 1 Disease

RATIONALE

The findings of the NLST (National Lung Screening Trial) are the basis for screening high-risk individuals according to age and smoking history. Although screening is covered for eligible Medicare beneficiaries, the generalizability of the NLST in the elderly population has been questioned.

OBJECTIVES

Compare outcomes of patients diagnosed with stage 1 non-small cell lung cancer in the NLST to a nationally representative cohort of elderly patients Methods: Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare and NLST datasets for patients with stage 1 disease aged 65 to 74 years.

MEASUREMENTS AND MAIN RESULTS

Lung cancer-specific mortality, all-cause mortality, and 30-, 60-, and 90-day treatment mortality were measured. When compared with the NLST group undergoing surgery for stage 1 non-small cell lung cancer, those in the SEER-Medicare NLST eligible cohort had no difference in adjusted odds ratios for 30-, 60-, and 90-day surgical mortality (P values = 0.97, 0.65, and 0.46, respectively). Although the 5-year cancer-specific survival did not differ between cohorts (hazard ratio [HR], 0.84 NLST vs. SEER-Medicare NLST eligible; P = 0.21), the adjusted HR estimate for all-cause mortality was better in the NLST cohort (HR, 0.71; P < 0.01). For patients who did not receive surgery for early-stage disease (presumably for curative intent), the outcomes were far worse (13.1, 18.9, 23.9%, for 30-, 60-, and 90-day treatment mortality, respectively).

CONCLUSIONS

Elderly patients with minimal comorbid conditions meeting the inclusion criteria of the NLST who underwent surgery had excellent postoperative outcomes and similar lung cancer-specific 5-year survivorship. In those with significant comorbidities or those not undergoing surgery, competing causes of death may diminish the benefit, and there is no evidence to recommend screening in this group.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Radiation Therapy is Independently Associated with Worse Survival After R0-Resection for Stage I-II Non-small Cell Lung Cancer: An Analysis of the National Cancer Data Base

BACKGROUND

The 1998 post-operative radiotherapy meta-analysis for lung cancer showed a survival detriment associated with radiation for stage I-II resected non-small cell lung cancer (NSCLC), but has been criticized for including antiquated radiation techniques. We analyzed the National Cancer Database (NCDB) to determine the impact of radiation after margin-negative (R0) resection for stage I-II NSCLC on survival.

METHODS

Adult patients from 2004 to 2014 were analyzed from the NCDB with respect to receiving radiation as part of their first course of treatment for resected stage I-II NSCLC; the primary outcome measure was overall survival.

RESULTS

A total of 197,969 patients underwent R0 resection for stage I-II NSCLC, and 4613 received radiation. Median radiation dose was 55 Gy with a 50-60 Gy interquartile range. On adjusted analysis, treatment at a community cancer program, sublobectomy, tumor size (3-7 cm), and pN1/Nx were associated with receiving radiation (odds ratio > 1, p < 0.05). The irradiated group had shorter median survival (45.8 vs. 77.5 months, p < 0.001), and radiation was independently associated with worse overall survival (hazard ratio (HR) 1.339, 95% confidence interval (CI) 1.282-1.399). After propensity score matching, radiation remained associated with worse overall survival (HR 1.313, 95% CI 1.237-1.394, p < 0.001).

CONCLUSIONS

Radiotherapy was independently associated with worse survival after R0 resection of stage I-II NSCLC in the NCDB and was more likely to be delivered in community cancer programs.

The Role of International Volunteers in the Growth of Surgical Capacity in Post-earthquake Haiti

BACKGROUND

The 2010 Haiti earthquake severely strained local healthcare infrastructure. In the wake of this healthcare crisis, international organizations provided volunteer support. Studies demonstrate that this support improved short-term recovery; however, it is unclear how long-term surgical capacity has changed and what role volunteer surgical relief efforts have played. Our goal was to investigate the role of international surgical volunteers in the increase of surgical capacity following the 2010 Haiti earthquake.

METHODS

We retrospectively analyzed the operative reports of 3208 patients at a general, trauma and critical care hospital in Port-au-Prince from June 2010 through December 2013. We collected data on patient demographics and operation subspecialty. Surgeons and anesthesiologists were categorized by subspecialty training and as local healthcare providers or international volunteers. We performed analysis of variance to detect changes in surgical capacity over time and to estimate the role volunteers play in these changes.

RESULTS

Overall number of monthly operations increased over the 2.5 years post-earthquake. The percentage of orthopedic operations declined while the percentage of other subspecialty operations increased (p = 0.0003). The percentage of operations performed by international volunteer surgeons did not change (p = 0.51); however, the percentage of operations staffed by volunteer anesthesiologists declined (p = 0.058). The percentage of operations performed by matching specialty- and subspecialty-trained international volunteers has not changed (p = 0.54).

CONCLUSIONS

Haitian post-earthquake local and overall surgical capacity has steadily increased, particularly for provision of subspecialty operations. Surgical volunteers have played a consistent role in the recovery of surgical capacity. An increased focus on access to surgical services and resource-allocation for long-term surgical efforts particularly in the realm of subspecialty surgery may lead to full recovery of surgical capacity after a large and devastating natural disaster.

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.

Institutional Enrollment and Survival Among NSCLC Patients Receiving Chemoradiation: NRG Oncology Radiation Therapy Oncology Group (RTOG) 0617

BACKGROUND

The purpose of this analysis is to evaluate the effect of institutional accrual volume on clinical outcomes among patients receiving chemoradiation for locally advanced non-small cell lung cancer (LA-NSCLC) on a phase III trial.

METHODS

Patients with LA-NSCLC were randomly assigned to 60 Gy or 74 Gy radiotherapy (RT) with concurrent carboplatin/paclitaxel +/- cetuximab on NRG Oncology RTOG 0617. Participating institutions were categorized as low-volume centers (LVCs) or high-volume centers (HVCs) according to the number of patients accrued (≤3 vs > 3). All statistical tests were two-sided.

RESULTS

Range of accrual for LVCs (n = 195) vs HVCs (n = 300) was 1 to 3 vs 4 to 18 patients. Baseline characteristics were similar between the two cohorts. Treatment at a HVC was associated with statistically significantly longer overall survival (OS) and progression-free survival (PFS) compared with treatment at a LVC (median OS = 26.2 vs 19.8 months; HR = 0.70, 95% CI = 0.56 to 0.88, P = .002; median PFS: 11.4 vs 9.7 months, HR = 0.80, 95% CI = 0.65-0.99, P = .04). Patients treated at HVCs were more often treated with intensity-modulated RT (54.0% vs 39.5%, P = .002), had a lower esophageal dose (mean = 26.1 vs 28.0 Gy, P = .03), and had a lower heart dose (median = V5 Gy 38.2% vs 54.1%, P = .006; V50 Gy 3.6% vs 7.3%, P < .001). Grade 5 adverse events (AEs) (5.3% vs 9.2%, P = .09) and RT termination because of AEs (1.3% vs 4.1%, P = .07) were less common among patients treated at HVCs. HVC remained independently associated with longer OS (P = .03) when accounting for other factors.

CONCLUSION

Treatment at institutions with higher clinical trial accrual volume is associated with longer OS among patients with LA-NSCLC participating in a phase III trial.

Developing an Interventional Pulmonary Service in a Community-Based Private Practice: A Case Study

Interventional pulmonology (IP) is a field that uses minimally invasive techniques to diagnose, treat, and palliate advanced lung disease. Technology, formal training, and reimbursement for IP procedures have been slow to catch up with other interventional subspecialty areas. A byproduct of this pattern has been limited IP integration in private practice settings. We describe the key aspects and programmatic challenges of building an IP program in a community-based setting. A philosophical and financial buy-in by stakeholders and a regionalization of services, within and external to a larger practice, are crucial to success. Our experience demonstrates that a successful launch of an IP program increases overall visits as well as procedural volume without cannibalizing existing practice volume. We hope this might encourage others to provide this valuable service to their own communities.

Inequalities in non-small cell lung cancer treatment and mortality

BACKGROUND

Non-small cell lung cancer (NSCLC) comprises approximately 85% of all lung cancer cases, and surgery is the preferred treatment for patients. The National Health Service established Primary Care Trusts (PCTs) in 2002 to manage local health needs. We investigate whether PCTs with a lower uptake of surgical treatment are those with above-average mortality 1 year after diagnosis. The applied methods can be used to monitor the performance of any administrative bodies responsible for the management of patients with cancer.

METHODS

All adults diagnosed with NSCLC lung cancer during 1998-2006 in England were identified. We fitted mixed effect logistic models to predict surgical treatment within 6 months after diagnosis, and mortality within 1 year of diagnosis.

RESULTS

Around 10% of the NCSLC patients received curative surgery. Older deprived patients and those who did not receive surgery had much higher odds of death 1 year after being diagnosed with cancer. In total, 69% of the PCTs were below the lower control limit of surgery and have predicted random intercepts above the mean value of zero of the random effect for mortality, whereas 40% were above the upper control limit of mortality within 1 year.

CONCLUSIONS

Our main results suggest the presence of clear geographical variation in the use of surgical treatment of NSCLC and mortality. Mixed-effects models combined with the funnel plot approach were useful for assessing the performance of PCTs that were above average in mortality and below average in surgery.

Improving lung cancer outcomes by improving the quality of surgical care

Surgical resection remains the most important curative treatment modality for non-small cell lung cancer, but variations in short- and long-term surgical outcomes jeopardize the benefit of surgery for certain patients, operated on by certain types of surgeons, at certain types of institutions. We discuss current understanding of surgical quality measures, and their role in promoting understanding of the causes of outcome disparities after lung cancer surgery. We also discuss the use of minimally invasive surgical resection approaches to expand the playing field for surgery in lung cancer care, and end with a discussion of the future role of surgery in a world of alternative treatment possibilities.

What is quality, and can we define it in lung cancer?-the case for quality improvement

Decades worth of advances in diagnostics and therapeutics are associated with only marginal improvements in survival among lung cancer patients. An obvious explanation is late stage at presentation, but gaps in the quality of care may be another reason for stifled improvements in survival rates. A framework for quality put forth by Avedis Donabedian consists of measuring structures-of-care, processes, and outcomes. Using this approach to explore for potential quality gaps, there is evidence of inexplicable variability in outcomes across patients and hospitals; variation in outcomes across differing provider types (structures-of-care); and variation in approaches to staging (processes-of-care). However, this research has limitations and incontrovertible evidence of quality gaps is challenging to obtain. Other challenges to defining quality include scientific and clinical uncertainty among providers and the fact that quality is a multi-dimensional construct that cannot be measured by a single metric. Nonetheless, two facts compel us to pursue quality improvement: (I) both empirically and anecdotally, actual care falls short of expected care; and (II) evidence of potential quality gaps is not ignorable primarily on ethical grounds.

The association between surgical volume, survival and quality of care

Improving surgical outcomes is important to the thoracic surgical community and operative mortality is often used as a benchmark to gauge the quality of lung resection. In lung cancer surgery, increasing hospital volume is associated with better survival although the categorisation of procedure volume is arbitrary. When US and UK data are scrutinised, the association holds true for increasingly higher volumes up to 150 resection per year and more. The reason may be due to better infrastructure, better-staffed units, more resources and wider specialist and technology-based services in higher volume centers. For individual surgeon volume, reports are not consistent. However, studies suggest that surgeon sub-specialty is an important consideration. The results of general thoracic surgeons and cardiac surgeons are reported to be better than general surgeons for lung resection surgery, and the effects of specialty training was also associated with an increase in the number of patients undergoing lung resection. We conclude that the current evidence strongly supports the association between increasing hospital volume with lower mortality and improved long-term survival following lung resection. Whilst the data presented supports centralization of lung cancer surgery in high volume hospitals, patient choice and the threshold of quality of improvement required to overcome travel and closure of local services need to be considered.

Positive correlation between care given by specialists and registered nurses and improved outcomes for stroke patients

BACKGROUND

Cerebrovascular diseases are the second-highest cause of death in South Korea (9.6% of all causes of mortality in 2013). South Korea has a shortage of trained medical personnel compared with other countries and the demands for health care are continuously increasing. Our study sought to determine the relationship between hospital human resources and the outcomes of stroke patients.

METHODS

We used data from NHI claims (n=99,464) at 120 hospitals to analyze readmission or death within 30 days after discharge or hospitalization for stroke patients during 2010-2013. We used multilevel models that included both patient-level and hospital-level variables to examine factors associated with readmission or death within 30 days.

RESULTS

A total of 1782 (1.8%) patients were readmitted within 30 days, and death occurred within 30 days for 6926 (7.0%) patients. Patients cared for by a higher percentages of specialists or registered nurses had a lower risk of readmission or death within 30 days (readmission per 10% increase in registered nurses, OR=0.89 and SD=0.85-0.94; death per 10% increase in specialists, OR=0.93 and SD=0.89-0.98).

CONCLUSIONS

The percentages of specialist and registered nurses caring for stroke patients were positively correlated with better patient outcomes, particularly for patients with cerebral infarction.

Lung cancer screening

The United States Preventive Services Task Force recommends lung cancer screening with low-dose computed tomography (LDCT) in adults of age 55 to 80 years who have a 30 pack-year smoking history and are currently smoking or have quit within the past 15 years. This recommendation is largely based on the findings of the National Lung Screening Trial. Both policy-level and clinical decision-making about LDCT screening must consider the potential benefits of screening (reduced mortality from lung cancer) and possible harms. Effective screening requires an appreciation that screening should be limited to individuals at high risk of death from lung cancer, and that the risk of harm related to false positive findings, overdiagnosis, and unnecessary invasive testing is real. A comprehensive understanding of these aspects of screening will inform appropriate implementation, with the objective that an evidence-based and systematic approach to screening will help to reduce the enormous mortality burden of lung cancer.

Steadily improving survival in lung cancer

BACKGROUND

National data demonstrate minimal improvement in survival for patients diagnosed with lung cancer despite a number of apparent advances during the past 3 decades. We wished to know how demographic characteristics, staging, therapy, and survival have changed over time for patients with lung cancer who were accessioned to the cancer registry of a large community hospital in southern California.

PATIENTS AND METHODS

Clinical features and survival data were collected on patients diagnosed during each of the successive 6-year eras of 1986 to 1991 (n = 812), 1992 to 1997 (n = 1072), 1998 to 2003 (n = 1209), and 2004 to 2009 (n = 1365).

RESULTS

Median survival improved from 11 to 13 to 16 to 26 months and overall 5-year survival steadily improved from 16.5% to 19.1% to 24.0% to 31.1%. The proportion of patients with localized disease at diagnosis increased from 18.4% to 24.1% to 24.9% to 31.6%. Improvements in relative survival were much greater than have occurred nationally. Other obvious trends over time were increasing age of patients, increasing proportions with diagnoses of adenocarcinoma with concomitant decreases in squamous cell and small cell histologies, and decreases in the proportion of large cell carcinoma with reciprocal increases in neuroendocrine diagnoses. The use of chemotherapy for patients with local disease tripled in the most recent era.

CONCLUSION

Survival has steadily improved for patients in this community who were diagnosed with lung cancer. The explanations for this improvement are multifactorial, but include earlier stage at diagnosis, decreases in histologic types associated with active smoking, and increased use of systemic therapies.

Postoperative mortality is an inadequate quality indicator for lung cancer resection

BACKGROUND

Postoperative mortality is the most commonly reported surgical quality measure. However, such metrics may be incapable of identifying performance outliers. The purpose of this study was to compare different measures of postoperative mortality after lung cancer resection using a large multiinstitutional database.

METHODS

Data were extracted for lung cancer resection patients from the linked Surveillance Epidemiology and End Results-Medicare Registry (2006 to 2010), which provides detailed and longitudinal information about Medicare beneficiaries with cancer. Four definitions of postoperative mortality were evaluated: in-hospital, 30-day, perioperative, and 90-day. Hierarchical regression models were used to estimate mortality risk at 30 and 90 days, and provider quality was assessed by comparing observed versus expected mortality.

RESULTS

We identified 11,787 lung cancer resection patients from 686 hospitals. The median age was 74 years, and 52% of patients were treated with open lobectomy. Although 30-day, perioperative, and in-hospital mortality rates were between 3% and 4%, 90-day mortality was almost double (6.89%). Clinical variables associated with 90-day mortality included sex, preexisting comorbidities, and procedure type. There were no statistically significant differences in 30-day or 90-day mortality rates among providers.

CONCLUSIONS

Currently reported measures of in-hospital and 30-day postoperative mortality do not adequately represent a patient's true mortality risk as mortality almost doubles by 90 days. Because of low occurrence rate and variable provider volumes, neither 30-day nor 90-day mortality is a suitable quality indicator for lung resection.

The business of interventional pulmonology

Interventional pulmonologists are regularly asked to perform more complicated and advanced procedures, but reimbursement for the time, effort and skill involved in these procedures has not kept up with other procedural specialties. Further changes in funding and reimbursement are likely under the Affordable Care Act. Understanding and effectively using the current system of funding for interventional pulmonology practices are imperative as we adapt to changing medical needs, legislative mandates, and reimbursement policy. This article reviews the current landscape of insurance and reimbursement in health care and anticipates some changes that might be expected from implementation of the Affordable Care Act.

Lung cancer screening update

Lung cancer is the leading cause of cancer-related mortality globally and the American cancer society estimates approximately 226,160 new cases and 160,340 deaths from lung cancer in the USA in the year 2012. The majority of lung cancers are diagnosed in the later stages which impacts the overall survival. The 5-year survival rate for pathological st age IA lung cancer is 73% but drops to only 13% for stage IV. Thus, early detection through screening and prevention are the keys to reduce the global burden of lung cancer. This article discusses the current state of lung cancer screening, including the results of the National Lung Cancer Screening Trial, the consideration of implementing computed tomography screening, and a brief overview of the role of bronchoscopy in early detection and potential biomarkers that may aid in the early diagnosis of lung cancer.

Screening for Lung Cancer: Who Should Be Screened?

Lung cancer is the most common cause of death from cancer in the United States. Previous studies of screening with chest radiographs and sputum cytology have not been shown to decrease lung cancer mortality. For the first time, a randomized screening trial with low-dose computed tomography scans has demonstrated a 20% lung cancer mortality reduction compared with screenings with a chest x-ray. Investigation is underway on many breath, sputum, and blood biomarkers to determine markers of high risk. The hope is that some (or one) of them will add to the early detection of lung cancer observed with low-dose computed tomography.

A comparison of quality and cost indicators by surgical specialty for lobectomy of the lung

OBJECTIVES

This investigation compared patients undergoing lobectomy for non-small cell lung cancer by either a general surgeon or a cardiothoracic surgeon across a geographically diverse system of hospitals to see whether a significant difference in quality or cost was present.

METHODS

The Premiere administrative database and tumor registry data of a single health system's hospitals was used to compare adherence to national treatment guidelines, patient outcomes, and charges for patients undergoing lobectomy for non-small cell lung cancer in a 5-year period. Surgeons performing lobectomy were designated as a general surgeon or cardiothoracic surgeon according to their national provider number and board certification status. Excluded from analysis were centers that performed fewer than 50 lobectomies during the study period.

RESULTS

During the study period, 2823 lobectomies were performed by 46 general surgeons and 3653 lobectomies were performed by 29 cardiothoracic surgeons in 54 hospitals in a single health care system. Significant differences were found between general and cardiothoracic surgeons with respect to adherence to national guidelines in staging and treatment, mean length of stay, significant morbidity, and operative mortality. Mean charges for lobectomy of the lung were also found to differ significantly between general and cardiothoracic surgeons.

CONCLUSIONS

This review found that currently measurable indicators for quality of care were significantly superior and overall charges were significantly reduced when a lobectomy for non-small cell lung cancer was performed by a cardiothoracic surgeon rather than by a general surgeon.