While smoking is a well-established risk factor for surgical complications, it is unclear how frequently guideline-concordant tobacco treatments are prescribed to surgical patients. In this ...cross-sectional study including 164673 unique patients evaluated in outpatient surgery clinics at a single institution in 2020, despite a relatively high smoking prevalence (14.7%), guideline-concordant treatment rates were very low, with only 12.7% of patients receiving pharmacotherapy and 31.7% receiving any treatment. Addressing disparities in smoking cessation treatments are critical given the disproportionate impact of smoking on surgical outcomes.
The European Society of Thoracic Surgery (ESTS) and the Society of Thoracic Surgeons (STS) general thoracic surgery databases collect thoracic surgical data from Europe and North America, ...respectively. Their objectives are similar: to measure processes and outcomes so as to improve the quality of thoracic surgical care. Future collaboration between the two databases and their integration could generate significant new knowledge. However, important discrepancies exist in terminology and definitions between the two databases. The objective of this collaboration between the ESTS and STS is to identify important differences between databases and harmonize terminology and definitions to facilitate future endeavors.
Background The Society of Thoracic Surgeons (STS) creates risk-adjustment models for common cardiothoracic operations for quality improvement purposes. Our aim was to update the lung cancer resection ...risk model utilizing the STS General Thoracic Surgery Database (GTSD) with a larger and more contemporary cohort. Methods We queried the STS GTSD for all surgical resections of lung cancers from January 1, 2012, through December 31, 2014. Logistic regression was used to create three risk models for adverse events: operative mortality, major morbidity, and composite mortality and major morbidity. Results In all, 27,844 lung cancer resections were performed at 231 centers; 62% (n = 17,153) were performed by thoracoscopy. The mortality rate was 1.4% (n = 401), major morbidity rate was 9.1% (n = 2,545), and the composite rate was 9.5% (n = 2,654). Predictors of mortality included age, being male, forced expiratory volume in 1 second, body mass index, cerebrovascular disease, steroids, coronary artery disease, peripheral vascular disease, renal dysfunction, Zubrod score, American Society of Anesthesiologists rating, thoracotomy approach, induction therapy, reoperation, tumor stage, and greater extent of resection (all p < 0.05). For major morbidity and the composite measure, cigarette smoking becomes a risk factor whereas stage, renal dysfunction, congestive heart failure, and cerebrovascular disease lose significance. Conclusions Operative mortality and complication rates are low for lung cancer resection among surgeons participating in the GTSD. Risk factors from the prior lung cancer resection model are refined, and new risk factors such as prior thoracic surgery are identified. The GTSD risk models continue to evolve as more centers report and data are audited for quality assurance.
Treatment of stage I non–small cell lung cancer: What's trending? McMurry, Timothy L., PhD; Shah, Puja M., MD, MS; Samson, Pamela, MD, MPH ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
09/2017, Letnik:
154, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Abstract Objectives Stage I non–small cell lung cancer traditionally is treated with lobectomy. Sublobar resection and stereotactic body radiation therapy provide alternative treatments for ...higher-risk groups. The purpose of this study was to determine the national treatment trends for stage I lung cancer. Methods The National Cancer Database was queried for patients with clinical stage I non–small cell lung cancer between 1998 and 2012. Patients were compared across treatment groups, and trends in treatment and disease were evaluated over the 15-year time period. Results The National Cancer Database contained 369,931 patients with clinical stage I non–small cell lung cancer. After removing patients who received chemotherapy as a first course of treatment and patients with pathologic stage IV, 357,490 patients were analyzed. The first recorded cases of stereotactic body radiation therapy are in 2003 and rapidly increased to 6.6% (2063) of all patients treated in 2012. The number of diagnoses of stage I non–small cell lung cancer steadily increased over the 15-year period, whereas the rate of lobectomy decreased from 55% in 1998 to 50% in 2012 ( P < .001). Most of the decrease in lobectomy can be explained by the increase in the rate of sublobar resection from 12% to 17% ( P < .001). The percentage of untreated patients remained stable at approximately 7% ( P = .283). Conclusions Although the number of stage I non–small cell lung cancer cases continues to increase, lobectomy rates are decreasing while sublobar resection and stereotactic body radiation therapy rates are increasing. Although the increasing popularity of alternative therapies to lobectomy for treatment of stage I non–small cell lung cancer should allow more patients to undergo treatment, we did not observe this trend in the data.
Abstract Objective To review the published literature using propensity scoring, describe shortcomings in the use of this technique, and provide conceptual background for understanding and correctly ...implementing studies that use propensity matching. Methods We survey the published statistical literature and make recommendations for a set of standard criteria for studies that use propensity matching. We evaluated adherence to these criteria in recent publications in the Journal of Thoracic and Cardiovascular Surgery and determined how well the standards were applied. Results We found that studies that use propensity matching are rarely documented well enough to be convincing in their results. When documentation is available, statistical shortcomings are common. Conclusions Improved statistical practice is needed when using propensity scoring. This article suggests standard criteria for using this method in Journal publications.
Background The aim of this study is to create models for perioperative risk of lung cancer resection using the STS GTDB (Society of Thoracic Surgeons General Thoracic Database). Methods The STS GTDB ...was queried for all patients treated with resection for primary lung cancer between January 1, 2002 and June 30, 2008. Three separate multivariable risk models were constructed (mortality, major morbidity, and composite mortality or major morbidity). Results There were 18,800 lung cancer resections performed at 111 participating centers. Perioperative mortality was 413 of 18,800 (2.2%). Composite major morbidity or mortality occurred in 1,612 patients (8.6%). Predictors of mortality include the following: pneumonectomy ( p < 0.001), bilobectomy ( p < 0.001), American Society of Anesthesiology rating ( p < 0.018), Zubrod performance status ( p < 0.001), renal dysfunction ( p = 0.001), induction chemoradiation therapy ( p = 0.01), steroids ( p = 0.002), age ( p < 0.001), urgent procedures ( p = 0.015), male gender ( p = 0.013), forced expiratory volume in one second ( p < 0.001), and body mass index ( p = 0.015). Conclusions Thoracic surgeons participating in the STS GTDB perform lung cancer resections with a low mortality and morbidity. The risk-adjustment models created have excellent performance characteristics and identify important predictors of mortality and major morbidity for lung cancer resections. These models may be used to inform clinical decisions and to compare risk-adjusted outcomes for quality improvement purposes.
The effect of surgeon volume on mortality for off-pump coronary artery bypass grafting LaPar, Damien J., MD, MSc; Mery, Carlos M., MD, MPH; Kozower, Benjamin D., MD, MPH ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
04/2012, Letnik:
143, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Objective Recent trials comparing on-pump (CABG) with off-pump coronary artery bypass grafting (OPCAB) have been criticized by those who believe that surgeon inexperience may explain the apparent ...worse outcomes for OPCAB. However, the true effect of surgeon volume on outcomes after OPCAB remains unknown. The purpose of this study was to examine the effect of surgeon volume on risk-adjusted mortality after OPCAB. Methods From 2003 to 2007, 709,483 patients underwent coronary artery bypass grafting operations (CABG = 439,253; OPCAB = 270,230) within the Nationwide Inpatient Sample database. Hierarchic generalized linear regression modeling with spline functions for annual individual operating surgeon volume was used to assess the relationship between annual surgeon volume and inpatient mortality, adjusted for comorbid disease and other potential confounders. Results OPCAB was performed in 38.1% of coronary artery bypass grafting operations. The average age for those undergoing OPCAB was 66.1 ± 11.1 years, and female patients accounted for 29.3% of operations with 1-vessel (20.4%), 2-vessel (36.6%), 3-vessel (20.5%), or 4 vessels or more (13.6%). Median surgeon volume for OPCAB was 105 (56–156) operations per year. A highly significant nonlinear relationship between surgeon volume and risk-adjusted mortality was observed for OPCAB operations ( P < .01). Specifically, an estimated 5% decrease in the absolute probability of death occurred after OPCAB performed by the surgeons with the highest volume, which is greater than the 3% estimated decrease for conventional CABG. Of note, the effect of surgeon volume on mortality was significantly less than other risk factors, such as the presence of heart failure, renal failure, type of bypass conduit, and gender. Conclusions A significant surgeon volume–outcome relationship exists for mortality after OPCAB with a threshold of more than 50 operations per year. However, the contribution of surgeon volume to the probability of death is incrementally small compared with other patient and operative characteristics. This demonstrates that outcomes after OPCAB are more dependent on patient risk factors than on surgeon volume.
Background Hypoglycemia is a known risk of intensive postoperative glucose control in patients undergoing cardiac operations. However, neither the consequences of hypoglycemia relative to ...hyperglycemia, nor the possible interaction effects, have been well described. We examined the effects of postoperative hypoglycemia, hyperglycemia, and their interaction on short-term morbidity and mortality. Methods Single-institution Society of Thoracic Surgeons (STS) database patient records from 2010 to 2014 were merged with clinical data, including blood glucose values measured in the intensive care unit (ICU). Exclusion criteria included fewer than three glucose measurements and absence of an STS predicted risk of morbidity or mortality score. Primary outcomes were operative mortality and composite major morbidity (permanent stroke, renal failure, prolonged ventilation, pneumonia, or myocardial infarction). Secondary outcomes included ICU and postoperative length of stay. Hypoglycemia was defined as below 70 mg/dL, and hyperglycemia as above 180 mg/dL. Simple and multivariable regression models were used to evaluate the outcomes. Results A total of 2,285 patient records met the selection criteria for analysis. The mean postoperative glucose level was 140.8 ± 18.8 mg/dL. Overall, 21.4% of patients experienced a hypoglycemic episode (n = 488), and 1.05% (n = 24) had a severe hypoglycemic episode (<40 mg/dL). The unadjusted odds ratio (UOR) for operative mortality for patients with any hypoglycemic episode compared with those without was 5.47 (95% confidence interval CI 3.14 to 9.54), and the UOR for major morbidity was 4.66 (95% CI 3.55 to 6.11). After adjustment for predicted risk of morbidity or mortality and other significant covariates, the adjusted odds (AOR) of operative mortality were significant for patients with any hypoglycemia (AOR 4.88, 95% CI 2.67 to 8.92) and patients with both events (AOR 8.29, 95% CI 1.83 to 37.5) but not hyperglycemia alone (AOR 1.62, 95% CI 0.56 to 4.69). The AOR of major morbidity for patients with both hypoglycemic and hyperglycemic events was 14.3 (95% CI 6.50 to 31.4). Conclusions Postoperative hypoglycemia is associated with both mortality and major morbidity after cardiac operations. The combination of both hyperglycemia and hypoglycemia represents a substantial increase in risk. Although it remains unclear whether hypoglycemia is a cause, an early warning sign, or a result of adverse events, this study suggests that hypoglycemia may be an important event in the postoperative period after cardiac operations.
Background The Society of Thoracic Surgeons (STS) has developed multidimensional composite quality measures for common cardiac surgery procedures. This first composite measure for general thoracic ...surgery evaluates STS participant performance for lobectomy in lung cancer patients. Methods The STS lobectomy composite score is composed of two outcomes: risk-adjusted mortality; and any-or-none, risk-adjusted major complications. General Thoracic Surgery Database data were included from 2011 to 2014 to provide adequate sample size, and 95% Bayesian credible intervals were used to determine “star ratings.” The STS participants were also compared with national benchmarks (including non-STS participants) using the National Inpatient Sample. Comparisons of discharge mortality, postoperative length of stay, and percent of stage I lung cancers resected using minimally invasive approaches are not included in star ratings but will be reported to participants in STS feedback reports. Results The study population included 20,657 lobectomy patients from 231 participating centers. Operative mortality was 1.5%, major complication rate was 9.6%, and median postoperative length of stay was 4 days. Risk-adjusted mortality and major complication rates varied threefold from highest performing (three-star) to lowest performing (one-star) programs. Approximately 5% of participants were one-star, 7% were three-star, and 88% were two-star programs. Conclusions The STS has developed the first general thoracic surgery quality composite measure to compare programs performing lobectomy for lung cancer. This measure will be used for quality assessment and provider feedback, and will be made available for voluntary public reporting.
Background Clinical guidelines are created to reduce variation in care practices, with the goal of improving patient outcomes. There is currently no international consensus on best practices for ...pulmonary resection. Our aim was to evaluate variation in treatment patterns and outcomes for pulmonary resection by comparing The Society of Thoracic Surgeons (STS) and the European Society of Thoracic Surgery (ESTS) general thoracic surgery databases (GTSDs). Methods An international collaboration was established between the STS and ESTS GTSD task forces. Patients who underwent pulmonary resection between 2010 and 2013 were identified from the 2 databases. Data on patient demographics, disease characteristics, treatment strategies, morbidity, and mortality were compared. Results There were 78,212 lung resections captured in the STS (n = 47,539) and ESTS databases (n = 30,673). Patients from the STS database were more likely to be of the female sex, have no pathologic N2 disease, have had previous cardiothoracic operations, and have received preoperative thoracic irradiation compared with patients from the ESTS database. In addition, patients from the STS database were more likely to have undergone a thoracoscopic operation and have received a sublobar resection. Although there was an increased risk of reintubation, atrial arrhythmias, and return to the operating room in the STS patients, the mean hospital length of stay was shorter than in patients from the ESTS database, regardless of operation performed. Thirty-day mortality was higher in the STS patients for wedge resection ( p < 0.001) but lower for lobectomy ( p < 0.001) and pneumonectomy ( p < 0.001) compared with the ESTS patients. Conclusions Differences exists in patient population, procedures performed, and outcomes for pulmonary resections between the STS and ESTS databases, suggesting an opportunity for quality improvement initiatives.
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