The Lung Cancer Prediction Model "Stress Test": Assessment of Models' Performance in a High-Risk Prospective Pulmonary Nodule Cohort.

BACKGROUND: Pulmonary nodules represent a growing health care burden because of delayed diagnosis of malignant lesions and overtesting for benign processes. Clinical prediction models were developed to inform physician assessment of pretest probability of nodule malignancy but have not been validated in a high-risk cohort of nodules for which biopsy was ultimately performed. RESEARCH QUESTION: Do guideline-recommended prediction models sufficiently discriminate between benign and malignant nodules when applied to cases referred for biopsy by navigational bronchoscopy? STUDY DESIGN AND METHODS: We assembled a prospective cohort of 322 indeterminate pulmonary nodules in 282 patients referred to a tertiary medical center for diagnostic navigational bronchoscopy between 2017 and 2019. We calculated the probability of malignancy for each nodule using the Brock model, Mayo Clinic model, and Veterans Affairs (VA) model. On a subset of 168 patients who also had PET-CT scans before biopsy, we also calculated the probability of malignancy using the Herder model. The performance of the models was evaluated by calculating the area under the receiver operating characteristic curves (AUCs) for each model. RESULTS: The study cohort contained 185 malignant and 137 benign nodules (57% prevalence of malignancy). The malignant and benign cohorts were similar in terms of size, with a median longest diameter for benign and malignant nodules of 15 and 16 mm, respectively. The Brock model, Mayo Clinic model, and VA model showed similar performance in the entire cohort (Brock AUC, 0.70; 95% CI, 0.64-0.76; Mayo Clinic AUC, 0.70; 95% CI, 0.64-0.76; VA AUC, 0.67; 95% CI, 0.62-0.74). For 168 nodules with available PET-CT scans, the Herder model had an AUC of 0.77 (95% CI, 0.68-0.85). INTERPRETATION: Currently available clinical models provide insufficient discrimination between benign and malignant nodules in the common clinical scenario in which a patient is being referred for biopsy, especially when PET-CT scan information is not available.

Preparing for Bundled Payments: Impact of Complications Post-Coronary Artery Bypass Grafting on Costs.

BACKGROUND: Bundled payments for coronary artery bypass grafting (CABG) provide a single reimbursement for care provided from admission through 90 days post-discharge. We aim to explore the impact of complications on total institutional costs, as well as the drivers of high costs for index hospitalization. METHODS: We linked clinical and internal cost data for patients undergoing CABG from 2014 to 2017 at a single institution. We compared unadjusted average variable direct costs, reporting excess cost from an uncomplicated baseline. We stratified by The Society of Thoracic Surgeons preoperative risk and quality outcome measures as well as value-based outcomes (readmission, post-acute care utilization). We performed multivariable linear regression to evaluate drivers of high costs, adjusting for preoperative and intraoperative characteristics and postoperative complications. RESULTS: We reviewed 1789 patients undergoing CABG with an average of 2.7 vessels (SD 0.89). A significant proportion of patients were diabetic (51.2%) and obese (mean body mass index 30.6, SD 6.1). Factors associated with increased adjusted costs were preoperative renal failure (P = .001), diabetes (P = .001) and body mass index (P = .05), and postoperative stroke (P < .001), prolonged ventilation (P < .001), rebleeding requiring reoperation (P < .001) and renal failure (P < .001) with varying magnitude. Preoperative ejection fraction and insurance status were not associated with increased adjusted costs. CONCLUSIONS: Preoperative characteristics had less of an impact on costs post-CABG than postoperative complications. Postoperative complications vary in their impact on internal costs, with reoperation, stroke, and renal failure having the greatest impact. In preparation for bundled payments, hospitals should focus on understanding and preventing drivers of high cost.

Cost-Effectiveness Analysis of Fibrinolysis vs Thoracoscopic Decortication for Early Empyema.

BACKGROUND: Surgical decortication is recommended by national guidelines for management of early empyema, but intrapleural fibrinolysis is frequently used as a first-line therapy in clinical practice. This study compared the cost-effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema. METHODS: A decision analysis model was developed. The base clinical case was a 65-year-old man with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator and deoxyribonuclease. The likelihood of key outcomes occurring was derived from the literature. Medicare diagnosis-related groups and manufacturers' drug prices were used for cost estimates. Successful treatment was defined as complete or nearly complete resolution of empyema on imaging. Effectiveness was defined as health utility 1 year after empyema. RESULTS: Intrapleural tissue plasminogen activator and deoxyribonuclease were more cost-effective than VATS decortication for treating early empyema for the base clinical case. Surgical decortication had a slightly lower cost than fibrinolysis ($13,345 vs $13,965), but fibrinolysis had marginally higher effectiveness at 1 year (health utility of 0.80 vs 0.71). Therefore, fibrinolysis was the more cost-effective option. Sensitivity analyses found that fibrinolysis as the initial therapy was more cost-effective when the probability of success was greater than 60% or the initial cost was less than $13,000. CONCLUSIONS: Surgical decortication and intrapleural fibrinolysis have nearly equivalent cost-effectiveness for early empyema in patients who can tolerate both procedures. Surgeons should consider patient-specific factors, as well as the cost and effectiveness of both modalities, when deciding on an initial treatment for early empyema.

Modeling the Impact of Delaying Bariatric Surgery due to COVID-19: a Decision Analysis.

We developed a decision analysis model to evaluate risks and benefits of delaying scheduled bariatric surgery during the novel coronavirus disease (COVID-19) pandemic. Our base case was a 45-year-old female with diabetes and a body mass index of 45 kg/m2. We compared immediate with delayed surgery after 6 months to allow for COVID-19 prevalence to decrease. We found that immediate and delayed bariatric surgeries after 6 months resulted in similar 20-year overall survival. When the probability of COVID-19 infection exceeded 4%, then delayed surgery improved survival. If future COVID-19 infection rates were at least half those in the immediate scenario, then immediate surgery was favored and local infection rates had to exceed 9% before surgical delay improved survival. Surgeons should consider local disease prevalence and patient comorbidities associated with increased mortality before resuming bariatric surgery programs.

Racial Disparities in Lung Cancer Survival: The Contribution of Stage, Treatment, and Ancestry.

INTRODUCTION: Lung cancer is a leading cause of cancer-related death worldwide. Racial disparities in lung cancer survival exist between blacks and whites, yet they are limited by categorical definitions of race. We sought to examine the impact of African ancestry on overall survival among blacks and whites with NSCLC cases. METHODS: Incident cases of NSCLC in blacks and whites from the prospective Southern Community Cohort Study (N = 425) were identified through linkage with state cancer registries in 12 southern states. Vital status was determined by linkage with the National Death Index and Social Security Administration. We evaluated the impact of African ancestry (as estimated by using genome-wide ancestry-informative markers) on overall survival by calculating the time-dependent area under the curve (AUC) for Cox proportional hazards models, adjusting for relevant covariates such as stage and treatment. We replicated our findings in an independent population of NSCLC cases in blacks. RESULTS: Global African ancestry was not significantly associated with overall survival among NSCLC cases. There was no change in model performance when Cox proportional hazards models with and without African ancestry were compared (AUC = 0.79 for each model). Removal of stage and treatment reduced the average time-dependent AUC from 0.79 to 0.65. Similar findings were observed in our replication study. CONCLUSIONS: Stage and treatment are more important predictors of survival than African ancestry is. These findings suggest that racial disparities in lung cancer survival may disappear with similar early detection efforts for blacks and whites.

Assessment of Fluorodeoxyglucose F18-Labeled Positron Emission Tomography for Diagnosis of High-Risk Lung Nodules.

Importance: Clinicians rely heavily on fluorodeoxyglucose F18-labeled positron emission tomography (FDG-PET) imaging to evaluate lung nodules suspicious for cancer. We evaluated the performance of FDG-PET for the diagnosis of malignancy in differing populations with varying cancer prevalence. Objective: To determine the performance of FDG-PET/computed tomography (CT) in diagnosing lung malignancy across different populations with varying cancer prevalence. Design, Setting, and Participants: Multicenter retrospective cohort study at 6 academic medical centers and 1 Veterans Affairs facility that comprised a total of 1188 patients with known or suspected lung cancer from 7 different cohorts from 2005 to 2015. Exposures: 18F fluorodeoxyglucose PET/CT imaging. Main Outcome and Measures: Final diagnosis of cancer or benign disease was determined by pathological tissue diagnosis or at least 18 months of stable radiographic follow-up. Results: Most patients were male smokers older than 60 years. Overall cancer prevalence was 81% (range by cohort, 50%-95%). The median nodule size was 22 mm (interquartile range, 15-33 mm). Positron emission tomography/CT sensitivity and specificity were 90.1% (95% CI, 88.1%-91.9%) and 39.8% (95% CI, 33.4%-46.5%), respectively. False-positive PET scans occurred in 136 of 1188 patients. Positive predictive value and negative predictive value were 86.4% (95% CI, 84.2%-88.5%) and 48.7% (95% CI, 41.3%-56.1%), respectively. On logistic regression, larger nodule size and higher population cancer prevalence were both significantly associated with PET accuracy (odds ratio, 1.027; 95% CI, 1.015-1.040 and odds ratio, 1.030; 95% CI, 1.021-1.040, respectively). As the Mayo Clinic model-predicted probability of cancer increased, the sensitivity and positive predictive value of PET/CT imaging increased, whereas the specificity and negative predictive value dropped. Conclusions and Relevance: High false-positive rates were observed across a range of cancer prevalence. Normal PET/CT scans were not found to be reliable indicators of the absence of disease in patients with a high probability of lung cancer. In this population, aggressive tissue acquisition should be prioritized using a comprehensive lung nodule program that emphasizes advanced tissue acquisition techniques such as CT-guided fine-needle aspiration, navigational bronchoscopy, and endobronchial ultrasonography.

Minority Underrepresentation in Academia: Factors Impacting Careers of Surgery Residents.

BACKGROUND: Underrepresentation of minorities within academic surgery is an ever present problem with a profound impact on healthcare. The factors influencing surgery residents to pursue an academic career have yet to be formally investigated. We sought to elucidate these factors, with a focus on minority status. METHODS: A web-based questionnaire was sent to all administered to all ACGME-accredited general surgery programs in the United States. The main outcome was the decision to pursue a fully academic versus non-academic career. Multivariable logistic regression was used to identify characteristics impacting career choice. RESULTS: Of the 3,726 residents who received the survey, a total of 1,217 residents completed it - a response rate of 33%. Forty-seven percent planned to pursue non-academic careers, 35% academic careers, and 18% were undecided. There was no association between underrepresented minority status and academic career choice (Odds Ratio = 1.0, 95% Confidence Interval 0.6 - 1.6). Among all residents, research during training (OR=4.0, 95% CI 2.7-5.9), mentorship (OR=2.1, 95% CI 1.6-2.9), and attending a residency program requiring research (OR=2.3, 95% CI 1.5-3.4) were factors associated with choosing an academic career. When the analysis was performed among only senior residents (i.e., 4th and 5th year residents), a debt burden >$150,000 was associated with choosing a non-academic career (OR=0.4, 95% CI 0.1-0.9). CONCLUSIONS: Underrepresented minority status is not associated with career choice. Intentional recruitment of minorities into research-oriented training programs, increased mentorship and research support among current minority residents, and improved financial options for minorities may increase the number choosing an academic surgical career.

Cost-effectiveness of initial diagnostic strategies for pulmonary nodules presenting to thoracic surgeons.

BACKGROUND: Patients presenting to thoracic surgeons with pulmonary nodules suggestive of lung cancer have varied diagnostic options including navigation bronchoscopy (NB), computed tomography-guided fine-needle aspiration (CT-FNA), (18)F-fluoro-deoxyglucose positron emission tomography (FDG-PET) and video-assisted thoracoscopic surgery (VATS). We studied the relative cost-effective initial diagnostic strategy for a 1.5- to 2-cm nodule suggestive of cancer. METHODS: A decision analysis model was developed to assess the costs and outcomes of four initial diagnostic strategies for diagnosis of a 1.5- to 2-cm nodule with either a 50% or 65% pretest probability of cancer. Medicare reimbursement rates were used for costs. Quality-adjusted life years were estimated using patient survival based on pathologic staging and utilities derived from the literature. RESULTS: When cancer prevalence was 65%, tissue acquisition strategies of NB and CT-FNA had higher quality-adjusted life years compared with either FDG-PET or VATS, and VATS was the most costly strategy. In sensitivity analyses, NB and CT-FNA were more cost-effective than FDG-PET when FDG-PET specificity was less than 72%. When cancer prevalence was 50%, NB, CT-FNA, and FDG-PET had similar cost-effectiveness. CONCLUSIONS: Both NB and CT-FNA diagnostic strategies are more cost-effective than either VATS biopsy or FDG-PET scan to diagnose lung cancer in moderate- to high-risk nodules and resulted in fewer nontherapeutic operations when FDG-PET specificity was less than 72%. An FDG-PET scan for diagnosis of lung cancer may not be cost-effective in regions of the country where specificity is low.

Poor survival for veterans with pathologic stage I non-small-cell lung cancer.

BACKGROUND: Pathologic stage (pStage) IA and IB non-small-cell lung cancer (NSCLC) has a median survival time of 119 and 81 months, respectively. We describe the outcomes of veterans with pStage I NSCLC. METHODS: A retrospective review of 78 patients with pStage I NSCLC who underwent cancer resection was performed at the Tennessee Valley Veterans Affairs Hospital between 2005 and 2010. All-cause 30-day, 90-day, and overall mortality were determined. Survival was assessed with the Kaplan-Meier and Cox proportional hazards methods. RESULTS: There were 55 (71%) pStage IA and 23 (29%) IB patients. Thirty- and 90-day mortality was 3.8% (3 of 78) and 6.4% (5 of 78), respectively. Median survival was 59 and 28 months for pStage 1A and 1B, respectively. Postoperative events were associated with impaired survival on multivariable analysis (hazard ratio, 1.26, P = .03). CONCLUSIONS: Veterans with pStage I NSCLC at our institution have poorer survival than the general population. More research is needed to determine the etiology of this disparity.

Thoracic operations for pulmonary nodules are frequently not futile in patients with benign disease.

INTRODUCTION: Pulmonary nodules often require operative resection to obtain a diagnosis. However, 10 to 30% of operations result in a benign diagnosis. Our purpose was to determine whether negative thoracic operations are futile by describing the pathological diagnoses; determining new diagnoses and treatment changes initiated based on operative findings; and assessing morbidity, mortality, and cost of the procedure. METHODS: At our academic medical center, 278 thoracic operations were performed for known or suspected cancer between January 1, 2005, and April 1, 2009. We collected and summarized data pertaining to preoperative patient and nodule characteristics, pathologic diagnosis, postoperative treatment changes resulting from surgical resection, perioperative morbidity and mortality, and hospital charges for patients with benign pathology. RESULTS: Twenty-three percent (65/278) of patients who underwent surgical resection for a suspicious nodule had benign pathology. We report granulomatous disease in 57%, benign tumors in 15%, fibrosis in 12%, and autoimmune and vascular diseases in 9%. Definitive diagnosis or treatment changes occurred in 85% of cases. Surgical intervention led to a new diagnosis in 69%, treatment course changes in 68% of benign cases, medication changes in 38%, new consultation in 31%, definitive treatment in 9%, and underlying disease management in 34%. There was no intraoperative, in-hospital, or 30-day mortality. Postoperative in-hospital events occurred in seven patients. The mean total cost was $25,515 with a mean cost per day of $7618. CONCLUSIONS: Patients with a benign diagnosis after surgical resection for a pulmonary nodule received a new diagnosis or had a treatment course change in 85% of the cases.

Radiotracer-guided thoracoscopic resection is a cost-effective technique for the evaluation of subcentimeter pulmonary nodules.

BACKGROUND: Excisional biopsy of small subcentimeter pulmonary nodules can be difficult using standard thoracoscopic techniques and may require thoracotomy. Radiotracer-guided thoracoscopic resection (RGTR) was developed to facilitate resection of intraparenchymal subcentimeter pulmonary nodules. Decision analysis, used to model cost and effectiveness, is useful to compare treatment options. We hypothesize that RGTR strategy is more cost-effective compared with thoracotomy for subcentimeter pulmonary nodules. METHODS: The cost-effectiveness of RGTR versus thoracotomy for evaluating highly suspicious subcentimeter pulmonary nodules was examined with a decision analysis model (Fig 1). A 40-patient institutional cohort who underwent RGTR was used to estimate probabilities and costs of the two treatment options within the model. Effectiveness was estimated using 5-year, stage-specific cancer survival and population survival curves. The Society of Thoracic Surgeons General Thoracic Database was queried obtaining mortality estimates for thoracotomy and thoracoscopic wedge resections. These were used to adjust the 5-year survival estimates of patients with benign disease. Sensitivity analyses determined model robustness and the thresholds at which the most cost-effective strategy changed. RESULTS: Radiotracer-guided thoracoscopic resection was 95% successful with no mortality. The average cost-to-effectiveness ratio of RGTR strategy was $27,887 versus $32,271 for thoracotomy. Sensitivity analyses demonstrated that the thoracotomy strategy was more cost-effective if the estimated cost of RGTR increased by 33% or the estimated cost-effectiveness of thoracotomy decreased by 14% or more. Radiotracer-guided thoracoscopic resection was more cost-effective as long as the probability of success was greater than 44%. CONCLUSIONS: Decision analysis is a useful tool to evaluate treatment options for thoracic surgeons, and RGTR is a more cost-effective strategy than thoracotomy for subcentimeter pulmonary nodules.

Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan.

BACKGROUND: In the evaluation of the cervical spine (c-spine), helical CT scan has higher sensitivity and specificity than plain radiographs in the moderate- and high-risk trauma population, but is more costly. We hypothesize that institutional costs associated with missed injuries make helical CT scan the least costly approach. STUDY DESIGN: A cost-minimization study was performed using decision analysis examining helical CT scan versus radiographic evaluation of the c-spine. Parameter estimates were obtained from the literature for probability of c-spine injury, probability of paralysis after missed injury, plain film sensitivity and specificity, CT scan sensitivity and specificity, and settlement cost of missed injuries resulting in paralysis. Institutional costs of CT scan and plain radiography were used. Sensitivity analyses tested robustness of strategy preference, accounted for parameter variability, and determined threshold values for individual parameters on strategy preference. RESULTS: C-spine evaluation with helical CT scan has an expected cost of US 554 dollars per patient compared with US 2,142 dollars for plain films. CT scan is the least costly alternative if threshold values exceed US 58,180 dollars for institutional settlement costs, 0.9% for probability of c-spine fracture, and 1.7% for probability of paralysis. Plain films are least costly if CT scan costs surpass US 1,918 dollars or plain film sensitivity exceeds 90%. CONCLUSIONS: Helical CT scan is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are taken into account.