RESUMEN
BACKGROUND: Conversion to thoracotomy during minimally invasive lobectomy for lung cancer is occasionally necessary. Differences between video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) lobectomy conversion have not been described. METHODS: We queried The Society of Thoracic Surgeons General Thoracic Surgery Database from January 1, 2015 to December 31, 2018. Patients with prior thoracic operations and metastatic disease were excluded. Univariable comparisons with χ2 and Kruskal-Wallis tests and multivariable logistic regression modeling were performed. RESULTS: There were 27,695 minimally invasive lobectomies from 269 centers. Conversion to thoracotomy occurred in 11.0% of VATS and 6.0% of RATS (P < .001). Conversion was associated with increased mortality (P < .001), major complications (P < .001), and intraoperative (P < .001) and postoperative (P < .001) blood transfusions. Conversion from RATS occurred emergently (P < .001) and for vascular injury (P < .001) more frequently than from VATS, but there was no difference in overall major complications or mortality. Mortality after conversion was 3.1% for RATS and 2.2% for VATS (P = .24). Clinical cancer stage II or III (P < .001), preoperative chemotherapy (P = .003), forced expiratory volume in 1 second (P = .006), body mass index (P < .001), and left-sided resection (P = .0002) independently predicted VATS conversion. For RATS clinical stage III (P = .037), left-sided resection (P = .041), and forced expiratory volume in 1 second (P = .002) predicted conversion. Lower volume centers had increased rates of conversion (P < .001) in both groups. CONCLUSIONS: Conversion from minimally invasive to open lobectomy is associated with increased morbidity and mortality. Conversion occurs more frequently during VATS compared with RATS, albeit less often emergently, and with similar rates of overall mortality and major complications. Predictors, urgency, and reasons for conversion differ between RATS and VATS lobectomy and may assist in patient selection.
Asunto(s)
Neoplasias Pulmonares , Procedimientos Quirúrgicos Robotizados , Humanos , Neoplasias Pulmonares/patología , Neumonectomía , Estudios Retrospectivos , Cirugía Torácica Asistida por Video , ToracotomíaRESUMEN
The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Cirugía Torácica , Anciano , Investigación Biomédica , Procedimientos Quirúrgicos Cardíacos/normas , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de la Atención de Salud , Resultado del TratamientoRESUMEN
The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive database in cardiac surgery and one of the most respected clinical data registries in health care. It is widely acknowledged for accurately benchmarking risk-adjusted outcomes and serving as the foundation for quality measurement and improvement activities in cardiac surgery. In addition, the database is a valuable resource for novel research. The advent of the database's fourth decade in operation is being heralded with major revisions to its functionality, ease of use, and value to multiple stakeholders. This report is the fifth in a series of annual reports that provides updated national outcomes, volume trends, and database-related developments, as well as a summary of research performed in the past year using data from this valuable repository on quality and performance improvement.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Bases de Datos Factuales , Sociedades Médicas , Cirugía Torácica , Adulto , Investigación Biomédica , Procedimientos Quirúrgicos Cardíacos/tendencias , Humanos , Resultado del TratamientoAsunto(s)
Investigación Biomédica , Cardiología , Enfermedad de la Arteria Coronaria/terapia , Revascularización Miocárdica , Evaluación de Resultado en la Atención de Salud/normas , Pautas de la Práctica en Medicina , American Heart Association , Investigación Biomédica/métodos , Investigación Biomédica/normas , Cardiología/métodos , Cardiología/normas , Reglas de Decisión Clínica , Exactitud de los Datos , Humanos , Revascularización Miocárdica/métodos , Revascularización Miocárdica/normas , Pautas de la Práctica en Medicina/organización & administración , Pautas de la Práctica en Medicina/normas , Reportes Públicos de Datos en Atención de Salud , Estados UnidosAsunto(s)
Investigación sobre la Eficacia Comparativa/normas , Enfermedad Coronaria/terapia , Exactitud de los Datos , Minería de Datos/normas , Bases de Datos Factuales/normas , Revascularización Miocárdica/normas , Consenso , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/epidemiología , Humanos , Revascularización Miocárdica/efectos adversos , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Terminología como Asunto , Resultado del Tratamiento , Vocabulario ControladoRESUMEN
BACKGROUND: International collaboration has an interest in health care quality evaluation. We compared characteristics and surgical outcomes between Asian patients in the United States and Japanese patients who undergo adult cardiac surgery. METHODS: Using the Japan Adult Cardiovascular Surgery Database (JCVSD) and The Society of Thoracic Surgeons (STS) National Database, we compared Asian patients undergoing isolated coronary artery bypass graft surgery between 2013 and 2016 in Japan and the United States. The STS had 16,903 Asian patients among 573,823 patients of all races undergoing isolated coronary artery bypass graft surgery (2.95%); the JCVSD had 55,570 patients, almost all of whom are Japanese. Descriptive statistics were analyzed independently, then the data were aggregated for comparison. RESULTS: The JCVSD patients were older (69 vs 65 years) with a smaller body surface area (1.65 m2 vs 1.81 m2) and body mass index (24 kg/m2 vs 26 kg/m2). The proportion of males (79% vs 78%), prevalence of chronic lung disease (82% vs 86%), and diabetes mellitus (54% vs 60%) were similar. The JCVSD had higher prevalence of renal disease requiring dialysis (11% vs 6%). The numbers of anastomoses were similar (3.1 vs 3.3); off-pump procedures and the usage of right internal mammary artery were more prevalent (60% vs 15% and 38% vs 7%, respectively) in the JCVSD. The unadjusted operative mortality was 2.7% in the JCVSD and 2.1% in the STS database. CONCLUSIONS: Comparisons of coronary artery bypass graft surgery characteristics and outcomes were conducted between the STS National Database and the JCVSD to illustrate the value of international collaboration on adult cardiac surgery databases.
Asunto(s)
Cardiología/estadística & datos numéricos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Complicaciones Posoperatorias/epidemiología , Mejoramiento de la Calidad , Medición de Riesgo/métodos , Sociedades Médicas , Anciano , Bases de Datos Factuales , Estudios de Seguimiento , Humanos , Incidencia , Japón/epidemiología , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety for cardiothoracic surgery. The STS National Database has 4 components, each focusing on a distinct discipline-Adult Cardiac Surgery, General Thoracic Surgery, Congenital Heart Surgery, and mechanical circulatory support with the STS Interagency Registry for Mechanical Circulatory Support (Intermacs)/Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides the fourth annual summary of the status of the STS National Database.
Asunto(s)
Bases de Datos Factuales , Sociedades Médicas , Cirugía Torácica , Sistema de Registros , Sociedades Médicas/estadística & datos numéricos , Cirugía Torácica/estadística & datos numéricosRESUMEN
OBJECTIVES: Beginning in 2002, all 14 Massachusetts nonfederal cardiac surgery programs submitted Society of Thoracic Surgeons (STS) National Database data to the Massachusetts Data Analysis Center for mandatory state-based analysis and reporting, and to STS for nationally benchmarked analyses. We sought to determine whether longitudinal prevalences and trends in risk factors and observed and expected mortality differed between Massachusetts and the nation. METHODS: We analyzed 2003 to 2014 expected (STS predicted risk of operative [in-hospital + 30-day] mortality), observed, and risk-standardized isolated coronary artery bypass graft mortality using Massachusetts STS data (N = 39,400 cases) and national STS data (N = 1,815,234 cases). Analyses included percentage shares of total Massachusetts coronary artery bypass graft volume and expected mortality rates of 2 hospitals before and after outlier designation. RESULTS: Massachusetts patients had significantly higher odds of diabetes, peripheral vascular disease, low ejection fraction, and age ≥75 years relative to national data and lower odds of shock (odds ratio, 0.66; 99% confidence interval, 0.53-0.83), emergency (odds ratio, 0.57, 99% confidence interval, 0.52-0.61), reoperation, chronic lung disease, dialysis, obesity, and female sex. STS predicted risk of operative [in-hospital + 30-day] mortality for Massachusetts patients was higher than national rates during 2003 to 2007 (P < .001) and no different during 2008 to 2014 (P = .135). Adjusting for STS predicted risk of operative [in-hospital + 30-day] mortality, Massachusetts patients had significantly lower odds (odds ratio, 0.79; 99% confidence interval, 0.66-0.96) of 30-day mortality relative to national data. Outlier programs experienced inconsistent, transient influences on expected mortality and their percentage shares of Massachusetts coronary artery bypass graft cases. CONCLUSIONS: During 12 years of mandatory public reporting, Massachusetts risk-standardized coronary artery bypass graft mortality was consistently and significantly lower than national rates, expected rates were comparable or higher, and evidence for risk aversion was conflicting and inconclusive.
Asunto(s)
Puente de Arteria Coronaria/estadística & datos numéricos , Notificación Obligatoria , Anciano , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Bases de Datos como Asunto , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Massachusetts/epidemiología , Persona de Mediana EdadRESUMEN
The Society of Thoracic Surgeons Adult Cardiac Surgery Database is one of the most mature, comprehensive, and respected clinical data registries in health care. Through nearly three decades of growth and refinement, it is widely recognized for accurately benchmarking risk-adjusted outcomes in cardiac surgery and serves as the foundation for all quality measurement and improvement activities of The Society of Thoracic Surgeons. This is the fourth in a series of annual reports that provides updated national outcomes, volume trends, and database-related developments in quality measurement and performance improvement.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Bases de Datos Factuales , Mejoramiento de la Calidad , Cirugía Torácica , Adulto , Humanos , Evaluación de Resultado en la Atención de Salud , Sociedades MédicasRESUMEN
The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. As of January 1, 2018, the STS National Database has four components, each focusing on a different area of cardiothoracic surgery-adult cardiac surgery, general thoracic surgery, and congenital heart surgery, as well as mechanical circulatory support through the STS Intermacs Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. As part of that series, this article provides an annual summary of the status of the STS National Database as of October 2018 and provides a synopsis of related articles that appeared in The Annals of Thoracic Surgery 2018 series entitled: "Outcomes Analysis, Quality Improvement, and Patient Safety".
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Bases de Datos Factuales , Sociedades Médicas , Cirugía Torácica , Informes Anuales como Asunto , Humanos , Estados UnidosRESUMEN
The Society of Thoracic Surgeons Adult Cardiac Database (ACSD) is an international voluntary registry that provides adult cardiac surgery programs with risk-adjusted outcome reports for quality improvement. With more than 6,300,000 procedural records in adult cardiac surgery, the ACSD has proven to be a leading instrument for clinical outcomes research. The ACSD generated numerous major original contributions that were either published or accepted for publication in 2017. These works significantly contributed to the practice of adult cardiac surgery through outcome measurement and quality improvement. This paper summarizes the recent ACSD contributions to the literature.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/normas , Bases de Datos Factuales , Evaluación de Resultado en la Atención de Salud , Seguridad del Paciente , Mejoramiento de la Calidad , Sistema de Registros , Adulto , Aorta Torácica/cirugía , Fibrilación Atrial/cirugía , Puente de Arteria Coronaria/normas , Válvulas Cardíacas/cirugía , Humanos , Cuidados Posoperatorios , Sociedades Médicas , Cirugía Torácica/organización & administración , Resultado del TratamientoRESUMEN
BACKGROUND: The Society of Thoracic Surgeons (STS) uses statistical models to create risk-adjusted performance metrics for Adult Cardiac Surgery Database (ACSD) participants. Because of temporal changes in patient characteristics and outcomes, evolution of surgical practice, and additional risk factors available in recent ACSD versions, completely new risk models have been developed. METHODS: Using July 2011 to June 2014 ACSD data, risk models were developed for operative mortality, stroke, renal failure, prolonged ventilation, mediastinitis/deep sternal wound infection, reoperation, major morbidity or mortality composite, prolonged postoperative length of stay, and short postoperative length of stay among patients who underwent isolated coronary artery bypass grafting surgery (n = 439,092), aortic or mitral valve surgery (n = 150,150), or combined valve plus coronary artery bypass grafting surgery (n = 81,588). Separate models were developed for each procedure and endpoint except mediastinitis/deep sternal wound infection, which was analyzed in a combined model because of its infrequency. A surgeon panel selected predictors by assessing model performance and clinical face validity of full and progressively more parsimonious models. The ACSD data (July 2014 to December 2016) were used to assess model calibration and to compare discrimination with previous STS risk models. RESULTS: Calibration in the validation sample was excellent for all models except mediastinitis/deep sternal wound infection, which slightly underestimated risk and will be recalibrated in feedback reports. The c-indices of new models exceeded those of the last published STS models for all populations and endpoints except stroke in valve patients. CONCLUSIONS: New STS ACSD risk models have generally excellent calibration and discrimination and are well suited for risk adjustment of STS performance metrics.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Modelos Estadísticos , Complicaciones Posoperatorias/etiología , Medición de Riesgo , Adulto , Bases de Datos Factuales , Humanos , Sociedades Médicas , Cirugía TorácicaRESUMEN
BACKGROUND: The last published version of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) risk models were developed in 2008 based on patient data from 2002 to 2006 and have been periodically recalibrated. In response to evolving changes in patient characteristics, risk profiles, surgical practice, and outcomes, the STS has now developed a set of entirely new risk models for adult cardiac surgery. METHODS: New models were estimated for isolated coronary artery bypass grafting surgery (CABG [n = 439,092]), isolated aortic or mitral valve surgery (n = 150,150), and combined valve plus CABG procedures (n = 81,588). The development set was based on July 2011 to June 2014 STS ACSD data; validation was performed using July 2014 to December 2016 data. Separate models were developed for operative mortality, stroke, renal failure, prolonged ventilation, reoperation, composite major morbidity or mortality, and prolonged or short postoperative length of stay. Because of its low occurrence rate, a combined model incorporating all operative types was developed for deep sternal wound infection/mediastinitis. RESULTS: Calibration was excellent except for the deep sternal wound infection/mediastinitis model, which slightly underestimated risk because of higher rates of this endpoint in the more recent validation data; this will be recalibrated in each feedback report. Discrimination (c-index) of all models was superior to that of 2008 models except for the stroke model for valve patients. CONCLUSIONS: Completely new STS ACSD risk models have been developed based on contemporary patient data; their performance is superior to that of previous STS ACSD models.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Modelos Estadísticos , Complicaciones Posoperatorias/etiología , Medición de Riesgo , Adulto , Bases de Datos Factuales , Humanos , Sociedades Médicas , Cirugía TorácicaRESUMEN
Through nearly 3 decades of iterative refinement, The Society of Thoracic Surgeons Adult Cardiac Surgery Database has evolved into one of the most comprehensive and respected clinical data registries in health care. It is a widely acknowledged exemplar for accurately benchmarking risk-adjusted outcomes in cardiac surgery and underpins all quality measurement and improvement activities of The Society of Thoracic Surgeons. This is the latest in a series of annual reports that outlines current national aggregate outcomes and volume trends in cardiac surgery and summarizes database-related work in quality measurement and performance improvement during the past year.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Bases de Datos Factuales , Mejoramiento de la Calidad , Sociedades Médicas , Cirugía Torácica , Adulto , Humanos , Estados UnidosRESUMEN
Part 1 of this review summarizes the consequences of risk aversion and the observational studies and surveys relevant to this phenomenon, almost all of which are derived from cardiac surgery and interventional cardiology. In Part 2, we describe the root cause of risk aversion-the belief by providers that current risk adjustment is inadequate to account for the severity of their highest-risk patients, thereby prejudicing their publicly reported performance scores. Evidence supporting the robustness of current risk adjustment is presented, as well as nine potential strategies to further mitigate risk aversion: optimization of data source, risk models, and performance measures; exclusion of high-risk patients; exclusion of non-procedure-related end points; separate reporting of high-risk patients; reporting by condition or diagnosis rather than by procedures; reporting at the hospital or program level rather than the physician level; collaborative, cross-disciplinary decision making; active surveillance for risk aversion; and improved stakeholder education. Of these, the first is most desirable, widely applicable, and resistant to gaming.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Cardiología , Toma de Decisiones , Cirugía Torácica/estadística & datos numéricos , HumanosRESUMEN
Risk aversion is a potential unintended consequence of health care public reporting. In Part 1 of this review, four possible consequences of this phenomenon are discussed, including the denial of interventions to some high-risk patients, stifling of innovation, appropriate avoidance of futile interventions, and better matching of high-risk patients to more capable providers. We also summarize relevant observational clinical reports and survey results from cardiovascular medicine and surgery, the two specialties from which almost all risk aversion observations have been derived. Although these demonstrate that risk aversion does occur, the empirical data are much more consistent and compelling for interventional cardiology than for cardiac surgery.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Cardiología , Cardiopatías/cirugía , Complicaciones Posoperatorias , Salud Pública/estadística & datos numéricos , Medición de Riesgo/métodos , Cirugía Torácica , HumanosRESUMEN
The Society of Thoracic Surgeons (STS) National Database has three major component databases: the STS Adult Cardiac Surgery Database (ACSD), the STS Congenital Heart Surgery Database (CHSD), and the STS General Thoracic Surgery Database (GTSD). Beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article summarizes the status of the STS National Database as of October 2017 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2017 series "Outcomes Analysis, Quality Improvement, and Patient Safety."
Asunto(s)
Bases de Datos Factuales , Evaluación de Resultado en la Atención de Salud , Seguridad del Paciente , Mejoramiento de la Calidad , Sociedades Médicas , Cirugía Torácica , Humanos , Estados UnidosRESUMEN
Established in 1989, The Society of Thoracic Surgeons Adult Cardiac Surgery Database is one of the most comprehensive clinical data registries in health care. It is widely regarded as the gold standard for benchmarking risk-adjusted outcomes in cardiac surgery and is the foundation for all quality measurement and improvement activities of The Society of Thoracic Surgeons. This is the second in a series of annual reports that summarizes current aggregate national outcomes in cardiac surgery and reviews database-related activities in the areas of quality measurement and performance improvement during the past year.