RESUMEN
BACKGROUND: The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures. METHODS: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration. RESULTS: C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample. CONCLUSIONS: New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Enfermedades de las Válvulas Cardíacas/cirugía , Modelos Estadísticos , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo/métodos , Sociedades Médicas , Cirugía Torácica , Adulto , Procedimientos Quirúrgicos Cardíacos/mortalidad , Causas de Muerte/tendencias , Bases de Datos Factuales , Femenino , Válvulas Cardíacas/cirugía , Humanos , Masculino , Morbilidad/tendencias , Estudios Retrospectivos , Factores de Riesgo , Cirujanos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is the world's premier adult cardiac surgery outcomes registry. This tutorial explains the following: how STS updates the risk models that are used to calculate the predicted risks of adverse events in the registry; why STS on a quarterly basis adjusts or "calibrates" the observed-to-expected ratios to equal 1 (O/E = 1), thereby effectively making the annual number of adverse events predicted by the model match the annual number of adverse events observed in the entire registry; the differences between the calibrated and uncalibrated O/E ratios; and how and when to use each.
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Puente de Arteria Coronaria/normas , Enfermedad de la Arteria Coronaria/cirugía , Sistema de Registros , Medición de Riesgo/métodos , Sociedades Médicas , Cirugía Torácica , Adulto , Calibración/normas , Enfermedad de la Arteria Coronaria/epidemiología , Bases de Datos Factuales , Estudios de Seguimiento , Humanos , Incidencia , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Failure to rescue (FTR) focuses on the ability to prevent death among patients who have postoperative complications. The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a new, risk-adjusted FTR quality metric for adult cardiac surgery. METHODS: The study population was taken from 1118 STS Adult Cardiac Surgery Database participants including patients who underwent isolated CABG, aortic valve replacement with or without CABG, or mitral valve repair or replacement with or without CABG between January 2015 and June 2019. The FTR analysis was derived from patients who had one or more of the following complications: prolonged ventilation, stroke, reoperation, and renal failure. Data were randomly split into 70% training samples (n = 89,059) and 30% validation samples (n = 38,242). Risk variables included STS predicted risk of mortality, operative procedures, and intraoperative variables (cardiopulmonary bypass and cross-clamp times, unplanned procedures, need for circulatory support, and massive transfusion). RESULTS: Overall mortality for patients undergoing any of the index operations during the study period was 2.6% (27,045 of 1,058,138), with mortality of 0.9% (8316 of 930,837), 8% (7618 of 94,918), 30.6% (8247 of 26,934), 51.9% (2661 of 5123), and 62.3% (203 of 326), respectively, among patients having none, one, two, three, or four complications. The FTR risk model calibration was excellent, as were model discrimination (c-statistic 0.806) and the Brier score (0.102). Using 95% Bayesian credible intervals, 62 participants (5.6%) performed worse and 53 (4.7%) performed better than expected. CONCLUSIONS: A new risk-adjusted FTR metric has been developed that complements existing STS performance measures. The metric specifically assesses institutional effectiveness of postoperative care, allowing hospitals to target quality improvement efforts.
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Procedimientos Quirúrgicos Cardíacos , Cirujanos , Cirugía Torácica , Adulto , Teorema de Bayes , Causas de Muerte , Humanos , Complicaciones Posoperatorias/epidemiología , Sociedades MédicasRESUMEN
BACKGROUND: The Society of Thoracic Surgeons (STS) original coronary artery bypass graft surgery (CABG) composite measure uses a 1-year analytic cohort and 98% credible intervals (CrI) to classify better than expected (3-star) performance or worse than expected (1-star) performance. As CABG volumes per STS participant (eg, hospital or practice group) have decreased, it has become more challenging to classify performance categories using this approach, especially for lower volume programs, and alternative approaches have been explored. METHODS: Among 990 STS Adult Cardiac Surgery Database participants, performance classifications for the CABG composite were studied using various analytic cohorts: 1 year (current approach, 2017); 3 years (2015 to 2017); last 450 cases within 3 years; and most recent year (2017) plus additional cases to 450 total. We also compared 98% CrI with 95% CrI (used in other STS composite measures). RESULTS: Using 3 years of data and 95% CrIs, 113 of 990 participants (11.4%) were classified 1-star and 198 (20%) 3-star. Compared with 1-year analytic cohorts and 98% CrI, the absolute and relative increases in the proportion of 3-star participants were 14 percentage points and 233% (n = 198 [20%] vs n = 59 [6%]). Corresponding changes for 1-star participants were 6.5 percentage points and 133% (n = 113 [11.4%] vs n = 48 [4.9%]). These changes were particularly notable among lower volume (fewer than 199 CABG per year) participants. Measure reliability with the 3-year, 95% CrI modification is 0.78. CONCLUSIONS: Compared with current STS CABG composite methodology, a 3-year analytic cohort and 95% CrI increases the number and proportion of better or worse than expected outliers, especially among lower-volume Adult Cardiac Surgery Database participants. This revised methodology is also now consistent with other STS procedure composites.
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Cirujanos , Cirugía Torácica , Adulto , Puente de Arteria Coronaria/métodos , Humanos , Complicaciones Posoperatorias , Reproducibilidad de los Resultados , Sociedades MédicasRESUMEN
BACKGROUND: Composite performance measures for the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database participants (typically hospital departments or practice groups) are currently available only for individual procedures. To assess overall participant performance, STS has developed a composite metric encompassing the most common adult cardiac procedures. METHODS: Analyses included 1-year (July 1, 2018 to June 30, 2019) and 3-year (July 1, 2016 to June 30, 2019) time windows. Operations included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve repair (MVr) or replacement (MVR), AVR + CABG, MVr or MVR + CABG, AVR + MVr or MVR, and AVR + (MVr or MVR) + CABG. The composite was estimated using Bayesian hierarchical models with risk-adjusted mortality and morbidity end points. Star ratings were based upon whether the 95% credible interval of a participant's score was entirely lower than (1 star), overlapping (2 star), or higher than (3 star) the STS average composite score. RESULTS: The North American procedural mix in the 3-year study cohort was as follows: 448 569 CABG, 72 067 AVR, 35 708 MVr, 29 953 MVR, 45 254 AVR + CABG, 12 247 MVr + CABG, 10 118 MVR + CABG, 3743 AVR + MVr, 6846 AVR + MVR, and 3765 AVR + (MVr or MVR) + CABG. Mortality and morbidity weightings were similar for 1- and 3-year analyses (76% and 24% [3-year]), as were composite score distributions (median, 94.7%; interquartile range, 93.6% to 95.6% [3-year]). The 3-year time frame was selected for operational use because of higher model reliability (0.81 [0.78-0.83]) and better outlier discrimination (26%, 3 star; 16%, 1 star). Risk-adjusted outcomes for 1-, 2-, and 3-star programs were 4.3%, 3.0%, and 1.8% mortality and 18.4%, 13.4%, and 9.7% morbidity, respectively. CONCLUSIONS: The STS participant-level, multiprocedural composite measure provides comprehensive, highly reliable, overall quality assessment of adult cardiac surgery practices.
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Procedimientos Quirúrgicos Cardíacos , Implantación de Prótesis de Válvulas Cardíacas , Cirugía Torácica , Adulto , Válvula Aórtica/cirugía , Teorema de Bayes , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Reproducibilidad de los ResultadosRESUMEN
Reporting of risk-adjusted surgical outcomes is commonly used to compare providers and track changes over time. Preferred graphical methods use the relationship of the observed to the expected values of outcome events, including their ratio (O/E), and the cumulative sum (CUSUM) of their differences over time, called Risk-Adjusted CUSUM (RA-CUSUM) or Variable Life Adjusted Display (VLAD). We demonstrate these methods using operative mortality data for 7255 isolated coronary artery bypass graft patients from January 2014 to June 2017. RA-CUSUM and VLAD are excellent techniques to display risk-adjusted outcomes and, unlike O/E, can provide continuous monitoring as performance varies over time.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Evaluación de Resultado en la Atención de Salud/métodos , Ajuste de Riesgo/métodos , Enfermedad de la Arteria Coronaria/mortalidad , Humanos , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Costs related to care of patients who undergo lobectomy for lung cancer may vary depending on patient, disease, and treating facility characteristics. We aimed to identify underlying case mix factors that contribute to variability of 90-day costs of lobectomy for early-stage lung cancer. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for lobectomy for clinical stage I lung cancer (2008-2013). Demographics, clinical outcomes, and 90-day episode-of-care costs across all care settings were analyzed for patients successfully linked to Medicare data. Hospital costs were estimated from charges using cost-to-charge ratios. Comprehensive regression models were created to identify impact of preoperative patient factors and hospital characteristics on costs, and to delineate additive costs due to perioperative outcomes and complications. RESULTS: The mean 90-day cost for lobectomy was $45,080 ± $38,239. Variables associated with significant additive costs were age greater than or equal to 75 years, American Society of Anesthesiologists classification III or IV, forced expiratory volume in 1 second less than 80% predicted, body mass index less than 18.5 or greater than 35, current or past smoker, cerebrovascular disease, chronic kidney disease, impaired functional status, open thoracotomy, prolonged operative time, government hospitals, metropolitan setting, and geographic location. Patients with 1 or more postoperative complication resulted in an overall mean added cost of $27,259. Added costs increased with the number of complications; isolated recurrent laryngeal nerve paresis ($3,911) and respiratory failure ($35,011) were associated with the least and most additive cost, respectively. CONCLUSIONS: Lobectomy is associated with substantial variability of episode-of-care costs. Variability is driven by patient demographic and clinical factors, hospital characteristics, and the occurrence and severity of complications.
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Costos de la Atención en Salud , Neoplasias Pulmonares/economía , Neoplasias Pulmonares/cirugía , Neumonectomía/economía , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Masculino , Medicare , Sociedades Médicas , Cirugía Torácica , Estados UnidosRESUMEN
BACKGROUND: The longitudinal cost of treating patients with non-small cell lung cancer (NSCLC) undergoing surgical resection has not been evaluated. We describe initial and 4-year resource use and cost for NSCLC patients aged 65 years of age or greater who were treated surgically between 2008 and 2013. METHODS: Using clinical data for NSCLC resections from The Society of Thoracic Surgeons General Thoracic Surgery Database linked to Medicare claims, resource use and cost of preoperative staging, surgery, and subsequent care through 4 years were examined ($2017). Cost of hospital-based care was estimated using cost-to-charge ratios; professional services and care in other settings were valued using reimbursements. Inverse probability weighting was used to account for administrative censoring. Outcomes were stratified by pathologic stage and by surgical approach for stage I lobectomy patients. RESULTS: Resection hospitalizations averaged 6 days and cost $31,900. In the first 90 days, costs increased with stage ($12,430 for stage I to $26,350 for stage IV). Costs then declined toward quarterly means more similar among stages. Cumulative costs ranged from $131,032 (stage I) to $205,368 (stage IV). In the stage I lobectomy cohort, patients selected for minimally invasive procedures had lower 4-year costs than did thoracotomy patients ($120,346 versus $136,250). CONCLUSIONS: The 4-year cost of surgical resection for NSCLC was substantial and increased with pathologic stage. Among stage I lobectomy patients, those selected for minimally invasive surgery had lower costs, particularly through 90 days. Potential avenues for improving the value of surgical resection include judicious use of postoperative intensive care and earlier detection and treatment of disease.
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Carcinoma de Pulmón de Células no Pequeñas/economía , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Costos de la Atención en Salud , Neoplasias Pulmonares/economía , Neoplasias Pulmonares/cirugía , Neumonectomía/economía , Anciano , Estudios de Cohortes , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: The use of near-continuous blood glucose (BG) monitoring has the potential to improve glycemic control in critically ill patients. The MANAGE IDE trial evaluated the performance of the OptiScanner (OS) 5000 in a multicenter cohort of 200 critically ill patients. METHODS: An Independent Group reviewed the BG run charts of all 200 patients and voted whether unblinded use of the OS, with alarms set at 90 and 130 to 150 mg/dL to alert the clinical team to impending hypoglycemia and hyperglycemia, respectively, would have eliminated episodes of dysglycemia: hypoglycemia, defined as a single BG <70 mg/dL; hyperglycemia, defined as >4 hours of BG >150 mg/dL; severe hyperglycemia, defined as >4 hours of BG >200 mg/dL and increased glucose variability (GV), defined as coefficient of variation (CV) >20%. RESULTS: At least one episode of dysglycemia occurred in 103 (51.5%) of the patients, including 6 (3.0%) with hypoglycemia, 83 (41.5%) with hyperglycemia, 18 (9.0%) with severe hyperglycemia, and 40 (20.0%) with increased GV. Unblinded use of the OS with appropriate alarms would likely have averted 97.1% of the episodes of dysglycemia: hypoglycemia (100.0%), hyperglycemia (96.4%), severe hyperglycemia (100.0%), and increased GV (97.5%). Point accuracy of the OS was very similar to that of the point of care BG monitoring devices used in the trial. CONCLUSION: Unblinded use of the OS would have eliminated nearly every episode of dysglycemia in this cohort of critically ill patients, thereby markedly improving the quality and safety of glucose control.
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Hiperglucemia , Hipoglucemia , Glucemia , Enfermedad Crítica , Humanos , Hipoglucemia/prevención & control , Estudios RetrospectivosRESUMEN
BACKGROUND: The oncologic efficacy of segmentectomy is controversial. We compared long-term survival in clinical stage IA (T1N0) Medicare patients undergoing lobectomy and segmentectomy in The Society of Thoracic Surgeons database. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database was linked to Medicare data in 14,286 lung cancer patients who underwent segmentectomy (n = 1654) or lobectomy (n = 12,632) for clinical stage IA disease from 2002 to 2015. Cox regression was used to create a long-term survival model. Patients were then propensity matched on demographic and clinical variables to derive matched pairs. RESULTS: In Cox modeling segmentectomy was associated with survival similar to lobectomy in the entire cohort (hazard ratio, 1.04; 95% confidence interval, 0.89-1.20; P = .64) and in the matched subcohort. A subanalysis restricted to the 2009 to 2015 population (n = 11,811), when T1a tumors were specified and positron emission tomography results and mediastinal staging procedures were accurately recorded in the database, also showed that segmentectomy and lobectomy continue to have similar survival (hazard ratio, 1.00; 95% confidence interval, 0.87-1.16). Subanalysis of the pathologic N0 patients demonstrated the same results. CONCLUSIONS: Lobectomy and segmentectomy for early-stage lung cancer are equally effective treatments with similar survival. Surgeons from The Society of Thoracic Surgeons database appear to be selecting patients appropriately for sublobar procedures.
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Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/cirugía , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Neoplasias Pulmonares/patología , Masculino , Medicare , Estadificación de Neoplasias , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Tasa de Supervivencia , Estados UnidosRESUMEN
OBJECTIVE: Outcomes for lung cancer surgery are currently measured according to perioperative morbidity and mortality. However, the oncologic efficacy of the surgery is reflected by long-term survival. We examined correlation between measures of short-term and long-term performance for lung cancer surgery. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database linked to Medicare survival data was queried for pathologic stage I lung cancer resected between 2009 and 2013. Two separate multivariable models were created: (1) short-term: avoidance of perioperative major morbidity and mortality; and (2) long-term: 3-year survival. Standardized incidence ratios were calculated for the Society of Thoracic Surgeons programs (participants) to determine risk-adjusted participant performance measures for the short- and long-term time points. Correlation of participant standardized incidence ratios for short- and long-term performance was assessed using the Pearson correlation coefficient. RESULTS: The study population included 12,596 patients from 229 participating programs. One hundred fifty-one participants met minimum volume and follow-up requirements for analysis. Overall, performance for the short-term measure was uniform with only 2 (1.3%) participants performing better than expected and 2 (1.3%) worse than expected. For the long-term measure, 9 (6%) participants achieved better than expected and 5 (3.3%) worse than expected survival. No participant was an above or below average performer for the short- and long-term measures. Further, no correlation was observed between participant short- and long-term performance (Pearson correlation coefficient, 0.12; 95% confidence interval, -0.04 to 0.28; P = .14). CONCLUSIONS: Avoidance of perioperative morbidity and mortality is an incomplete measure of performance in lung cancer surgery. Lung cancer surgery performance metrics should assess the safety of surgery and long-term survival.
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Neoplasias Pulmonares/cirugía , Neumonectomía , Sobrevivientes , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Masculino , Estadificación de Neoplasias , Neumonectomía/efectos adversos , Neumonectomía/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Not all surgeons performing lobectomy in the United States report outcomes to The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD). We examined penetration, completeness, and representativeness of the STS GTSD for lobectomy in the Centers for Medicare and Medicaid Services (CMS) patient population. METHODS: The STS GTSD lobectomies from 2002 to 2013 were linked and matched to CMS data using a deterministic matching algorithm. Penetration at center- and patient-level were determined by the number of CMS lobectomy sites and patients, matched to STS GTSD data, divided by the total number of CMS lobectomy sites and patients, respectively. Completeness was defined as the ratio of lobectomies linked to STS GTSD data to the total number of lobectomies. Representativeness was determined by comparing outcomes for patients undergoing lobectomy at matched and unmatched STS GTSD sites. RESULTS: A total of 9,569 centers were included in the study. Center level penetration steadily increased from 1.2% (10 of 859 sites) in 2002 to 25% (169 of 675 sites) in 2013. Patient-level penetration was highest, 38% (4,177 of 11,018), in 2013. Completeness at GTSD sites varied from 59% to 78% over the study period. Postoperative length of stay was longer for nonparticipants than for STS GTSD surgeons (median 6 versus 5 days, p < 0.001); 30-day mortality was higher for nonparticipants than for STS GTSD participants (3.3% versus 1.6%, p < 0.001). CONCLUSIONS: Participation in the STS GTSD has increased over time, but penetration lags behind that of the other STS National Databases. The STS GTSD participants have superior observed perioperative outcomes for lobectomy compared with nonparticipants. Database participation may reflect high quality care, and ongoing efforts to increase surgeon participation in the STS GTSD should be continued.
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Algoritmos , Neoplasias Pulmonares/cirugía , Neumonectomía/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Sociedades Médicas , Cirujanos/estadística & datos numéricos , Cirugía Torácica , Anciano , Bases de Datos Factuales , Femenino , Humanos , Masculino , Estudios Retrospectivos , Estados UnidosRESUMEN
Purpose The prevalence of minimally invasive lung cancer surgery using video-assisted thoracic surgery (VATS) has increased dramatically over the past decade, yet recent studies have suggested that the lymph node evaluation during VATS lobectomy is inadequate. We hypothesized that the minimally invasive approach to lobectomy for stage I lung cancer resulted in a longitudinal outcome that was not inferior to thoracotomy. Patients and Methods Patients > 65 years of age who had undergone lobectomy for stage I lung cancer between 2002 and 2013 were analyzed within the Society of Thoracic Surgeons General Thoracic Surgery Database, which had been linked to Medicare data, as part of a retrospective-cohort, noninferiority study. Results A total of 10,597 patients with clinical stage I lung cancer who underwent lobectomy were evaluated (4,448 patients underwent thoracotomy, and 6,149 underwent VATS). VATS patients had a more favorable distribution of all health-related variables, including pulmonary function (59% of VATS patients had intact spirometry v 51% of thoracotomy patients; P < .001). Cox proportional hazards models were performed over two eras to account for an evolving practice standard. The mortality risk associated with the VATS approach was not greater than thoracotomy in either the earlier era (2002 to 2008; hazard ratio, 0.97; 95% CI, 0.87 to 1.09; P = .62) or the more recent era (2009 to 2013; hazard ratio, 0.84; 95% CI, 0.75 to 0.93; P < .001). Kaplan-Meier survival estimates of 2,901 propensity-matched VATS-thoracotomy pairs demonstrated that the 4-year survival associated with VATS (68.6%) was modestly superior to thoracotomy (64.8%; P = .003). The analyses detailed above were replicated in a separate cohort of pathologic stage I patients with similar findings. Conclusion The long-term efficacy of lobectomy for stage I lung cancer performed using the VATS approach by board-certified thoracic surgeons does not seem to be inferior to that of thoracotomy.
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Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/estadística & datos numéricos , Toracotomía/estadística & datos numéricos , Anciano , Estudios de Cohortes , Femenino , Humanos , Estimación de Kaplan-Meier , Estudios Longitudinales , Neoplasias Pulmonares/patología , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Estadificación de Neoplasias , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Toracotomía/métodos , 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.
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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.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Modelos Estadísticos , Complicaciones Posoperatorias/etiología , Medición de Riesgo , Adulto , Bases de Datos Factuales , Humanos , Sociedades Médicas , Cirugía TorácicaRESUMEN
OBJECTIVE: Complications adversely affect survival after lung cancer surgery. We tested the hypothesis that effects of complications after lung cancer surgery on survival vary substantially across the spectrum of postoperative complications. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database was linked to Medicare data for lung cancer resections from 2002 through 2013. Linkage was achieved for 29,899 patients. A survival model was created that included operative complications as explanatory variables and adjusted for relevant baseline covariates. Because of violation of the proportional hazard assumption, we used time-varying coefficient Cox modeling for the complication variables. RESULTS: Median patient age was 73 years, and 48% were male. Procedures performed were lobectomy in 69%, wedge in 17%, segmentectomy in 7%, bilobectomy in 3%, pneumonectomy in 3%, and sleeve lobectomy in 1%. Most frequent complications were atrial arrhythmia (14%), pneumonia (4.3%), reintubation (3.8%), delirium (2%), and acute kidney injury (1.4%). In the early period (0-90 days), 12 complications are associated with worse survival. From 3 to 18 months after surgery, only 4 complications are associated with survival: delirium, blood transfusion, reintubation, and pneumonia. After 18 months, only sepsis and blood transfusion are associated with a significant late hazard. CONCLUSIONS: Our analysis confirmed the presence of differential magnitude and time-varying effects on survival of individual complications after lung cancer surgery. We conclude that the derived time-dependent hazard ratios can serve as objective weights in future models that enhance performance measurement and focus attention on prevention and management of complications with greatest effects.
Asunto(s)
Neoplasias Pulmonares/cirugía , Neumonectomía , Complicaciones Posoperatorias/epidemiología , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Masculino , Medicare , Neumonectomía/efectos adversos , Complicaciones Posoperatorias/mortalidad , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Sociedades Médicas , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Prior risk models using the STS General Thoracic Surgery database (STS-GTSD) have been limited to 30-day outcomes. We have now linked STS data to Medicare data and sought to create a risk prediction model for long-term mortality after lung cancer resection in patients older than 65 years. METHODS: The STS-GTSD was linked to Medicare data for lung cancer resections from 2002 to 2013 as previously reported. Successful linkage was performed in 29,899 lung cancer resection patients. Cox proportional hazards modeling was used to create a long-term survival model. Variable selection was performed using statistically significant univariate factors and known clinical predictors of outcome. Calibration was assessed by dividing the cohort into deciles of predicted survival and discrimination assessed with a C-statistic corrected for optimism via 1,000 bootstrap replications. RESULTS: Median age was 73 years (interquartile range, 68 to 78 years), and 48% of the patients were male. Of the 29,094 patients with nonmissing pathologic stage, 69% were stage I, 18% stage II, 11% stage III, and 2% stage IV. Procedure performed was lobectomy in 69%, bilobectomy in 3%, pneumonectomy in 3%, segmentectomy in 7%, sleeve lobectomy in 1%, and wedge resection in 17%. Thoracoscopic approach was performed in 47% of resections. The final Cox model reveals that stage and age are the strongest predictors of long-term survival. Even after controlling for stage, wedge resection, segmentectomy, bilobectomy, and pneumonectomy are all associated with increased hazard of death in comparison with lobectomy. Thoracoscopic approach is associated with improved long-term survival in comparison with thoracotomy. Other modifiable predictive factors include smoking and low body mass index. Calibration of the model demonstrates excellent performance across all survival deciles and a C-statistic of 0.694. CONCLUSIONS: The STS-GTSD-Medicare long-term risk model includes several novel factors associated with mortality. Although medical factors predict long-term survival, age and stage are the strong predictors. Despite this, procedure choice and thoracoscopic/open approach are potentially modifiable predictors of long-term survival after lung cancer resection.
Asunto(s)
Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/cirugía , Neumonectomía , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Masculino , Medicare , Pronóstico , Estudios Retrospectivos , Sociedades Médicas , Tasa de Supervivencia , Cirugía Torácica , Factores de Tiempo , Estados UnidosRESUMEN
BACKGROUND: The role of surgical resection in patients with clinical stage IIIA-N2 positive (cIIIA-N2) lung cancer is controversial, partly because of the variability in short- and long-term outcomes. The objective of this study was to characterize the management of cIIIA-N2 lung cancer in The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD). METHODS: The STS-GTSD was queried for patients who underwent operations for cIIIA-N2 lung cancer between 2002 and 2012. A subset of patients aged older than 65 years was linked to Medicare data. RESULTS: Identified were 3,319 surgically managed, cIIIA-N2 patients, including 1,784 (54%) treated with upfront resection (treatment naïve upfront surgery group, and 1,535 (46%) with induction therapy. A positron emission tomography scan was documented in 93% of patients, and 51% of patients were coded in STS-GTSD as having undergone invasive mediastinal staging. Nodal overstaging (cN2âpN0/N1) was observed in 43% of upfront surgery patients. Lobectomy was performed in 69% of patients and pneumonectomy in 11%. Operative mortality was similar between patients treated with upfront surgery (1.9%) and induction therapy (2.5%, p = .2583). The unadjusted Kaplan-Meier estimate of 5-year survival of cIII-N2 patients treated with induction therapy then resection was 35%. CONCLUSIONS: STS surgeons achieve excellent short- and long-term results treating predominantly lobectomy-amenable cIIIA-N2 lung cancer. However, prevalent overstaging and abstention from induction therapy suggest "overcoding" of false positives on imaging or variable compliance with current guidelines for cIIIA-N2 lung cancer. Efforts are needed to improve clinical stage determination and guideline compliance in the GTSD for this cohort.
Asunto(s)
Neoplasias Pulmonares/cirugía , Estadificación de Neoplasias , Neumonectomía/métodos , Sistema de Registros , Sociedades Médicas , Cirugía Torácica , Anciano , Bases de Datos Factuales , Femenino , Humanos , Neoplasias Pulmonares/diagnóstico , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del Tratamiento , Estados UnidosRESUMEN
To compare structural valve deterioration (SVD) among bioprosthetic aortic valve types, a PubMed search found 54 papers containing SVD-free curves extending to at least 10 years. The curves were digitized and fit to Weibull distributions, and the mean times to valve failure (MTTF) were calculated. Twelve valve models were collapsed into four valve types: Medtronic (Medtronic, Minneapolis, MN) and Edwards (Edwards Lifesciences, Irvine, CA) porcine; and Sorin (Sorin Group [now LivaNova], London, United Kingdom) and Edwards pericardial. Meta-regression found MTTF was associated with the patient's age, publication year, SVD definition, and valve type. Sorin pericardial valves had significantly lower risk-adjusted MTTF (higher SVD risk), and there were no significant differences in MTTF among the other three valve types.
Asunto(s)
Válvula Aórtica/cirugía , Bioprótesis , Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas , Animales , Humanos , Diseño de PrótesisRESUMEN
BACKGROUND: The performance of concomitant tricuspid valve repair (TVr) at the time of mitral valve repair or replacement (MVRR) has previously been associated with elevated short-term risk. Outcomes were assessed at incremental grades of tricuspid regurgitation (TR) to quantify the contemporary risk of concomitant TVr. METHODS: Between July 2011 and June 2014, 88,473 patients undergoing MVRR were examined using The Society of Thoracic Surgeons database. Outcomes with or without TVr, after isolated MVRR (n = 62,118) and MVRR with coronary artery bypass graft surgery (CABG [n = 26,355]), were independently analyzed at three levels of TR: none-mild, moderate, and severe. Risk-adjusted morbidity and mortality associated with the performance of concomitant TVr were evaluated using multivariable logistic regression. RESULTS: The TR was graded as none-mild in 74.3% of patients (65,769 of 88,473), moderate in 17.2% (15,222 of 88,473), and severe in 8.5% (7,482 of 88,473). The rate of TVr by TR grade was 3.5% (2,308 of 65,769) for none-mild, 30.6% (4,661 of 15,222) for moderate, and 75.6% (5,654 of 7,482) for severe. Overall risk-adjusted occurrence of any morbidity associated with performance of TVr was increased in both groups (MVRR odds ratio [OR] 1.36, 95% confidence interval [CI]: 1.24 to 1.48; and MVRR plus CABG OR 1.33, 95% CI: 1.19 to 1.49). However, at all grades of TR, TVr was not associated with increased risk-adjusted mortality (MVRR OR 0.99, 95% CI: 0.84 to 1.17; and MVRR plus CABG OR 1.04, 95% CI: 0.85 to 1.27). CONCLUSIONS: In contemporary patients, concomitant TVr is not associated with a risk-adjusted increase in mortality, regardless of TR severity. A more liberal approach to TVr at the time of MVRR may be justified when long-term benefits are thought to outweigh incremental short-term morbidity risk. Further investigation of longitudinal TVr outcomes is warranted.