Varun Puri1, Henning A Gaissert2, David W Wormuth3, Eric L Grogan4, William R Burfeind5, Andrew C Chang6, Christopher W Seder7, Felix G Fernandez8, Lisa Brown9, Mitchell J Magee10, Andrzej S Kosinski11, Daniel P Raymond12, Stephen R Broderick13, Robert J Welsh14, Malcolm M DeCamp15, Farhood Farjah16, Melanie A Edwards17, Benjamin D Kozower18. 1. Department of Surgery, Washington University School of Medicine, St. Louis, Missouri. Electronic address: varunpuri@wustl.edu. 2. Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 3. Department of Surgery, St. Joseph's Hospital, Syracuse, New York. 4. Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. 5. Department of Surgery, St. Luke's University Hospital, Bethlehem, Pennsylvania. 6. Department of Surgery, University of Michigan, Ann Arbor, Michigan. 7. Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois. 8. Emory University School of Medicine, Atlanta, Georgia. 9. Department of Surgery, University of California Davis Health, Sacramento, California. 10. Department of Surgery, Baylor University Medical Center, Dallas, Texas. 11. Department of Biostatistics and Bioinformatics and Duke Clinical Research Institute, Duke University, Durham, North Carolina. 12. Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. 13. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. 14. Department of Surgery, Beaumont Health, Royal Oak, Michigan. 15. Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. 16. Department of Surgery, University of Washington, Seattle, Washington. 17. Division of Cardiothoracic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri. 18. Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
Abstract
BACKGROUND: Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. METHODS: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. RESULTS: Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p = 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p = 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. CONCLUSIONS: VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.
BACKGROUND: Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. METHODS: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. RESULTS: Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p = 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p = 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. CONCLUSIONS: VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.
Authors: Melanie P Subramanian; Jingxia Liu; William C Chapman; Margaret A Olsen; Yan Yan; Ying Liu; Tara R Semenkovich; Bryan F Meyers; Varun Puri; Benjamin D Kozower Journal: Ann Thorac Surg Date: 2019-08-07 Impact factor: 4.330