Healthcare Workforce andHealthcare Workforce and
Regionalization of Services:Regionalization of Services:
Lung Cancer Rese...
DisclosuresDisclosures
OverviewOverview
 Incidence of lung cancerIncidence of lung cancer
 Study background/methodsStudy background/methods
 R...
The High Incidence of Lung CancerThe High Incidence of Lung Cancer
* Jemal et al, CA 2006
Lung and Bronchus 92,700 13% Lun...
Prior Studies ExaminingPrior Studies Examining
Surgical OutcomesSurgical Outcomes
 Surgeon volumeSurgeon volume
 Hospita...
Origin of the StudyOrigin of the Study
Teaching HospitalsTeaching Hospitals
 Teaching hospitalsTeaching hospitals
Fellows, residents, medical and nursing stude...
Thoracic vs. General SurgeonsThoracic vs. General Surgeons
 Lung resections traditionally performedLung resections tradit...
Benefit of Teaching HospitalsBenefit of Teaching Hospitals
 Unclear whether perioperative outcomesUnclear whether periope...
Methods - 1Methods - 1
 Study Design:Study Design: Retrospective analysis usingRetrospective analysis using
Nationwide In...
Definitions:Definitions: Lung Cancer OperationsLung Cancer Operations
Methods - 2Methods - 2
 Variables:Variables:
Age, gender, raceAge, gender, race
Charlson Index of comorbiditiesCharlson...
DefinitionsDefinitions
Teaching Hospitals (NIS):
- At least 1 residency program (not necessarily
surgery)
- Member of Coun...
Outcome AnalysisOutcome Analysis
 Outcome:Outcome:
 In-hospital death from any cause as endIn-hospital death from any ca...
Overall Hospital
Status
Teaching
28,101
Non-Teaching
22,780
55.2% 44.8%
Surgical and Hospital DemographicsSurgical and Hos...
Resection DemographicsResection Demographics
TeachingTeaching Non-TeachingNon-Teaching
HospitalsHospitals 1095 (34.1%)1095...
Patient DemographicsPatient Demographics
TeachingTeaching Non-TeachingNon-Teaching
Median AgeMedian Age 66 years66 years 6...
Unadjusted MortalityUnadjusted Mortality: Teaching vs. Non-: Teaching vs. Non-
Teaching HospitalsTeaching Hospitals
0%
2%
...
Multivariate Analysis of LobectomiesMultivariate Analysis of Lobectomies
at Teaching vs. Non-Teachingat Teaching vs. Non-T...
0%
1%
2%
3%
4%
5%
6% Teaching
N
on-Teach
G
en
Surg
N
on-G
en
Surg
ThorSurg
N
on-Thor
Surg
In-HospitalMortalityRateIn-Hospi...
SummarySummary
Statistically significant difference in mortality rate forStatistically significant difference in mortality...
Teaching Hospitals:Teaching Hospitals: Process of CareProcess of Care
Subspecialty trained surgeonsSubspecialty trained su...
Study LimitationsStudy Limitations
 Retrospective database designRetrospective database design
 Definition of teaching h...
ConclusionsConclusions
 These data suggest that post-operativeThese data suggest that post-operative
mortality is improve...
ConclusionsConclusions
 Our data refute the fears of patients seekingOur data refute the fears of patients seeking
surgic...
Application of NIS/HCUP/AHRQApplication of NIS/HCUP/AHRQ
 Limitations: patient level dataLimitations: patient level data
...
Policy ImplicationsPolicy Implications
 If data is taken at face value, AHRQ couldIf data is taken at face value, AHRQ co...
Thank YouThank You
Robert A. Meguid, MD, MPHRobert A. Meguid, MD, MPH
Benjamin S. Brooke, MDBenjamin S. Brooke, MD
David C...
0
0.5
1.0
1.5
2.0
2.5
Overall
Seg.
Lobe.
Pneumon.
Overall
Seg.
Lobe.
Pneumon.
Overall
Seg.
Lobe.
Pneumon.
Adjusted Odds Ra...
Hypotheses:Hypotheses:
 Post-Operative mortality after lungPost-Operative mortality after lung
resection is reduced at te...
0%
2%
4%
6%
8%
10%
12%
Overall Seg. Lobe. Pneumon.
Gen Surg Teaching
Non-Gen Surg Teaching
Unadjusted MortalityUnadjusted ...
0%
2%
4%
6%
8%
10%
12%
Overall Seg. Lobe. Pneumon.
Thor Surg Teaching
Non-Thor Surg Teaching
Unadjusted MortalityUnadjuste...
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  • I have no disclosures
  • Classic triad of symptoms
    Pain unlikely to occur in the normal achalasia patient
    Psychological problems usually antedate esophageal dysfunction
    More tolerant to warm than cold, solid more than liquid especially early stage, in contradistinction to ca or strictures
    Large quantities of liquids help passage
  • Slide 2: The number of surgical resections for lung cancer continues to be on the rise, likely due to several factors, including the general rise in lung cancer cases, the heightened awareness and screening protocols, and extension of traditional indications. As surgical management of lung cancer has improved, the associated morbidity and mortality necessitates exploration of different measures to improve perioperative outcomes and optimize long-term results. <CLICK>
  • Slide 3: “much attention has been focused recently on outcomes after surgery, in part to define centers of excellence.<CLICK>
    Work has examined surgeon volume <CLICK> and hospital volume, correlating increased volumes with improved outcomes. <CLICK>
    Studies have shown this for pulmonary and esophageal resection, coronary artery bypass, carotid endarterectomy, and other complex cancer surgeries. <CLICK>
    However, to date, hospital characteristics associated with improved outcomes have been poorly defined.”
    <CLICK>
  • Slide 4: “teaching hospitals, which constitute a large portion of the tertiary care centers in this country, are generally where fellows, residents, medical students, nursing students and other physician extenders are trained.<CLICK>
    Usually teaching hospital status is a surrogate for higher levels of care and services.<CLICK>
    However, there is a public perception that teaching hospitals can be dangerous because of training issues. Concerns are frequently voiced by patients, and echoed in the lay press, regarding the fear of physicians in training “practicing” on them. These concerned patients often request that they be exempt from care by physicians in training. <CLICK>
    Prior published studies have shown that surgical outcomes for some procedures are equivocal at teaching hospitals, and that improved outcomes are due to increased hospital volume.” <CLICK>
  • Slide 5: In addition, Esophagectomies traditionally performed by General Surgeons as well as specialty-trained Thoracic Surgeons <CLICK> Debate persists over whether Thoracic Surgeons should preferentially perform esophagectomies, given their specific training. <CLICK> To date, few large, nationwide studies have examined this issue, however some have shown that this is independent of volume for some procedures.<CLICK>
  • Slide 5: “bearing this in mind, the impact of teaching hospitals on surgical outcomes, specifically after lung cancer surgery, has not been addressed, which catalyzed our interest in examining this as a factor in outcomes. <CLICK>
    We wanted to determine if there is an improved outcome at teaching institutions, and if this is related to hospital volume, or characteristics of the hospital environment.<CLICK>
    Therefore, WE HYPOTHESIZED that in-hospital mortality after lung cancer resection at Teaching Hospitals is improved, and is independent of hospital procedure volume.”<CLICK>
  • Slide 6: “To do this, we examined the LARGE retrospective Nationwide Inpt Sample database between 1998 and 2003.
    This database comprises approximately 1000 hospitals per year totaling 7million pt discharge records per year. Data available within the NIS include patient and hospital demographics, payer information, treating and concomitant diagnoses, in-patient procedures, in-patient mortality, length of stay, and total charges. This study was deemed by the Johns Hopkins Institutional Review Board as exempt.<click>
    We selected pts who had primary lung cancer and underwent either segmentectomy, lobectomy or pneumonectomy. <CLICK>
    Variables that we examined included pt age, gender, race, their comorbidities as identified by the Charlson index, and the annual hospital procedure volumes Once the cohort was established, the teaching status of the hospitals where pts were treated were determined.
    <CLICK>
  • Slide 6: “To do this, we examined the LARGE retrospective Nationwide Inpt Sample database between 1998 and 2003.
    This database comprises approximately 1000 hospitals per year totaling 7million pt discharge records per year. Data available within the NIS include patient and hospital demographics, payer information, treating and concomitant diagnoses, in-patient procedures, in-patient mortality, length of stay, and total charges. This study was deemed by the Johns Hopkins Institutional Review Board as exempt.<click>
    We selected pts who had primary lung cancer and underwent either segmentectomy, lobectomy or pneumonectomy. <CLICK>
    Variables that we examined included pt age, gender, race, their comorbidities as identified by the Charlson index, and the annual hospital procedure volumes Once the cohort was established, the teaching status of the hospitals where pts were treated were determined.
    <CLICK>
  • Slide 7: In the Nationwide Inpt Sample, teaching hospitals are defined as hospitals with at least 1 residency program of any type, Of note, these includes hospitals even without surgical residency programs, <CLICK>
    Hospitals which are members of the Council of Teaching Hospitals<CLICK>
    or Hospitals which have a maximum 4-to-1 ratio of beds to full-time residents.” <CLICK>
    For comparison, an academic hospital is defined as one with a university affiliation, and/or where the faculty is university based and engaged in research as part of their structured time.
    Since OUR INITIAL abstract includes ACADEMIC HOSPITALS, we were limited by the NIS database definition to TEACHING HOSPITALS.<CLICK>
  • Slide 8: “For our outcomes analysis, we used in-hospital death from any cause as the end result based on these discharge summaries<CLICK>
    We analyzed our statistics using multivariate logistic regression analysis, using a value of p less than or equal to 0.05 as significant.”
    <CLICK>
  • Slide 9: A total of 50,576 lung resections were identified in the NIS dataset between 1998 and 2003 that fit our search parameters. The lung resection volumes were distributed equally over the 6 year time period with approximately 17% of cases performed per year. When these were broken down by type of lung resection, nearly 75% of patients underwent lobectomy, 16% segmentectomy, and 10 % pneumonectomy<CLICK>
    When the hospital status was analyzed depicted here on the right, just over ½ of these procedures were performed at teaching hospitals.
    <CLICK>
  • Slide 10: Though more procedures were performed at teaching institutions in our study population , the percent breakdown of each type of anatomic resection was similar between teaching and non-teaching hospitals, and followed the same distribution overall for the study.
  • Slide 11: In looking at the patient demographics for both Teaching and non-teaching hospitals, median ages, gender and race distribution, which is not depicted here, were similar, <CLICK> with comparable Charlson indices of comorbidities <CLICK> and median hospital stay.
    <CLICK>
  • Slide 12: In this graph, we look at the UNADJUSTED mortality rates for each of the different surgical resection, and compared the results in teaching here in red with non-teaching hospitals here in yellow.
    The mortality rate for the entire cohort of patients was 3.82%. <CLICK> After stratifying by teaching status, the overall mortality rate for pulmonary resections was 3.63 % at teaching hospitals, significantly lower as compared to 4.0% at non-teaching hospitals, with a p value of 0.016. <CLICK> When further stratified by procedure type, the in-hospital mortality rate for patients undergoing a lobectomy was significantly lower at teaching hospitals, 2.94% vs. 3.62% at non-teaching hospitals, with a p value less than 0.001. There was no statistical difference for mortality between the two hospital types for segmentectomies or pneumonectomies. <CLICK>
  • Slide 13: In this table, the multivariate logistic regression analysis is presented comparing teaching and non-teaching hospitals, <CLICK>taking into account patient demographics, comorbidities, and hospital volume. In comparing the two hospital types, the odds ratio was 0.81, which translates into an overall reduction in odds of death by 19% <CLICK> at teaching hospitals vs non-teaching hospitals, which was significant.
    Given findings of similar published papers in associated fields, we further examined our data, sub-grouping annual hospital volumes into these 4 categories. <CLICK> and even with the different volume groups, this difference between teaching and non-teaching hospitals persisted suggesting that mortality is INDEPENDENT of hospital volume.
    <CLICK>
  • Slide 12: This graph summarizes the unadjusted Mortalities of the different types of Teaching Hospitals <CLICK>…
  • Slide 14: “In summary, the results of our study demonstrate that there are significant improved perioperative outcomes for pulmonary resections at teaching hospitals, as evidenced by differences in mortality rate,
    and this translates into an overall 19% improvement in post-operative survival for lobectomies at teaching hospitals. These findings are independent of hospital volume.
    Why do we see this difference in outcomes between teaching and non-teaching hospitals?”
  • Slide 15:
    There have been many different methods used to evaluate patient care delivery and health care outcomes. We suspect that many of the factors contributing to the observed outcome are due to differences in the process of care that exist at teaching and non-teaching hospitals, which is the model most widely recognized to measure quality of healthcare. These may include the presence of subspeciality training, such as thoracic surgeons vs general surgeons, in-house resident/fellow care, and at our Institution now physician extenders such as nurse practitioners and physician assistants, dedicated Surgical intensive care units directed by intensive care specialists, the availability of dedicated ancillary services including thoracic-specific anesthesiology, physical therapy and respiratory therapy, an interdisciplinary team approach to the management of lung cancer patients, and clinical care pathway protocols for post-operative management <click>
  • Slide 16: “We recognize that there are several limitations to this study.
    They include the retrospective database design and the associated constraints of the level of the data used for analysis <click>,
    the definition of teaching hospital status in the NIS <click>,
    the inability to account for surgical specialty training <click>,
    the difficulty in examining other postoperative outcomes such as complications and causes of death, <click>
    and the inability to further delineate what difference exist between teaching and non-teaching hospitals like the processes of care. <click>
  • Slide 17: “In conclusion, the data from our study refute the fears of patients of seeking care at teaching hospitals, and suggest that post-operative survival is improved for patients undergoing lobectomy at teaching hospitals likely due to process of care and not hospital volume. <click>
    Further research is needed to better elucidate the influence of hospital status and the process of care on post-operative outcomes for high-risk operations.
    On consideration of the limitations of our study, in conjunction with the finding of others, it is more likely that teaching hospital status is a surrogate marker for systems which contribute to improved perioperative survival. It is NOT our intention to say that these resections should be done at teaching institutions, but rather to further identify those factors contributing to the difference in outcomes between teaching and non-teaching hospitals, observed in this study.
    While the processes of care described this morning are certainly not specific to teaching hospitals alone, they would ultimately improve all thoracic surgery outcomes for such processes to be widely available, at teaching and non-teaching hospitals, large and small. <click>
    Subsequently, information regarding these factors could be disseminated to improve patient care and outcomes nationally.
    Therefore, we propose that new standards in the process of care be considered for the benefit of patients undergoing resection for lung cancer independent of hospital volume and teaching status.
    Again, on behalf of my colleagues I would like to thank the Society for the privilege of presenting our paper, and am most flattered and honored to be amongst the J. Maxwell Chamberlain papers. Thank you.
  • Slide 17: “In conclusion, the data from our study refute the fears of patients of seeking care at teaching hospitals, and suggest that post-operative survival is improved for patients undergoing lobectomy at teaching hospitals likely due to process of care and not hospital volume. <click>
    Further research is needed to better elucidate the influence of hospital status and the process of care on post-operative outcomes for high-risk operations.
    On consideration of the limitations of our study, in conjunction with the finding of others, it is more likely that teaching hospital status is a surrogate marker for systems which contribute to improved perioperative survival. It is NOT our intention to say that these resections should be done at teaching institutions, but rather to further identify those factors contributing to the difference in outcomes between teaching and non-teaching hospitals, observed in this study.
    While the processes of care described this morning are certainly not specific to teaching hospitals alone, they would ultimately improve all thoracic surgery outcomes for such processes to be widely available, at teaching and non-teaching hospitals, large and small. <click>
    Subsequently, information regarding these factors could be disseminated to improve patient care and outcomes nationally.
    Therefore, we propose that new standards in the process of care be considered for the benefit of patients undergoing resection for lung cancer independent of hospital volume and teaching status.
    Again, on behalf of my colleagues I would like to thank the Society for the privilege of presenting our paper, and am most flattered and honored to be amongst the J. Maxwell Chamberlain papers. Thank you.
  • Slide 17: “In conclusion, the data from our study refute the fears of patients of seeking care at teaching hospitals, and suggest that post-operative survival is improved for patients undergoing lobectomy at teaching hospitals likely due to process of care and not hospital volume. <click>
    Further research is needed to better elucidate the influence of hospital status and the process of care on post-operative outcomes for high-risk operations.
    On consideration of the limitations of our study, in conjunction with the finding of others, it is more likely that teaching hospital status is a surrogate marker for systems which contribute to improved perioperative survival. It is NOT our intention to say that these resections should be done at teaching institutions, but rather to further identify those factors contributing to the difference in outcomes between teaching and non-teaching hospitals, observed in this study.
    While the processes of care described this morning are certainly not specific to teaching hospitals alone, they would ultimately improve all thoracic surgery outcomes for such processes to be widely available, at teaching and non-teaching hospitals, large and small. <click>
    Subsequently, information regarding these factors could be disseminated to improve patient care and outcomes nationally.
    Therefore, we propose that new standards in the process of care be considered for the benefit of patients undergoing resection for lung cancer independent of hospital volume and teaching status.
    Again, on behalf of my colleagues I would like to thank the Society for the privilege of presenting our paper, and am most flattered and honored to be amongst the J. Maxwell Chamberlain papers. Thank you.
  • Slide 17: “In conclusion, the data from our study refute the fears of patients of seeking care at teaching hospitals, and suggest that post-operative survival is improved for patients undergoing lobectomy at teaching hospitals likely due to process of care and not hospital volume. <click>
    Further research is needed to better elucidate the influence of hospital status and the process of care on post-operative outcomes for high-risk operations.
    On consideration of the limitations of our study, in conjunction with the finding of others, it is more likely that teaching hospital status is a surrogate marker for systems which contribute to improved perioperative survival. It is NOT our intention to say that these resections should be done at teaching institutions, but rather to further identify those factors contributing to the difference in outcomes between teaching and non-teaching hospitals, observed in this study.
    While the processes of care described this morning are certainly not specific to teaching hospitals alone, they would ultimately improve all thoracic surgery outcomes for such processes to be widely available, at teaching and non-teaching hospitals, large and small. <click>
    Subsequently, information regarding these factors could be disseminated to improve patient care and outcomes nationally.
    Therefore, we propose that new standards in the process of care be considered for the benefit of patients undergoing resection for lung cancer independent of hospital volume and teaching status.
    Again, on behalf of my colleagues I would like to thank the Society for the privilege of presenting our paper, and am most flattered and honored to be amongst the J. Maxwell Chamberlain papers. Thank you.
  • Slide 16: I’d like to take this opportunity to thank all of my colleagues for their hard work and dedication to this project, as well as to my audience for their attention.
    On behalf of my colleagues I would like to thank the audience for their time and attention, and to thank my colleagues for their dedication to this project.
  • Slide 15: In comparing the same at general surgery training hospitals, without including volume, the odds of in-hospital death after esophagectomy for a patient undergoing treatment at a general surgery training hospital is 0.56, or a 44% reduction in risk of death as compared to non-general surgery training hospitals, and this is significant. When volume is added, the protective effect of general surgery training hospitals is diminished somewhat, but only minimally. <CLICK>
  • Slide 5: Therefore, we hypothesized the following:<CLICK> Post-Operative mortality after esophagectomy is reduced at teaching hospitals <CLICK> This reduction is independent of volume <CLICK> and Mortality outcomes for Thoracic Surgeons are improved over General Surgeons <CLICK>
  • PowerPoint® File

    1. 1. Healthcare Workforce andHealthcare Workforce and Regionalization of Services:Regionalization of Services: Lung Cancer ResectionsLung Cancer Resections Stephen C. Yang, M.D.Stephen C. Yang, M.D. Chief of Thoracic SurgeryChief of Thoracic Surgery The Arthur B. and Patricia B. ModellThe Arthur B. and Patricia B. Modell Professor in Thoracic SurgeryProfessor in Thoracic Surgery The Johns Hopkins Medical InstitutionsThe Johns Hopkins Medical Institutions AHRQ 9/10/08AHRQ 9/10/08
    2. 2. DisclosuresDisclosures
    3. 3. OverviewOverview  Incidence of lung cancerIncidence of lung cancer  Study background/methodsStudy background/methods  Result:Result: Teaching vs non-teachingTeaching vs non-teaching General surgery residencyGeneral surgery residency Thoracic surgery residencyThoracic surgery residency  AHRQ ImplicationsAHRQ Implications
    4. 4. The High Incidence of Lung CancerThe High Incidence of Lung Cancer * Jemal et al, CA 2006 Lung and Bronchus 92,700 13% Lung and Bronchus 81,770 12% Lung and Bronchus 90,330 31% Lung and Bronchus 73,130 36% RAM 01/07
    5. 5. Prior Studies ExaminingPrior Studies Examining Surgical OutcomesSurgical Outcomes  Surgeon volumeSurgeon volume  Hospital volumeHospital volume Pulmonary resectionPulmonary resection Esophageal resectionEsophageal resection Coronary artery bypassCoronary artery bypass Carotid endarterectomyCarotid endarterectomy Other complex cancer surgeryOther complex cancer surgery  Hospital characteristics associated withHospital characteristics associated with improved outcomes poorly definedimproved outcomes poorly defined
    6. 6. Origin of the StudyOrigin of the Study
    7. 7. Teaching HospitalsTeaching Hospitals  Teaching hospitalsTeaching hospitals Fellows, residents, medical and nursing studentsFellows, residents, medical and nursing students Surrogate of higher levels of tertiary care andSurrogate of higher levels of tertiary care and servicesservices Public perception: “dangerous”Public perception: “dangerous”  Published studies:Published studies: Benefit of teaching hospitals is due to increasedBenefit of teaching hospitals is due to increased volumevolume
    8. 8. Thoracic vs. General SurgeonsThoracic vs. General Surgeons  Lung resections traditionally performedLung resections traditionally performed by general surgeons as well as specialty-by general surgeons as well as specialty- trained thoracic surgeonstrained thoracic surgeons  Debate persists over whether thoracicDebate persists over whether thoracic surgeons should preferentially performsurgeons should preferentially perform lung (and esophageal) resectionslung (and esophageal) resections  Few large, nationwide studies haveFew large, nationwide studies have examined this issueexamined this issue
    9. 9. Benefit of Teaching HospitalsBenefit of Teaching Hospitals  Unclear whether perioperative outcomesUnclear whether perioperative outcomes are improved at teaching hospitals due toare improved at teaching hospitals due to volume or environmentvolume or environment “In-hospital mortality after lung cancer resection at teaching hospitals is low and improved at thoracic teaching programs, while independent of hospital procedure volume.” • Hypothesis:
    10. 10. Methods - 1Methods - 1  Study Design:Study Design: Retrospective analysis usingRetrospective analysis using Nationwide Inpatient Sample (HCUP/AHRQ)Nationwide Inpatient Sample (HCUP/AHRQ) 1998-20031998-2003 Combined with ACGME to identify generalCombined with ACGME to identify general and thoracic surgery residency programsand thoracic surgery residency programs Primary lung cancerPrimary lung cancer Segmentectomy, lobectomy, pneumonectomySegmentectomy, lobectomy, pneumonectomy
    11. 11. Definitions:Definitions: Lung Cancer OperationsLung Cancer Operations
    12. 12. Methods - 2Methods - 2  Variables:Variables: Age, gender, raceAge, gender, race Charlson Index of comorbiditiesCharlson Index of comorbidities Annual hospital procedure volumesAnnual hospital procedure volumes Teaching hospital statusTeaching hospital status
    13. 13. DefinitionsDefinitions Teaching Hospitals (NIS): - At least 1 residency program (not necessarily surgery) - Member of Council of Teaching Hospitals - Maximum 4:1 beds:residents Academic Hospitals: - University affiliation - Faculty: university-based, engage in research
    14. 14. Outcome AnalysisOutcome Analysis  Outcome:Outcome:  In-hospital death from any cause as endIn-hospital death from any cause as end result based on discharge summary (notresult based on discharge summary (not usual 30-day mortality)usual 30-day mortality)  Analyzed Statistics:Analyzed Statistics:  Multivariate logistic regression analysisMultivariate logistic regression analysis
    15. 15. Overall Hospital Status Teaching 28,101 Non-Teaching 22,780 55.2% 44.8% Surgical and Hospital DemographicsSurgical and Hospital Demographics Overall Resections Seg. 8,143 Lobectomy 37,882 Pneum. 4,901 9.7% 74.9% 16.1% 50,576 3215
    16. 16. Resection DemographicsResection Demographics TeachingTeaching Non-TeachingNon-Teaching HospitalsHospitals 1095 (34.1%)1095 (34.1%) 2115 (65.9%)2115 (65.9%) Total ResectionsTotal Resections 28,10128,101 22,78022,780 SegmentectomySegmentectomy 4,383 (15.7%)4,383 (15.7%) 3,753 (16.5%)3,753 (16.5%) LobectomyLobectomy 20,740 (73.8%)20,740 (73.8%) 17,110 (75.1%)17,110 (75.1%) PneumonectomyPneumonectomy 2,978 (10.6%)2,978 (10.6%) 1,917 (8.4%)1,917 (8.4%)
    17. 17. Patient DemographicsPatient Demographics TeachingTeaching Non-TeachingNon-Teaching Median AgeMedian Age 66 years66 years 67 years67 years FemaleFemale 46.8%46.8% 45.6%45.6% Median CharlsonMedian Charlson IndexIndex 33 33 Median HospitalMedian Hospital StayStay 77 77
    18. 18. Unadjusted MortalityUnadjusted Mortality: Teaching vs. Non-: Teaching vs. Non- Teaching HospitalsTeaching Hospitals 0% 2% 4% 6% 8% 10% Overall Seg. Lobe. Pneum. p=0.016 * p<0.001 * Teaching Non-Teaching p<0.05 *
    19. 19. Multivariate Analysis of LobectomiesMultivariate Analysis of Lobectomies at Teaching vs. Non-Teachingat Teaching vs. Non-Teaching Odds Ratio*Odds Ratio* 95% CI95% CI P-valueP-value OverallOverall 0.810.81 0.69 - 0.960.69 - 0.96 0.0120.012 Sub-Groups:Sub-Groups: VolumeVolume << 55 0.830.83 0.70 - 0.970.70 - 0.97 0.0230.023 VolumeVolume << 1010 0.830.83 0.70 - 0.980.70 - 0.98 0.0260.026 VolumeVolume >> 1010 0.830.83 0.70 - 0.980.70 - 0.98 0.0260.026 VolumeVolume >> 2020 0.840.84 0.71 - 0.980.71 - 0.98 0.0310.031 * Adjusted for Age, Gender, Race, Comorbidities, Volume 19% Reduction in Mortality
    20. 20. 0% 1% 2% 3% 4% 5% 6% Teaching N on-Teach G en Surg N on-G en Surg ThorSurg N on-Thor Surg In-HospitalMortalityRateIn-HospitalMortalityRate Unadjusted Overall MortalityUnadjusted Overall Mortality:: Teaching vs. Non-Teaching HospitalsTeaching vs. Non-Teaching Hospitals 20.2%20.2% 27.3%27.3% 27.5%27.5%
    21. 21. SummarySummary Statistically significant difference in mortality rate forStatistically significant difference in mortality rate for lobectomies at teaching vs. non-teaching hospitalslobectomies at teaching vs. non-teaching hospitals (2.94% vs. 3.62%)(2.94% vs. 3.62%) 19% improvement in post-operative survival for19% improvement in post-operative survival for lobectomy at teaching hospitallobectomy at teaching hospital (95% CI: 0.69 - 0.96)(95% CI: 0.69 - 0.96) These findings areThese findings are independentindependent of hospital volumeof hospital volume
    22. 22. Teaching Hospitals:Teaching Hospitals: Process of CareProcess of Care Subspecialty trained surgeonsSubspecialty trained surgeons -- Thoracic vs. General surgeonsThoracic vs. General surgeons In-house resident / fellow careIn-house resident / fellow care Dedicated SICU directed by intensive care specialistsDedicated SICU directed by intensive care specialists Thoracic anesthesiologyThoracic anesthesiology Physical / Respiratory therapistsPhysical / Respiratory therapists Interdisciplinary team management of lung cancerInterdisciplinary team management of lung cancer patientspatients Pathway protocols for post-operative carePathway protocols for post-operative care
    23. 23. Study LimitationsStudy Limitations  Retrospective database designRetrospective database design  Definition of teaching hospital in NISDefinition of teaching hospital in NIS  Inability to account for differences in surgicalInability to account for differences in surgical specialty trainingspecialty training  Unable to examine other post-op outcomesUnable to examine other post-op outcomes  Inability to further delineate what differencesInability to further delineate what differences exist between teaching & non-teaching hospitalsexist between teaching & non-teaching hospitals
    24. 24. ConclusionsConclusions  These data suggest that post-operativeThese data suggest that post-operative mortality is improved for patientsmortality is improved for patients undergoing lobectomy at teaching hospitals.undergoing lobectomy at teaching hospitals.  More research is needed to define theMore research is needed to define the influence of hospital status and the processinfluence of hospital status and the process of care on post-operative outcomes for high-of care on post-operative outcomes for high- risk operations.risk operations.
    25. 25. ConclusionsConclusions  Our data refute the fears of patients seekingOur data refute the fears of patients seeking surgical care at teaching hospitalssurgical care at teaching hospitals  Information regarding these processes ofInformation regarding these processes of care could be disseminated to improvecare could be disseminated to improve patient care and outcomes nationally.patient care and outcomes nationally.  Critical steps in the process of care shouldCritical steps in the process of care should be identified for the benefit of patientsbe identified for the benefit of patients undergoing resection for lung cancerundergoing resection for lung cancer independent of hospital volume andindependent of hospital volume and teaching status.teaching status.
    26. 26. Application of NIS/HCUP/AHRQApplication of NIS/HCUP/AHRQ  Limitations: patient level dataLimitations: patient level data (staging, specific(staging, specific complications, etc)complications, etc)  Applicability of NIS increasedApplicability of NIS increased by combining with otherby combining with other datasets (ACGME in thisdatasets (ACGME in this study)study)  Specialty Datasets: Society ofSpecialty Datasets: Society of Thoracic Surgeons database inThoracic Surgeons database in adult cardiac, generaladult cardiac, general thoracic and pediatric cardiacthoracic and pediatric cardiac surgerysurgery
    27. 27. Policy ImplicationsPolicy Implications  If data is taken at face value, AHRQ couldIf data is taken at face value, AHRQ could propose national clinical practice guidelinespropose national clinical practice guidelines (i.e. beta-blockers for MI) to have complex(i.e. beta-blockers for MI) to have complex procedures performed at teaching hospitalsprocedures performed at teaching hospitals  If conclusions are extrapolated, and theIf conclusions are extrapolated, and the “processes of care” are felt to be essential“processes of care” are felt to be essential for improved outcomes, policy makersfor improved outcomes, policy makers could make these mandatory services forcould make these mandatory services for these proceduresthese procedures
    28. 28. Thank YouThank You Robert A. Meguid, MD, MPHRobert A. Meguid, MD, MPH Benjamin S. Brooke, MDBenjamin S. Brooke, MD David Chang, PhD, MPH, MBADavid Chang, PhD, MPH, MBA J. Timothy Sherwood, MDJ. Timothy Sherwood, MD Malcolm V. Brock, MDMalcolm V. Brock, MD
    29. 29. 0 0.5 1.0 1.5 2.0 2.5 Overall Seg. Lobe. Pneumon. Overall Seg. Lobe. Pneumon. Overall Seg. Lobe. Pneumon. Adjusted Odds Ratio of In-Hospital Death after LungAdjusted Odds Ratio of In-Hospital Death after Lung ResectionResection OddsofIn-HospitalDeathOddsofIn-HospitalDeath Teaching vs Non- Teaching Gen Surg vs Non- Gen Surg Thor Surg vs Non- Thor Surg
    30. 30. Hypotheses:Hypotheses:  Post-Operative mortality after lungPost-Operative mortality after lung resection is reduced at teachingresection is reduced at teaching hospitalshospitals  This reduction is independent of volumeThis reduction is independent of volume  Mortality outcomes for ThoracicMortality outcomes for Thoracic Surgeons are improved over GeneralSurgeons are improved over General SurgeonsSurgeons
    31. 31. 0% 2% 4% 6% 8% 10% 12% Overall Seg. Lobe. Pneumon. Gen Surg Teaching Non-Gen Surg Teaching Unadjusted MortalityUnadjusted Mortality:: General Surgery Teaching vs.General Surgery Teaching vs. Non-Gen Surg Teaching HospitalsNon-Gen Surg Teaching Hospitals InHospitalMortalityRate p<0.05 p<0.05
    32. 32. 0% 2% 4% 6% 8% 10% 12% Overall Seg. Lobe. Pneumon. Thor Surg Teaching Non-Thor Surg Teaching Unadjusted MortalityUnadjusted Mortality:: Thoracic Surgery Teaching vs.Thoracic Surgery Teaching vs. Non-Thor Surg Teaching HospitalsNon-Thor Surg Teaching Hospitals InHospitalMortalityRate p<0.05 p<0.05

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