Healthcare Workforce and Regionalization of Services: Lung Cancer Resections

Slide Presentation from the AHRQ 2008 Annual Conference

On September 10, 2008, Stephen C. Yang, M.D. made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.7 MB; ).

Slide 1

Healthcare Workforce and Regionalization of Services: Lung Cancer Resections

Stephen C. Yang, M.D.
Chief of Thoracic Surgery
The Arthur B. and Patricia B. Modell
Professor in Thoracic Surgery

The Johns Hopkins Medical Institutions

AHRQ 9/10/08

Slide 2

Disclosures

I have no disclosures.

Slide 3

Are Surgical Outcomes for Lung Cancer Resections Improved at Teaching Hospitals?

The slide shows the abstract from an article from the Society of Thoracic Surgeons, 2008. The citation is: Meguid R.A., Brooke B.S., and Chang, D.C. et al. Are Surgical Outcomes for Lung Cancer Resections Improved at Teaching Hospitals? Ann Thorac Surg 2008;85:1015-25.

Slide 4

Overview

• Incidence of lung cancer.
• Study background/methods.
• Result:
  • Teaching vs non-teaching.
  • General surgery residency.
  • Thoracic surgery residency.
• AHRQ Implications.

Slide includes cartoon image of an operating room with the surgeons reading a book called "Time-Life Books Lung Surgery Made Easy."

Slide 5

It Looks Just as Stupid When You Do It

Slide shows image of a poster from the Minnesota Department of Health showing various animals smoking with the slogan "It Looks Just As Stupid When You Do It"

Slide 6

The High Incidence of Lung Cancer

Slide includes a chart of Estimated New Cases and Estimated Deaths for different cancer sites in male and female populations.

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.

Note: The data is cited from: Jemal et al., CA 2006.

Slide 7

Prior Studies Examining Surgical Outcomes

• Surgeon volume.
• Hospital volume:
  • Pulmonary resection.
  • Esophageal resection.
  • Coronary artery bypass.
  • Carotid endarterectomy.
  • Other complex cancer surgery.
• Hospital characteristics associated with improved outcomes poorly defined

Slide 8

Origin of the Study

Slide includes a cartoon of an operating room with several small children preparing to begin the surgery. An adult physician informs the patient, "Try not to worry, Mr. Thomas. It's just a minor operation."

Slide 9

Teaching Hospitals

• Teaching hospitals:
  • Fellows, residents, medical and nursing students.
  • Surrogate of higher levels of tertiary care and services.
  • Public perception: "dangerous."

• Published studies:
  • Benefit of teaching hospitals is due to increased volume.

Slide 10

Thoracic vs. General Surgeons

• Lung resections traditionally performed by general surgeons as well as specialty-trained thoracic surgeons.
• Debate persists over whether thoracic surgeons should preferentially perform lung (and esophageal) resections.
• Few large, nationwide studies have examined this issue.

Slide 11

Benefit of Teaching Hospitals

• Unclear whether perioperative outcomes are improved at teaching hospitals due to volume or environment.
• Hypothesis:
  • "In-hospital mortality after lung cancer resection at teaching hospitals is low and improved at thoracic teaching programs, while independent of hospital procedure volume."

Slide 12

Methods—1

• Study Design: Retrospective analysis using Nationwide Inpatient Sample (NIS, Healthcare Cost and Utilization Project [HCUP]/AHRQ):
  • 1998-2003.
  • Combined with Accreditation Council for Graduate Medical Education (ACGME) to identify general and thoracic surgery residency programs.
  • Primary lung cancer.
  • Segmentectomy, lobectomy, pneumonectomy.

Slide 13

Definitions: Lung Cancer Operations

The slide includes drawings of lung cancer operations:

• Wedge resection removes a small portion of a lobe.
• Segment resection removes a larger portion of a lobe.
• Lobectomy removes an entire lobe.
• Pneumonectomy removes the entire lung.

Slide 14

Methods—2

Variables:

• Age, gender, race.
• Charlson Index of comorbidities.
• Annual hospital procedure volumes.
• Teaching hospital status.

Slide 15

Definitions

• 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.

Slide 16

Outcome Analysis

• Outcome:
  • In-hospital death from any cause as end result based on discharge summary (not usual 30-day mortality).
• Analyzed Statistics:
  • Multivariate logistic regression analysis.

Slide 17

Surgical and Hospital Demographics

Pie chart showing percentages of overall resections. Total number of resections is 50,576.

Lobectomy: 74.9% (37,882)
Pneum.: 9.7% (4,901)
Seg.: 16.1% (8,143)

Pie chart showing overall hospital status. Total number of hospitals in the study were 3,215.

Teaching: 55.2% (28,101)
Non-Teaching: 44.8% (22,780)

Slide 18

Resection Demographics

Slide 19

Patient Demographics

Slide 20

Unadjusted Mortality: Teaching vs. Non-Teaching Hospitals

Slide includes a bar graph, showing mortality from 0%-10% with teaching and non-teaching comparisons for each of the following procedures:

Slide 21

Multivariate Analysis of Lobectomies at Teaching vs. Non-Teaching

Overall there is a 19% reduction in mortality.

* Adjusted for Age, Gender, Race, Comorbidities, Volume.

Slide 22

Unadjusted Overall Mortality: Teaching vs. Non-Teaching Hospitals

Slide includes a bar graph with in-hospital mortality rates. Rates are approximated.

Teaching: 3.5%
Non-Teaching: 4.3%
Gen Surg: 3%
Non-Gen Surg: 4%
Thor Surg: 2.9%
Non-Thor Surg: 4.2%

It also shows rates of 20.2%, 27.3% and 27.5%.

Slide 23

Summary

• Statistically significant difference in mortality rate for lobectomies at teaching vs. non-teaching hospitals (2.94% vs. 3.62%).
• 19% improvement in post-operative survival for lobectomy at teaching hospital, (95% CI: 0.69—0.96).
• These findings are independent of hospital volume

Slide 24

Teaching Hospitals: Process of Care

• Subspecialty trained surgeons:
  • Thoracic vs. General surgeons.
• In-house resident/fellow care.
• Dedicated SICU directed by intensive care specialists.
• Thoracic anesthesiology.
• Physical/Respiratory therapists.
• Interdisciplinary team management of lung cancer patients.
• Pathway protocols for post-operative care.

Slide 25

Study Limitations (continued)

• Retrospective database design.
• Definition of teaching hospital in NIS.
• Inability to account for differences in surgical specialty training.
• Unable to examine other post-op outcomes.
• Inability to further delineate what differences exist between teaching & non-teaching hospitals.

Slide 26

Conclusions

• These data suggest that post-operative mortality is improved for patients undergoing lobectomy at teaching hospitals.
• More research is needed to define the influence of hospital status and the process of care on post-operative outcomes for high-risk operations.

Slide 27

Conclusions (continued)

• Our data refute the fears of patients seeking surgical care at teaching hospitals.
• Information regarding these processes of care could be disseminated to improve patient care and outcomes nationally.
• Critical steps in the process of care should be identified for the benefit of patients undergoing resection for lung cancer independent of hospital volume and teaching status.

Slide 28

Application of NIS/HCUP/AHRQ

• Limitations: patient level data (staging, specific complications, etc).
• Applicability of NIS increased by combining with other datasets (ACGME in this study).
• Specialty Datasets: Society of Thoracic Surgeons database in adult cardiac, general thoracic and pediatric cardiac surgery.

Slide 29

Policy Implications

• If data is taken at face value, AHRQ could propose national clinical practice guidelines (i.e. beta-blockers for myocardial infarction (MI) to have complex procedures performed at teaching hospitals.
• If conclusions are extrapolated, and the "processes of care" are felt to be essential for improved outcomes, policymakers could make these mandatory services for these procedures.

Slide 30

Thank You

Robert A. Meguid, MD, MPH
Benjamin S. Brooke, MD
David Chang, PhD, MPH, MBA
J. Timothy Sherwood, MD
Malcolm V. Brock, MD

Slide includes a photo of The Johns Hopkins Hospital.

Slide 31

Blank Slide

Slide 32

Adjusted Odds Ratio of In-Hospital Death after Lung Resection

Slide includes a chart that compares the odds of in-hospital death, using different surgical methods, for teaching vs. non-teaching, gen surg vs non-gen surg, and thor surg vs non-thor surg.

Slide 33

Hypotheses:

• Post-Operative mortality after lung resection is reduced at teaching hospitals.
• This reduction is independent of volume.
• Mortality outcomes for Thoracic Surgeons are improved over General Surgeons.

Slide 34

Unadjusted Mortality: General Surgery Teaching vs. Non-Gen Surg Teaching Hospitals

Slide 35

Unadjusted Mortality: Thoracic Surgery Teaching vs. Non-Thor Surg Teaching Hospitals