# Presentation: 578365

## 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

**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***

## Disclosures

**Disclosures**

**Notes:**
I have no disclosures

## Slide 3

## Overview

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

**Notes:**
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 5

## The High Incidence of Lung Cancer

- * Jemal et al, CA 2006

- RAM 01/07

**Notes:**
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>

## 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**

**Notes:**
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>

## Origin of the Study

**Origin of the Study**

## 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**

**Notes:**
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>

## 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**

**Notes:**
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>

## Benefit of Teaching Hospitals

**Unclear whether perioperative outcomes are improved at teaching hospitals due to volume or environment**

**Notes:**
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>

## Methods - 1

**Study Design:**** ****Retrospective analysis using Nationwide Inpatient Sample (HCUP/AHRQ) **
**1998-2003**
**Combined with ACGME to identify general and thoracic surgery residency programs**
**Primary lung cancer**
**Segmentectomy, lobectomy, pneumonectomy**

**Notes:**
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>

## Definitions:  Lung Cancer Operations

**Definitions:  *****Lung Cancer Operations***

## Methods - 2

**Variables: **
**Age, gender, race**
**Charlson Index of comorbidities**
**Annual hospital procedure volumes**
**Teaching hospital status**

**Notes:**
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>

## 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**

**Notes:**
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>

## 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**

**Notes:**
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>

## Surgical and Hospital Demographics

**Surgical and Hospital Demographics**

**Overall Resections**

- Seg.
- 8,143

- Lobectomy
- 37,882

- Pneum.
- 4,901

**9.7%**

**74.9%**

**16.1%**

**50,576**

**3215**

**Notes:**
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 1⁄2 of these procedures were performed at teaching hospitals.
<CLICK>

## Resection Demographics

|  | Teaching | Non-Teaching |
| --- | --- | --- |
| Hospitals | 1095 (34.1%) | 2115 (65.9%) |
| Total Resections | 28,101 | 22,780 |
| Segmentectomy | 4,383 (15.7%) | 3,753 (16.5%) |
| Lobectomy | 20,740 (73.8%) | 17,110 (75.1%) |
| Pneumonectomy | 2,978 (10.6%) | 1,917 (8.4%) |

**Notes:**
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.

## Patient Demographics

|  | Teaching | Non-Teaching |
| --- | --- | --- |
| Median Age | 66 years | 67 years |
| Female | 46.8% | 45.6% |
| Median Charlson Index | 3 | 3 |
| Median Hospital Stay | 7 | 7 |

**Notes:**
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>

## Unadjusted Mortality: Teaching vs. Non-Teaching Hospitals

**p=0.016**
- *

**p<0.001**
- *

- Teaching

- Non-Teaching

**p<0.05**
- *

**Notes:**
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> 

## Multivariate Analysis of Lobectomies at Teaching vs. Non-Teaching

|  | Odds Ratio* | 95% CI | P-value |
| --- | --- | --- | --- |
| Overall | 0.81 | 0.69 - 0.96 | 0.012 |
| Sub-Groups: |  |  |  |
| Volume < 5 | 0.83 | 0.70 - 0.97 | 0.023 |
| Volume < 10 | 0.83 | 0.70 - 0.98 | 0.026 |
| Volume > 10 | 0.83 | 0.70 - 0.98 | 0.026 |
| Volume > 20 | 0.84 | 0.71 - 0.98 | 0.031 |

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

**Notes:**
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>

## Unadjusted Overall Mortality:Teaching vs. Non-Teaching Hospitals

**0%**

**1%**

**2%**

**3%**

**4%**

**5%**

**6%**

**Teaching**

**Non-Teach**

**Gen Surg**

**Non-Gen**
**Surg**

**Thor Surg**

**Non-Thor**
**Surg**

**In-Hospital Mortality Rate**

***Unadjusted Overall Mortality*****:****Teaching vs. Non-Teaching Hospitals**

**Notes:**
Slide 12: This graph summarizes the unadjusted Mortalities of the different types of Teaching Hospitals <CLICK>...

## 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**

**Notes:**
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?”

## 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**

**Notes:**
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>

## Study Limitations

**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**

**Notes:**
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>

## 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.**

**Notes:**
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.

## Conclusions

**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. **

**Notes:**
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.

## 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**

**Notes:**
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.

## Policy Implications

**If data is taken at face value, AHRQ could propose national clinical practice guidelines (i.e. beta-blockers for 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, policy makers could make these mandatory services for these procedures**

**Notes:**
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.

## Thank You

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

**Notes:**
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 31

## Adjusted Odds Ratio of In-Hospital Death after Lung Resection

**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 Lung Resection**

**Odds of In-Hospital Death**

- Teaching vs Non-Teaching

- Gen Surg vs Non-Gen Surg

- Thor Surg vs Non-Thor Surg

**Notes:**
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>

## 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*

**Notes:**
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> 

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

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

**In Hospital Mortality Rate**

**p<0.05**

**p<0.05**

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

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

**In Hospital Mortality Rate**

**p<0.05**

**p<0.05**