Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States

Our plain-English summary of Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States, by J. Hadaya, V. Dobaria, E. Aguayo, et al (The Annals of Thoracic Surgery, 2020).

The study

• Authors: J. Hadaya, V. Dobaria, E. Aguayo, A. Mandelbaum, Y. Sanaiha, S.L. Revels, P. Benharash
• Journal: The Annals of Thoracic Surgery
• Published: 2020;110(6):1874-1881
• Cited by: 20 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy.

Methods: We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay.

Results: During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication.

Conclusions: High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

In plain English

This study did not examine asbestos. It was a retrospective analysis of a US hospital database, the National Inpatient Sample. It covered an estimated 22,739 adults who had elective pneumonectomy (removal of a whole lung) from 2005 to 2014. Patients with mesothelioma, patients under 18, trauma cases and non-elective admissions were excluded. Hospitals were grouped into four levels by their yearly number of elective anatomic lung resections (lobectomy, segmentectomy and pneumonectomy combined). Nationally, pneumonectomies fell from 2845 in 2005 to 1715 in 2014, and in-hospital mortality fell from 7.9% to 5.5%. After adjusting for patient and hospital factors, the lowest-volume hospitals had higher odds of death than the highest-volume hospitals (adjusted odds ratio 1.74, 95% CI 1.14-2.66). Adjusted odds of complications were mostly similar. Among patients with a complication, however, death was more common at the lowest-volume than the highest-volume hospitals (18.3% vs 12.7%). The authors concluded that high hospital volume was strongly associated with lower mortality. They noted that the data relied on hospital coding and lacked information on disease severity and surgeons.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a national hospital discharge database (National Inpatient Sample)
• Who was studied: An estimated 22,739 adult patients who underwent elective pneumonectomy in US hospitals, 2005-2014, in the National Inpatient Sample. Patients under 18 years and those with trauma-related diagnoses, mesothelioma, or a non-elective admission were excluded.
• Exposure: Not an asbestos exposure. The factor studied was hospital volume: hospitals were divided into four quartiles (low, medium, high, very high) by annual institutional number of elective anatomic lung resections, meaning lobectomy, segmentectomy and pneumonectomy. Annual pneumonectomy volume alone was used for a sensitivity analysis.
• Main results:
  • National pneumonectomy volume fell from 2845 in 2005 to 1715 in 2014. In-hospital mortality across all hospitals fell from 7.9% to 5.5% (P-trend=0.045).
  • Unadjusted in-hospital mortality was 9.0% at low-volume, 7.3% at medium-volume, 6.6% at high-volume and 5.3% at very high-volume hospitals.
  • After adjustment for patient and hospital factors, pneumonectomy at low-volume hospitals was associated with increased odds of mortality compared with very high-volume hospitals (AOR 1.74, 95% CI 1.14-2.66).
  • Unadjusted rates of any complication were 46.5% at low-volume vs 39.3% at very high-volume hospitals. After adjustment, hospital volume was not associated with odds of complications, except lower odds of cardiovascular complications at high-volume hospitals (AOR 0.70, 95% CI 0.52-0.93) compared with very high-volume hospitals.
  • Failure-to-rescue (death after any complication) was 18.3% at low-volume vs 12.7% at very high-volume hospitals (P=0.024). The adjusted odds were 1.70 (95% CI 1.09-2.64).
  • In a sensitivity analysis that grouped hospitals by pneumonectomy volume, low-volume hospitals again had increased odds of mortality compared with very high-volume hospitals (AOR 1.57, 95% CI 1.09-2.25).
  • Length of stay was similar across volume groups. Hospitalization costs were highest at very high-volume hospitals ($37,300 vs $32,100 at low-volume hospitals, p<0.001).
• The authors' conclusion: The authors concluded that high hospital volume is strongly associated with reduced mortality and failure-to-rescue after pneumonectomy. They suggested pneumonectomy be considered a target for regionalization.
• Limitations the authors state:
  • Patients, medical history and complications were identified by ICD-9-CM codes, which depend on hospital coding practices.
  • Disease or complication severity and use of neoadjuvant therapy could not be studied.
  • The effect of individual surgeon volume could not be assessed because surgeons are not tracked in the database.
  • Outcomes of patients not requiring pneumonectomy or managed without surgery were not examined.
  • Patients with mesothelioma were excluded because they likely underwent extrapleural pneumonectomy, so the findings do not cover them.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer.

Medical terms in this study, explained in our Lexicon: Pneumonectomy, Mesothelioma, confidence interval.

Related studies

• Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions — O. Lauk, M.A. Hoda, et al. (2014)
• Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma — M. van Gerwen, A. Wolf, et al. (2018)
• Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma — D.R. Gomez, D.S. Hong, et al. (2013)
• Postoperative morbidity and mortality after pneumonectomy: a 30-year experience of 2064 consecutive patients — C. Pricopi, P. Mordant, et al. (2015)
• Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? — P. Mordant, K. McRae, et al. (2016)
• Facility volume and postoperative outcomes for malignant pleural mesothelioma: A National Cancer Data Base analysis — V. Verma, C.A. Ahern, et al. (2018)

Browse more research in The Annals of Thoracic Surgery, or return to medical research.