STS General Thoracic Surgery Database (GTSD) Update

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1 STS General Thoracic Surgery Database (GTSD) Update Benjamin D. Kozower, MD, MPH Professor of Surgery Chair, STS GTSD Co-Director, Surgical Outcomes Research Center Washington University St. Louis, MO

2 GTSD: Updates Participation Risk Adjusted Model Updates Lung and esophageal cancer resection Quality composite measures Lobectomy and esophagectomy Challenges / Opportunities

3 GTSD Participation Programs

4 STS Lung Cancer Resection Risk Model: Higher Quality Data and Superior Outcomes FG Fernandez, A Kosinski, W Burfeind, B Park, MM DeCamp, C Seder, B Marshall, MJ Magee, CD Wright, BD Kozower STS General Thoracic Surgery Database Task Force Presented at the Southern Thoracic Surgical Association November 2015

5 General Thoracic Surgery Database (GTSD) Evolution Prior risk model: Current cohort: Lung Cancer resections 18,800 27,844 Centers reporting Thoracoscopy 37% 62% Database audited No Yes* * Magee MJ et al. Ann Thorac Surg 2013

6 Adverse Events Operative mortality: 1.4% (401/27,844) Major morbidity 9.1% (2,545/27,844) Composite mortality or major morbidity 9.5% (2,654/27,844)

7 Mortality Risk Model Variable Odds Ratio (95% CI) p-value Procedure: Pneumonectomy 4.80 (2.87, 8.02) <0.001 Bilobectomy Lobectomy* 3.57 (2.09, 6.12) 1.69 (1.14, 2.53) Approach Thoracotomy* 1.87 (1.49, 2.36) <0.001 Reoperation* 1.38 (1.00, 1.94) 0.05 Induction therapy 1.51 (1.09, 2.10) C statistic = 0.78 * - not significant in prior model

8 Predictors Of Major Morbidity Or Mortality After Resection For Esophageal Cancer: A Society Of Thoracic Surgeons General Thoracic Surgery Database Risk Adjustment Model Daniel Raymond, MD and STS GTSD Task Force 11/5/15 - STSA

9 Time to update the model... Increase in number of contributing centers 164 vs 73 Growth of minimally invasive esophageal procedures Transhiatal-Total esophagectomy, without thoracotomy, with cervical esophagogastrostomy (43107) Three hole-total esophagectomy with thoracotomy; with cervical esophagogastrostomy (43112) Ivor Lewis-Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision (43117) Thoracoabdominal-Partial esophagectomy, thoracoabdominal approach (43122) Minimally invasive three hole esophagectomy Minimally invasive esophagectomy, Ivor Lewis approach Minimally invasive esophagectomy, Abdominal and neck approach

10 Results 4321 procedures 4124 for multivariable analysis due to missing data Perioperative mortality: 3.1% Perioperative morbidity ( 1): 33.1% 2/3 overweight, 3% underweight 60% former smokers; 15% active smokers

11 Independent Predictors of Perioperative Morbidity or Mortality OR

12 OR for Combined Morbidity or Mortality Procedure Type OR

13 Quality Composite Measures Lobectomy for lung cancer Esophagectomy for esophageal cancer In progress (Andrew Chang U. Michigan) Ann Thorac Surg. 2016; 101(4): Submitted to STS 2017

14 Lobectomy for Lung Cancer Developed the first composite quality measure for thoracic surgery Lobectomy for lung cancer 2 domain measure Use 3 years of rolling data Compare hospitals with STS data along with national outcomes STS participants outperform national benchmarks

15 Composite Outcomes 20,657 lobectomies from 231 Participants Operative mortality 1.5% Major complications 9.6% Pneumonia 4.3% Unexpected return to OR 3.9% Reintubation 3.4% Pulmonary embolus 0.5% Initial Vent Support >48 Hours 0.5% Bronchopleural fistula 0.4% Tracheostomy 1.0% ARDS 0.7% Myocardial infarction 0.4% Length of stay (median) 4 days, IQR (3,7)

16 Lobectomy for Lung Cancer STS results are NOT Generalizable

17 GTSD: Challenges / Opportunities Increase participation Implement public reporting for GTSD Create an STS owned web based platform Enhance the value of the database

18 Lung Cancer Resection Volumes Small National Capture National - NIS NIS STS - GTSD GTDB 8% LaPar, Kozower. Ann Thorac Surg 2012;94:216

19 Increase Participation Improving Penetrance of the GTSD Lobectomy (2012) 6,925 in STS 26,015 in NIS = 26.6% Esophagectomy (2012) 1,491 in STS 5,200 in NIS = 28.7%

20 Increase Participation Improving Penetrance of the GTSD Need to capture the cardiac and general surgeons performing thoracic surgery Consider a lung cancer resection module Encourage primarily cardiac surgeons participating in adult cardiac STS Determine barriers to participation

21 Public Reporting of Surgical Outcomes Voluntary Participation: 41.7% in 2015

22 Thoracic Public Reporting Three Displays List of participants STS outperforms national benchmarks Compare STS with national outcomes STS database and participant comparisons Utilize the National Inpatient Sample (NIS) Star ratings

23 STS Database Platform Should the STS create and manage its own web based GTSD platform? Given the number of vendors with small numbers of participants, it s difficult and expensive to update the database Vendor Participants Participant generated software 6

24 Enhance the Value of GTSD Audit results Overall data accuracy 94.9% (Mitch Magee) Long term follow-up Critical for evaluation of oncology outcomes 5 year survival added for lung and esophageal cancer resection CMS linkage (PI Fernandez) Exploring linkage with NCDB Patient reported outcomes Regional quality collaboration Balance goals of research and quality Increase data capture balanced with burden on data managers Leverage the database for private/industry collaboration

25 Thank You

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