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
GTSD: Updates Participation Risk Adjusted Model Updates Lung and esophageal cancer resection Quality composite measures Lobectomy and esophagectomy Challenges / Opportunities
GTSD Participation 300 279 Programs 250 200 150 100 50 0 2003 2005 2007 2009 2011 2013 2016
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
General Thoracic Surgery Database (GTSD) Evolution Prior risk model: 2002-2008 Current cohort: 2012-2014 Lung Cancer resections 18,800 27,844 Centers reporting 111 231 Thoracoscopy 37% 62% Database audited No Yes* * Magee MJ et al. Ann Thorac Surg 2013
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)
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) 0.014 C statistic = 0.78 * - not significant in prior model
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
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
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
Independent Predictors of Perioperative Morbidity or Mortality OR
OR for Combined Morbidity or Mortality Procedure Type OR
Quality Composite Measures Lobectomy for lung cancer Esophagectomy for esophageal cancer In progress (Andrew Chang U. Michigan) Ann Thorac Surg. 2016; 101(4):1379-87 Submitted to STS 2017
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
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)
Lobectomy for Lung Cancer STS results are NOT Generalizable
GTSD: Challenges / Opportunities Increase participation Implement public reporting for GTSD Create an STS owned web based platform Enhance the value of the database
Lung Cancer Resection Volumes Small National Capture National - NIS NIS STS - GTSD GTDB 8% LaPar, Kozower. Ann Thorac Surg 2012;94:216
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%
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
Public Reporting of Surgical Outcomes Voluntary Participation: 41.7% in 2015
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
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 1 96 2 32 3 31 4 27 5 15 6 13 7 8 8 6 9 5 10 4 11 1 Participant generated software 6
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
Thank You