ICD-10-CM/PCS: potential methodologic strengths and challenges for thoracic surgery researchers and reviewers

The Clinical Impact of Heart Failure on the Postoperative Outcomes for Lung Cancer Patients Undergoing Lobectomy and Sublobar Resection by Video-Assisted Thoracic Surgery: A Propensity Score-Matched Analysis of 2016-2020 HCUP-NIS Data

Background

The clinical impact of heart failure (HF) on postoperative outcomes following video-assisted thoracic surgery (VATS) for lung cancer resection remains controversial. This study aimed to assess patient and hospital characteristics related to the type of surgery, as well as the independent impact of HF on surgical outcomes.

Methods

We conducted a retrospective analysis using data from the National Inpatient Sample database. A total of 20 693 patients aged 18 years or older, diagnosed with lung cancer, and undergoing lobectomy or sublobar resection via VATS between 2016 and 2020 were included. Patients were stratified based on the presence of HF. The HF-present cohorts were matched to HF-absent controls using a 1:2 nearest-neighbor propensity score-matching (PSM) analysis. The matched cohorts were then compared across several endpoints, including mortality, length of stay (LOS), hospitalization costs, and postoperative complications.

Results

After PSM, the study included 1781 patients who underwent lobectomy and 1157 who underwent sublobar resection, with 594 and 386 patients, respectively, having concurrent HF. In both the lobectomy and sublobar resection groups, patients with HF demonstrated significantly higher in-hospital mortality rates (P < .001), longer LOS (P < .001), increased total hospital charges (P < .001), and a greater risk for overall postoperative complications (P < .001).

Conclusions

Among patients with lung cancer undergoing VATS, the presence of HF is associated with an increased risk of postoperative complications. This finding underscores the necessity for enhanced monitoring and care for patients with HF should be treated during the postoperative recovery phase.

Understanding hospital length of stay in trauma laparotomy patients: a National Trauma Database Study

Introduction

The diverse procedures and varying patient conditions in trauma laparotomy cases lead to significant variability in hospital length of stay (HLOS), posing challenges for effective patient care. Strategies to reduce HLOS are varied, with multiple factors potentially modifiable through targeted interventions. These interventions are most effective when target populations and their associated factors are clearly defined. This study aimed to stratify trauma laparotomy patients by their HLOS and identify factors associated with HLOS to enhance patient care.

Methods

A retrospective analysis was conducted using the National Trauma Data Bank from January 2017 to December 2019. Adult trauma patients who underwent trauma laparotomy following blunt or penetrating abdominal injuries were identified using International Classification of Diseases, 10th Revision codes and Abbreviated Injury Scales. HLOS was stratified into three groups based on the IQR of the study population: short (< 5 days), medium (5-11 days) and long (> 11 days).

Results

A total of 27 434 trauma laparotomy patients were identified. The overall median HLOS was 7.0 (5.0, 11.0) days. Penetrating mechanisms, particularly stab wounds, were strongly associated with a short HLOS. Additionally, isolated abdominal trauma, splenic injuries or spleen-related procedure were more likely to result in a short HLOS. Patients with a long HLOS experienced higher rates of in-hospital complications and were more frequently discharged to home with home health services or to extended care facilities. Most comorbidities were associated with a long HLOS, and patients with Medicaid or Medicare had a higher likelihood of a long HLOS.

Conclusion

Despite the relatively homogenous trauma population, HLOS distribution varied significantly. Stratification based on HLOS revealed distinct factors associated with short and long HLOS categories, indicating that targeted interventions for each category could potentially reduce HLOS and enhance patient outcomes in the current era of constrained healthcare resources.

Level of evidence study type

Level IV, therapeutic/care management.

Outcomes After Surgical Management of Early-Stage Lung Cancer in Octogenarians: An In-Depth Analysis of a Nationally Representative Cohort

INTRODUCTION

As the United States population ages more octogenarians are undergoing surgical resection for lung cancer. We aimed to provide an updated and expanded assessment of age-related risks associated with surgical resections for early-stage NSCLC.

METHODS

The Surveillance, Epidemiology, and End Results and Medicare databases were queried for stage IA NSCLC cases treated by surgery between 2006 and 2018. Analyses included generalized linear models for one-year mortality and Cox proportional hazards models for five-year survival.

RESULTS

One-year all-cause mortality among 4061 octogenarians was more than double that of the youngest group (age: 65-69 y): 15.2% versus 7.3%, p value less than 0.001. Octogenarians were discharged to extended skilled nursing facility stays more than three times as often as the youngest group (19.9% versus 6.3%, p < 0.001). For those with skilled nursing facility duration greater than 30 days, there was a 36% greater one-year mortality risk compared with those discharged to home or home-health. In adjusted analyses, octogenarians had 62% greater one-year mortality risk compared with those aged below 80 years (risk ratio = 1.62, 95% confidence interval: 1.48-1.78). The risk of death within five years was 52% higher (hazard ratio = 1.52, 95% confidence interval: 1.42-1.62). Additional factors associated with one-year mortality included male sex, higher comorbidity burden, lower county median income, open approach, and sub-lobar resection.

CONCLUSIONS

This analysis provides an updated and expanded characterization of age-related outcomes on the basis of a large national cohort representative of elderly patients treated outside of clinical trials. Substantial gaps in survival and discharge disposition motivate further research and the development of interventions to help improve outcomes in older patients.

Predicting Lung Cancer in Korean Never-Smokers With Polygenic Risk Scores

In the last few decades, genome-wide association studies (GWAS) with more than 10,000 subjects have identified several loci associated with lung cancer and these loci have been used to develop novel risk prediction tools for cancer. The present study aimed to establish a lung cancer prediction model for Korean never-smokers using polygenic risk scores (PRSs); PRSs were calculated using a pruning-thresholding-based approach based on 11 genome-wide significant single nucleotide polymorphisms (SNPs). Overall, the odds ratios tended to increase as PRSs were larger, with the odds ratio of the top 5% PRSs being 1.71 (95% confidence interval: 1.31-2.23) using the 40%-60% percentile group as the reference, and the area under the curve (AUC) of the prediction model being of 0.76 (95% confidence interval: 0.747-0.774). The receiver operating characteristic (ROC) curves of the prediction model with and without PRSs as covariates were compared using DeLong's test, and a significant difference was observed. Our results suggest that PRSs can be valuable tools for predicting the risk of lung cancer.

Trends of utilization and perioperative outcomes of robotic and video-assisted thoracoscopic surgery in patients with lung cancer undergoing minimally invasive resection in the United States

OBJECTIVE

The objective of this study was to evaluate utilization and perioperative outcomes of video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS) for lung cancer in the United States using a nationally representative database.

METHODS

Hospital admissions for lobectomy or sublobar resection (segmentectomy or wedge resection) using VATS or RATS in patients with nonmetastatic lung cancer from October 2015 through December 2018 in the National Inpatient Sample were studied. Patient and hospital characteristics, perioperative complications and mortality, length of stay (LOS), and total hospital cost were compared. Logistic regression was used to assess whether the surgical approach was independently associated with adverse outcomes.

RESULTS

There were 83,105 patients who had VATS (n = 65,375) or RATS (n = 17,710) for lobectomy (72.7% VATS) or sublobar resection (84.2% VATS). Utilization of RATS for lobectomy and sublobar resection increased from 19.2% to 34% and 7.3% to 22%, respectively. Mortality, LOS, and conversion rates were comparable. The cost was higher for RATS (P <.01). Multivariate analyses showed comparable RATS and VATS complications with no independent association between the minimally invasive surgery approach used and adverse surgical outcomes, except for a decreased risk of pneumonia with RATS, relative to VATS sublobar resection (P <.01). Thoracic complication rates and LOS decreased after RATS lobectomy in 2018, compared with previous years (P <.005).

CONCLUSIONS

The utilization of robotic-assisted lung resection for cancer has increased in the United States between 2015 and 2018 for sublobar resection and lobectomy. In adjusted regression analysis, compared with VATS, patients who underwent RATS had similar complication rates and LOS. The robotic approach was associated with increased total hospital cost. LOS and thoracic complication rates trended down after RATS lobectomy.

Variations in Cost and Readmissions of Patients in the Bundled Payment for Care Improvement Bundle for Hip and Femur Fractures

Introduction

The Bundled Payment for Care Improvement (BPCI) for hip and femur fractures is an effort to increase care quality and coordination at a lower cost. The bundle includes all patients undergoing an operative fixation of a hip or femur fracture (diagnosis-related group codes 480-482). This study aims to investigate variance in the hospital cost and readmission rates for patients within the bundle.

Materials and Methods

The study is a retrospective analysis of patients ≥65 years old billed for a diagnosis-related groups 480-482 in 2016 in the National Readmission Database. Cost of admission and length of stay were compared between patients who were or were not readmitted. Regression analysis was used to determine the effects of the primary procedure code and anatomical location of the femur fracture on costs, length of stay, and readmission rates.

Results

Patients that were readmitted within 90 days of surgery had an increased cost on initial admission ($18,427 vs $16,844, P < .0001), and an increased length of stay (6.24 vs 5.42, P < .0001). When stratified by procedure, patients varied in readmission rates (20.7% vs 19.6% vs 21.8%), initial cost, and length of stay (LOS). Stratification by anatomical location also led to variation in readmission rates (20.7% vs 18.3% vs 20.6%), initial cost, and LOS.

Conclusion

The hip and femur fractures bundle includes a great number of procedures with variance in cost, readmission, and length of stay. This amount of variation may make standardization difficult and may put the hospital at potential financial risk.

Post-operative radiation therapy for non-small cell lung cancer: A comparison of radiation therapy techniques

OBJECTIVES

Post-operative radiation therapy (PORT) in locally advanced non-small cell lung cancer (LA-NSCLC) has historically been associated with toxicity. Conformal techniques like intensity modulated radiation therapy (IMRT) have the potential to reduce acute and long-term toxicity from radiation therapy. Among patients receiving PORT for LA-NSCLC, we identified factors associated with receipt of IMRT and evaluated the association between IMRT and toxicity.

METHODS

We queried the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between January 1, 2006 to December 31, 2014 to identify patients diagnosed with Stage II or III NSCLC and who received upfront surgery and subsequent PORT. Baseline differences between patients receiving 3-dimentional conformal radiation therapy (3D-CRT) and IMRT were assessed using the chi-squared test for proportions and the t-test for means. Multivariable logistic regression was used to identify predictors of receipt of IMRT and pulmonary, esophageal, and cardiac toxicity. Propensity-score matching was employed to reduce the effect of known confounders.

RESULTS

A total of 620 patients met the inclusion criteria, among whom 441 (71.2%) received 3D-CRT and 179 (28.8%) received IMRT. The mean age of the cohort was 73.9 years and 54.7% were male. The proportion of patients receiving IMRT increased from 6.2% in 2006 to 41.4% in 2014 (P < 0.001). IMRT was not associated with decreased pulmonary (OR 0.89; 95% CI, 0.62-1.29), esophageal (OR 1.09; 95% CI, 0.0.75-1.58), or cardiac toxicity (OR 1.02; 95% CI, 0.69-1.51). These findings held on propensity-score matching. Clinical risk factors including comorbidity and prior treatment history were associated with treatment toxicity.

CONCLUSION

In a cohort of elderly patients, the use of IMRT in the setting of PORT for LA-NSCLC was not associated with a difference in toxicity compared to 3D-CRT. This finding suggests that outcomes from PORT may be independent of radiotherapy treatment technique.

The Survival Advantage of Lobectomy over Wedge Resection Lessens as Health-Related Life Expectancy Decreases

Introduction

Patients with early-stage NSCLC typically must choose between a surgery with superior local control (lobectomy) or one that preserves lung parenchyma (wedge). Recognizing that many patients with cancer have competing mortality risks unrelated to cancer, we investigated whether an established model of predicting life expectancy could be used to identify patients with stage I NSCLC for whom survival after wedge is not different from lobectomy.

Methods

A retrospective cohort study using the National Cancer Institute's Surveillance Epidemiology and End Results-Medicare was performed to evaluate survival among treatment-naive patients, diagnosed 2005-2015, who underwent lobectomy or wedge for stage I (≤2 cm tumors) NSCLC. Comorbidity-related life expectancy (CR-LE) was estimated using a standard life-table approach based on comorbid conditions, sex, and age. Cox models and perioperative complications were stratified by 5-year CR-LE.

Results

A total of 4560 patients (median age 74, interquartile range 70-78) were identified. CR-LE was greater than or equal to 5 years for 4016 patients (wedge = 23%). CR-LE was less than 5 years for 544 patients (wedge = 41%). Among patients with CR-LE greater than or equal to 5, wedge resection was associated with higher risk of mortality than lobectomy (hazard ratio: 1.68, 95% confidence interval: 1.52-1.86, p < 0.001). For those with CR-LE less than 5, there was no significant difference in mortality risk between lobectomy and wedge (hazard ratio: 1.19, 95% confidence interval: 0.96-1.47; p = 0.11). CR-LE less than five patients who underwent a lobectomy had higher 90-day mortality compared with wedge (9% versus 4%, p = 0.04).

Conclusion

The survival advantage of lobectomy over wedge for stage I NSCLC seems to dissipate among patients with shorter life expectancy owing to age and comorbidities. Wedge resection may be a reasonable option for patients at high risk of dying from non-cancer-related causes.

Problems and Barriers during the Process of Clinical Coding: a Focus Group Study of Coders' Perceptions

Coded data are the basis of information systems in all countries that rely on Diagnosis Related Groups in order to reimburse/finance hospitals, including both administrative and clinical data. To identify the problems and barriers that affect the quality of the coded data is paramount to improve data quality as well as to enhance its usability and outcomes. This study aims to explore problems and possible solutions associated with the clinical coding process. Problems were identified according to the perspective of ten medical coders, as the result of four focus groups sessions. This convenience sample was sourced from four public hospitals in Portugal. Questions relating to problems with the coding process were developed from the literature and authors' expertise. Focus groups sessions were taped, transcribed and analyzed to elicit themes. Variability in the documents used for coding, illegibility of hand writing when coding on paper, increase of errors due to an extra actor in the coding process when transcribed from paper, difficulties in the diagnoses' coding, coding delay and unavailability of resources and tools designed to help coders, were some of the problems identified. Some problems were identified and solutions such as the standardization of the documents used for coding an episode, the adoption of the electronic coding, the development of tools to help coding and audits, and the recognition of the importance of coding by the management were described as relevant factors for the improvement of the quality of data.