RESUMEN
OBJECTIVES: This investigation compared patients undergoing lobectomy for non-small cell lung cancer by either a general surgeon or a cardiothoracic surgeon across a geographically diverse system of hospitals to see whether a significant difference in quality or cost was present. METHODS: The Premiere administrative database and tumor registry data of a single health system's hospitals was used to compare adherence to national treatment guidelines, patient outcomes, and charges for patients undergoing lobectomy for non-small cell lung cancer in a 5-year period. Surgeons performing lobectomy were designated as a general surgeon or cardiothoracic surgeon according to their national provider number and board certification status. Excluded from analysis were centers that performed fewer than 50 lobectomies during the study period. RESULTS: During the study period, 2823 lobectomies were performed by 46 general surgeons and 3653 lobectomies were performed by 29 cardiothoracic surgeons in 54 hospitals in a single health care system. Significant differences were found between general and cardiothoracic surgeons with respect to adherence to national guidelines in staging and treatment, mean length of stay, significant morbidity, and operative mortality. Mean charges for lobectomy of the lung were also found to differ significantly between general and cardiothoracic surgeons. CONCLUSIONS: This review found that currently measurable indicators for quality of care were significantly superior and overall charges were significantly reduced when a lobectomy for non-small cell lung cancer was performed by a cardiothoracic surgeon rather than by a general surgeon.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/cirugía , Cirugía General , Costos de Hospital , Neoplasias Pulmonares/cirugía , Evaluación de Procesos y Resultados en Atención de Salud , Neumonectomía , Indicadores de Calidad de la Atención de Salud , Cirugía Torácica , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Educación de Postgrado en Medicina , Femenino , Cirugía General/economía , Cirugía General/educación , Cirugía General/normas , Adhesión a Directriz , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Neoplasias Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Evaluación de Procesos y Resultados en Atención de Salud/economía , Evaluación de Procesos y Resultados en Atención de Salud/normas , Neumonectomía/efectos adversos , Neumonectomía/economía , Neumonectomía/educación , Neumonectomía/mortalidad , Neumonectomía/normas , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Indicadores de Calidad de la Atención de Salud/economía , Indicadores de Calidad de la Atención de Salud/normas , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Cirugía Torácica/economía , Cirugía Torácica/educación , Cirugía Torácica/normas , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Esophageal stent placement for the treatment of a perforation, anastomotic leak, or fistula has been adopted by some thoracic surgeons. Results have been reported for this technique, but little discussion has focused on treatment failures. This analysis reviews patients in whom esophageal stent placement was not successful in an attempt to identify factors that may increase the likelihood of failure of this technique. METHODS: Patients undergoing esophageal stent placement for the treatment of an esophageal perforation, anastomotic leak, or fistula in which the stent failed to adequately seal the esophageal leak were identified from a single institution's database. The anatomic location, chronicity, and cause of the esophageal leak were recorded using a newly developed classification system. Comparison was made to patients in whom stent placement was successful. RESULTS: Over a 7-year period, 187 patients had an esophageal stent placed for esophageal leaks. Fifteen (8%) of these patients required traditional operative repair when the esophageal stent failed to resolve the esophageal leak after an average of 3 days. A comparison of the 2 patient groups found that stent failure was significantly more frequent in patients who had an esophageal leak of the proximal cervical esophagus, 1 that traversed the gastroesophageal junction, an esophageal injury longer than 6 cm, or an anastomotic leak associated with a more distal conduit leak (p<0.05). Malignancy or previous radiation therapy was not associated with treatment failure. CONCLUSIONS: This investigation identified 4 factors that significantly reduce the effectiveness of esophageal stent placement for the treatment of esophageal perforation, fistula, or anastomotic leak. These potential contraindications should be considered when developing a treatment plan for individual patients and may prompt traditional operative repair as initial therapy.