Kevin L. Anderson

Each procedure matters: threshold for surgeon volume to minimize complications and decrease cost associated with adrenalectomy

Background. An association has been suggested between increasing surgeon volume and improved patient outcomes, but a threshold has not been defined for what constitutes a “high‐volume” adrenal surgeon. Methods. Adult patients who underwent adrenalectomy by an identifiable surgeon between 1998–2009 were selected from the Healthcare Cost and Utilization Project National Inpatient Sample. Logistic regression modeling with restricted cubic splines was utilized to estimate the association between annual surgeon volume and complication rates in order to identify a volume threshold. Results. A total of 3,496 surgeons performed adrenalectomies on 6,712 patients; median annual surgeon volume was 1 case. After adjustment, the likelihood of experiencing a complication decreased with increasing annual surgeon volume up to 5.6 cases (95% confidence interval, 3.27–5.96). After adjustment, patients undergoing resection by low‐volume surgeons (<6 cases/year) were more likely to experience complications (odds ratio 1.71, 95% confidence interval, 1.27–2.31, P = .005), have a greater hospital stay (relative risk 1.46, 95% confidence interval, 1.25–1.70, P = .003), and at increased cost (+26.2%, 95% confidence interval, 12.6–39.9, P = .02). Conclusion. This study suggests that an annual threshold of surgeon volume (≥6 cases/year) that is associated with improved patient outcomes and decreased hospital cost. This volume threshold has implications for quality improvement, surgical referral and reimbursement, and surgical training.

Impact of patient selection and treatment strategies on outcomes after lobectomy for biopsy-proven stage IIIA pN2 non-small cell lung cancer

OBJECTIVES We evaluated the impact of patient selection and treatment strategies on long-term outcomes of patients who had lobectomy after induction therapy for stage IIIA pN2 non-small cell lung cancer (NSCLC). METHODS The impact of various patient selection, induction therapy and operative strategies on survival of patients with biopsy-proven stage IIIA pN2 NSCLC who received induction chemotherapy ± radiation followed by lobectomy from 1995 to 2012 was assessed using Cox proportional hazards analysis. RESULTS From 1995 to 2012, 111 patients had lobectomy for stage IIIA pN2 NSCLC after chemotherapy ± radiation with an overall 5-year survival of 39%. The use of induction chemoradiation decreased over time; from 1996 to 2007, 46/65 (71%) patients underwent induction chemoradiation, whereas from 2007 to 2012, 36/46 (78%) patients underwent induction chemotherapy. The use of video-assisted thoracoscopic surgery (VATS) increased over the time period of the study, from 0/26 (0%) in 1996-2001, to 4/39 (10%) in 2002-07 to 33/46 (72%) in 2008-12. Compared with patients given induction chemotherapy alone, patients given additional induction radiation were more likely to have complete pathologic response (30 vs 11%, P = 0.01) but had worse 5-year survival in univariable analysis (31 vs 48%, log-rank P = 0.021). Patients who underwent pathologic mediastinal restaging following induction therapy but prior to resection had an improved overall survival compared with patients who did not undergo pathologic mediastinal restaging {5-year survival: 45.2 [95% confidence interval (CI): 33.9-55.9] vs 13.9% (95% CI: 2.5-34.7); log-rank, P = 0.004}. In multivariable analysis, the particular induction therapy strategy and the surgical approach used, as well as the extent of mediastinal disease were not important predictors of survival. However, pathologic mediastinal restaging was associated with improved survival (HR 0.39; 95% CI: 0.21-0.72; P = 0.003). CONCLUSIONS For patients with stage IIIA pN2 NSCLC, the VATS approach or the addition of radiation to induction therapy can be selectively employed without compromising survival. The strategy of assessing response to induction therapy with pathologic mediastinal restaging allows one to select appropriate patients for complete resection and is associated with a 5-year overall survival of 39% in this population.

The Role of Extent of Surgical Resection and Lymph Node Assessment for Clinical Stage I Pulmonary Lepidic Adenocarcinoma: An Analysis of 1991 Patients

Background This study examined the association of extent of lung resection, pathologic nodal evaluation, and survival for patients with clinical stage I (cT1–2N0M0) adenocarcinoma with lepidic histologic features in the National Cancer Data Base. Methods The association between extent of surgical resection and long‐term survival for patients in the National Cancer Data Base with clinical stage I lepidic adenocarcinoma who underwent lobectomy or sublobar resection was evaluated using Kaplan‐Meier and Cox proportional hazards regression analyses. Results Of the 1991 patients with cT1–2N0M0 lepidic adenocarcinoma who met the study criteria, 1544 underwent lobectomy and 447 underwent sublobar resection. Patients treated with sublobar resection were older, more likely to be female, and had higher Charlson/Deyo comorbidity scores, but they had smaller tumors and lower T status. Of the patients treated with lobectomy, 6% (n = 92) were upstaged because of positive nodal disease, with a median of seven lymph nodes sampled (interquartile range 4–10). In an analysis of the entire cohort, lobectomy was associated with a significant survival advantage over sublobar resection in univariate analysis (median survival 9.2 versus 7.5 years, p = 0.022, 5‐year survival 70.5% versus 67.8%) and after multivariable adjustment (hazard ratio = 0.81, 95% confidence interval: 0.68–0.95, p = 0.011). However, lobectomy was no longer independently associated with improved survival when compared with sublobar resection (hazard ratio = 0.99, 95% confidence interval: 0.77–1.27, p = 0.905) in a multivariable analysis of a subset of patients in which only those patients who had undergone a sublobar resection including lymph node sampling were compared with patients treated with lobectomy. Conclusions Surgeons treating patients with stage I lung adenocarcinoma with lepidic features should cautiously utilize sublobar resection rather than lobectomy, and they must always perform adequate pathologic lymph node evaluation.

Improving medical leadership education through the Feagin leadership program

With little or no formal training in medical school or residency, physicians today are often unprepared for their leadership roles within large interdisciplinary healthcare teams.1,2 These leadership roles range from leading individual patients to larger interdisciplinary organizations. Physicians are expected to lead effectively based on the assumption that the skills that made them successful as a physician will naturally transfer into success as a leader.3 Although this may be true for some physicians, it may not always be the case. Recognizing that many physicians lack the necessary leadership skills, healthcare organizations continue to fill many core leadership positions with skilled non-physician leaders.4 The American College of Graduate Medical Education5 (ACGME) and the Institute of Medicine6 (IOM) have acknowledged the need to develop physician leaders. The IOM has mandated academic medical centers to “develop leaders at all levels”6 who can not only “manage the organizational and systems changes necessary to improve health through innovation in health professions education, patient care, and research,”6 but can also “improve integration and foster cooperation within and across the academic health center enterprise.”5,6 However, few medical training centers have such a curriculum in place to make this happen. To help address this deficiency the Feagin Leadership Program was developed at Duke University in 2010 in honor of John A. Feagin, Jr., MD. The purpose of this paper is to describe this program and its positive effect on alumni. Medical leadership program

Induction chemotherapy for T3N0M0 non-small-cell lung cancer increases the rate of complete resection but does not confer improved survival

OBJECTIVES The objective of this study was to evaluate outcomes of induction therapy prior to an operation in patients with cT3 non-small-cell lung cancer (NSCLC). METHODS Patients diagnosed with cT3N0M0 NSCLC from 2006 to 2011 in the National Cancer Database who were treated with lobectomy or pneumonectomy were stratified by treatment strategy: an operation first versus induction chemotherapy. Propensity scores were developed and matched cohorts were generated. Short-term outcomes included margin status, 30- and 90-day mortality rates, readmission and length of stay. Survival analyses using Kaplan-Meier methods were performed on both the unadjusted and propensity matched cohorts. RESULTS A total of 3791 cT3N0M0 patients were identified for inclusion, of which 580 (15%) were treated with induction chemotherapy. Prior to adjustment, patients treated with induction chemotherapy were younger, had a higher comorbidity burden and were more likely to have private insurance (all P  < 0.001). Following matching, patients receiving induction chemotherapy were more likely to subsequently undergo an open procedure (87.3 vs 77.8%, P  = 0.005). These patients were more likely to obtain R0 resection (93.1% vs 90.0%, P  = 0.04) and were thereby less likely to have positive margins at the time of resection (6.9% vs 10.0%, P  = 0.03). Patients who received induction therapy had higher rates of 90-day mortality (6.6% vs 3.4%) but there was no difference in long-term survival between the groups. CONCLUSIONS Despite yielding increased rates of R0 resection, induction chemotherapy for cT3N0M0 NSCLC is not associated with improved survival and should not be considered routinely. Further studies are warranted to elucidate cohorts that may benefit from induction therapy.