Yinin Hu

Readmission after lung cancer resection is associated with a 6-fold increase in 90-day postoperative mortality

OBJECTIVES Postoperative readmission affects patient care and healthcare costs. There is a paucity of nationwide data describing the clinical significance of readmission after thoracic operations. The purpose of this study was to evaluate the relationship between postoperative readmission and mortality after lung cancer resection. METHODS Data were extracted for patients undergoing lung cancer resection from the linked Surveillance Epidemiology and End Results-Medicare registry (2006-2011), including demographics, comorbidities, socioeconomic factors, readmission within 30 days from discharge, and 90-day mortality. Readmitting facility and diagnoses were identified. A hierarchical regression model clustered at the hospital level identified predictors of readmission. RESULTS We identified 11,432 patients undergoing lung cancer resection discharged alive from 677 hospitals. The median age was 74.5 years, and 52% of patients received an open lobectomy. Thirty-day readmission rate was 12.8%, and 28.3% of readmissions were to facilities that did not perform the original operation. Readmission was associated with a 6-fold increase in 90-day mortality (14.4% vs 2.5%, P<.001). The most common readmitting diagnoses were respiratory insufficiency, pneumonia, pneumothorax, and cardiac complications. Patient factors associated with readmission included resection type; age; prior induction chemoradiation; preoperative comorbidities, including congestive heart failure and chronic obstructive pulmonary disease; and low regional population density. CONCLUSIONS Factors associated with early readmission after lung cancer resection include patient comorbidities, type of operation, and socioeconomic factors. Metrics that only report readmissions to the operative provider miss one-fourth of all cases. Readmitted patients have an increased risk of death and demand maximum attention and optimal care.

Propensity scores: Methods, considerations, and applications in the Journal of Thoracic and Cardiovascular Surgery.

OBJECTIVE To review the published literature using propensity scoring, describe shortcomings in the use of this technique, and provide conceptual background for understanding and correctly implementing studies that use propensity matching. METHODS We survey the published statistical literature and make recommendations for a set of standard criteria for studies that use propensity matching. We evaluated adherence to these criteria in recent publications in the Journal of Thoracic and Cardiovascular Surgery and determined how well the standards were applied. RESULTS We found that studies that use propensity matching are rarely documented well enough to be convincing in their results. When documentation is available, statistical shortcomings are common. CONCLUSIONS Improved statistical practice is needed when using propensity scoring. This article suggests standard criteria for using this method in Journal publications.

Postoperative mortality is an inadequate quality indicator for lung cancer resection.

BACKGROUND Postoperative mortality is the most commonly reported surgical quality measure. However, such metrics may be incapable of identifying performance outliers. The purpose of this study was to compare different measures of postoperative mortality after lung cancer resection using a large multiinstitutional database. METHODS Data were extracted for lung cancer resection patients from the linked Surveillance Epidemiology and End Results-Medicare Registry (2006 to 2010), which provides detailed and longitudinal information about Medicare beneficiaries with cancer. Four definitions of postoperative mortality were evaluated: in-hospital, 30-day, perioperative, and 90-day. Hierarchical regression models were used to estimate mortality risk at 30 and 90 days, and provider quality was assessed by comparing observed versus expected mortality. RESULTS We identified 11,787 lung cancer resection patients from 686 hospitals. The median age was 74 years, and 52% of patients were treated with open lobectomy. Although 30-day, perioperative, and in-hospital mortality rates were between 3% and 4%, 90-day mortality was almost double (6.89%). Clinical variables associated with 90-day mortality included sex, preexisting comorbidities, and procedure type. There were no statistically significant differences in 30-day or 90-day mortality rates among providers. CONCLUSIONS Currently reported measures of in-hospital and 30-day postoperative mortality do not adequately represent a patients true mortality risk as mortality almost doubles by 90 days. Because of low occurrence rate and variable provider volumes, neither 30-day nor 90-day mortality is a suitable quality indicator for lung resection.

Recent trends in National Institutes of Health funding for surgery: 2003 to 2013

BACKGROUND The purpose of this study is to compare the compositions of federally funded surgical research between 2003 and 2013, and to assess differences in funding trends between surgery and other medical specialties. DATA SOURCES The National Institutes of Health (NIH) Research Portfolio Online Reporting Tool database was queried for grants within core surgical disciplines during 2003 and 2013. Funding was categorized by award type, methodology, and discipline. Application success rates for surgery and 5 nonsurgical departments were trended over time. CONCLUSIONS Inflation-adjusted NIH funding for surgical research decreased 19% from

Early Removal of Urinary Catheter After Surgery Requiring Thoracic Epidural: A Prospective Trial

270 M in 2003 to

Long-term outcomes of helper peptide vaccination for metastatic melanoma.

219 M in 2013, with a shift from R-awards to U-awards. Proportional funding to outcomes research almost tripled, while translational research diminished. Nonsurgical departments have increased NIH application volume over the last 10 years; however, surgerys application volume has been stagnant. To preserve surgerys role in innovative research, new efforts are needed to incentivize an increase in application volume.

Comparative Effectiveness of Esophagectomy Versus Endoscopic Treatment for Esophageal High-grade Dysplasia.

OBJECTIVES To prevent urinary retention, urinary catheters commonly are removed only after thoracic epidural discontinuation after thoracotomy. However, prolonged catheterization increases the risk of infection. The purpose of this study was to determine the rates of urinary retention and catheter-associated infection after early catheter removal. DESIGN This study described a prospective trial instituting an early urinary catheter removal protocol compared with a historic control group of patients. SETTING The protocol was instituted at a single, academic thoracic surgery unit. PARTICIPANTS The study group was comprised of patients undergoing surgery requiring thoracotomy who received an intraoperative epidural for postoperative pain control. INTERVENTIONS An early urinary catheter removal protocol was instituted prospectively, with all catheters removed on or before postoperative day 2. Urinary retention was determined by bladder ultrasound and treated with recatheterization. MEASUREMENTS AND MAIN RESULTS The primary outcomes were urinary retention rate, defined as bladder volume>400 mL, and urinary tract infection rate. Results were compared with a retrospective cohort of 210 consecutive patients who underwent surgery before protocol initiation. Among the 101 prospectively enrolled patients, urinary retention rate was higher (26.7% v 12.4%, p = 0.003), while urinary tract infection rate improved moderately (1% v 3.8%, p = 0.280). CONCLUSIONS Early removal of urinary catheters with thoracic epidurals in place is associated with a high incidence of urinary retention. However, an early catheter removal protocol may play a role in a multifaceted approach to reducing the incidence of catheter-associated urinary tract infections.

Construct Validation of a Cost-Effective Vessel Ligation Benchtop Simulator

OBJECTIVE The objective of this study was to compare the long-term outcome of patients with metastatic melanoma vaccinated with 6MHP to that of a group of unvaccinated historical controls. BACKGROUND A multipeptide vaccine (6MHP), designed to induce helper T cells against melanocytic and cancer-testis antigens, has been shown to induce specific Th1-dominant CD4+ T cell responses. METHODS The 6MHP vaccine was administered to patients with metastatic melanoma. Circulating CD4+ T cell responses were measured by proliferation or direct IFN-gamma ELIspot assay. Overall survival of vaccinated patients was compared to a group of clinically comparable historical controls using multivariable Cox regression analysis and Kaplan-Meier survival analysis, taking into account age, metastatic site, and resection status. RESULTS Across 40 vaccinated patients and 87 controls, resection status (HR 0.54, P = 0.004) and vaccination (HR 0.24, P < 0.001) were associated with improved overall survival. Forty pairs of vaccinated patients and controls were matched by metastatic site, resection status, and age within 10 years. Median survival was significantly longer for vaccinated patients (5.4 vs 1.3 years, P < 0.001). Among the vaccinated patients, the development of a specific immune response after vaccination was associated with improved survival (HR 0.35, P = 0.040). CONCLUSIONS Helper peptide vaccination is associated with improved overall survival among patients with metastatic melanoma. These data support a randomized prospective trial of the 6MHP vaccine.

Localization of the Sentinel Lymph Node in Melanoma Without Blue Dye.

Objective:The purpose of this study is to determine the comparative effectiveness of esophagectomy versus endoscopic mucosal resection followed by radiofrequency ablation (EMR-RFA) for the treatment of Barrett esophagus with high-grade dysplasia (HGD). Background:HGD of the esophagus may be managed by surgical resection or EMR-RFA. National guidelines suggest that EMR-RFA is effective at eradicating HGD. The comparative effectiveness and cost-effectiveness of EMR-RFA versus esophagectomy for HGD remains unclear. Methods:A decision-analysis model was constructed to represent 3 management strategies for HGD: (1) esophagectomy, (2) EMR-RFA, and (3) endoscopic surveillance. Estimates for model variables were obtained from literature review, and costs were estimated from Medicare fee schedules. Costs and utilities were discounted at an annual rate of 3%. The baseline model was adjusted for alternative age groups and high-risk dysplastic variants. One-way and multivariable probabilistic sensitivity analyses were conducted. Results:For a 65-year-old patient, compared to esophagectomy, EMR-RFA yields equivalent utility (11.5 vs 11.4 discounted quality-adjusted life years) with lower total cost (

Vessel ligation training via an adaptive simulation curriculum

52.5K vs