Variability in length of stay after uncomplicated pulmonary lobectomy: is length of stay a quality metric or a patient metric?†.

OBJECTIVES: Previous studies have identified predictors of prolonged length of stay (LOS) following pulmonary lobectomy. LOS is typically described to have a direct relationship to postoperative complications. We sought to determine the LOS and factors associated with variability after uncomplicated pulmonary lobectomy. METHODS: Analysing the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality database, we reviewed lobectomies performed (2009-11) on patients in California, Florida and New York. LOS and comorbidities were identified. Multivariable regression analysis (MVA) was used to determine factors associated with LOS greater than the median. Patients with postoperative complications or death were excluded. RESULTS: Among 22 647 lobectomies performed, we identified 13 099 patients (58%) with uncomplicated postoperative courses (mean age = 66 years; 56% female; 76% white, 57% Medicare; median DEYO comorbidity score = 3, 55% thoracotomy, 45% thoracoscopy/robotic). There was a wide distribution in LOS [median LOS = 5 days; interquartile range (IQR) 4-7]. By MVA, predictors of prolonged LOS included, age ≥ 75 years [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.4-2.0], male gender (OR 1.2, 95% CI 1.1-1.2), chronic obstructive pulmonary disease (OR 1.6, 95% CI 1.5-1.7) and other comorbidities, Medicaid payer (OR 1.7, 95% CI 1.4-2.1) versus private insurance, thoracotomy (OR 3.0, 95% CI 2.8-3.3) versus video-assisted thoracoscopic surgery/robotic approach and low hospital volume (OR 2.4, 95% CI 2.1-2.6). CONCLUSIONS: Variability exists in LOS following even uncomplicated pulmonary lobectomy. Variability is driven by clinical factors such as age, gender, payer and comorbidities, but also by surgical approach and volume. All of these factors should be taken into account when designing clinical care pathways or when allocating payment resources. Attempts to define an optimal LOS depend heavily upon the patient population studied.

Incidence and Factors Associated With Hospital Readmission After Pulmonary Lobectomy.

BACKGROUND: Readmission rates after major procedures are used to benchmark quality of care. We sought to identify readmission diagnoses and factors associated with readmission in patients undergoing pulmonary lobectomy. METHODS: Analyzing the State Inpatient Databases (Healthcare Cost and Utilization Project), we reviewed all lobectomies performed from 2009 to 2011 in California, Florida, and New York. The group was subdivided into open (OL) versus minimally invasive lobectomy (MIL; thoracoscopic/robotic). We used unique identifiers to determine 30- and 90-day readmission rates and diagnoses and performed regression analysis to determine factors associated with readmission. RESULTS: A total of 22,647 lobectomies were identified (58.8% OL vs 41.2% MIL; median age, 68 years; median length of stay, 6 days). Most patients (59.8%) had routine discharge home (home health care, 29.4%; transfer to other facility, 8.8%; mortality, 1.9%). The 30-day readmission rate was 11.5% (OL 12.0% vs MIL 10.8%, p = 0.01), while the 90-day readmission rate was 19.8% (OL 21.1% vs MIL 17.9%, p < 0.001). The most common readmission diagnoses were pulmonary (24.1%), cardiovascular (16.3%), and complications related to surgical/medical procedures (15.1%). Preoperative factors associated with readmission included male gender (odds ratio, 1.19), Medicaid payer (odds ratio, 1.29), and several individual comorbidities. Surgical approach and postoperative complications were not independently associated with readmission. CONCLUSIONS: Readmission is a frequent event after pulmonary lobectomy and is strongly associated with preoperative demographic factors and comorbidities. Resources and services should be directed to patients at risk for readmission and multicomponent care pathways developed that may circumvent the need for repeat hospitalization.

Incidence and implications of postoperative supraventricular tachycardia after pulmonary lobectomy.

OBJECTIVE: We sought to determine the rate of postoperative supraventricular tachycardia (POSVT) in patients undergoing pulmonary lobectomy, and its association with adverse outcomes. METHODS: Using the State Inpatient Database, from the Healthcare Cost and Utilization Project, we reviewed lobectomies performed (2009-2011) in California, Florida, and New York, to determine POSVT incidence. Patients were grouped by presence or absence of POSVT, with or without other complications. Stroke rates were analyzed independently from other complications. Multivariable regression analysis was used to determine factors associated with POSVT. RESULTS: Among 20,695 lobectomies performed, 2449 (11.8%) patients had POSVT, including 1116 (5.4%) with isolated POSVT and 1333 (6.4%) with POSVT with other complications. Clinical predictors of POSVT included age ≥75 years, male gender, white race, chronic obstructive pulmonary disease, congestive heart failure, thoracotomy surgical approach, and pulmonary complications. POSVT was associated with an increase of: stroke (odds ratio [OR] 1.74; 95% confidence interval [CI] 1.03-2.94); in-hospital death (OR 1.85; 95% CI 1.45-2.35); LOS (OR 1.33; 95% CI 1.29-1.37); and readmission (OR 1.29; 95% CI 1.04-1.60). The stroke rate was <1% in patients who had isolated POSVT, and 1.5% in patients with POSVT with other complications. Patients with isolated POSVT had increased readmission and LOS, and a marginal increase in stroke rate, compared with patients with an uncomplicated course. CONCLUSIONS: POSVT is common in patients undergoing pulmonary lobectomy and is associated with adverse outcomes. Comparative studies are needed to determine whether strict adherence to recently published guidelines will decrease the rate of stroke, readmission, and death after POSVT in thoracic surgical patients.