ABSTRACT
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.
Subject(s)
Carcinoma, Non-Small-Cell Lung/surgery , General Surgery , Hospital Costs , Lung Neoplasms/surgery , Outcome and Process Assessment, Health Care , Pneumonectomy , Quality Indicators, Health Care , Thoracic Surgery , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/mortality , Education, Medical, Graduate , Female , General Surgery/economics , General Surgery/education , General Surgery/standards , Guideline Adherence , Hospital Mortality , Humans , Logistic Models , Lung Neoplasms/mortality , Male , Middle Aged , Multivariate Analysis , Odds Ratio , Outcome and Process Assessment, Health Care/economics , Outcome and Process Assessment, Health Care/standards , Pneumonectomy/adverse effects , Pneumonectomy/economics , Pneumonectomy/education , Pneumonectomy/mortality , Pneumonectomy/standards , Postoperative Complications/economics , Postoperative Complications/mortality , Postoperative Complications/therapy , Practice Guidelines as Topic , Practice Patterns, Physicians' , Quality Indicators, Health Care/economics , Quality Indicators, Health Care/standards , Registries , Retrospective Studies , Risk Assessment , Risk Factors , Thoracic Surgery/economics , Thoracic Surgery/education , Thoracic Surgery/standards , Treatment Outcome , United StatesABSTRACT
Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.
Subject(s)
Esophageal Neoplasms/therapy , Palliative Care/methods , Ablation Techniques , Chemoradiotherapy , Deglutition Disorders/etiology , Deglutition Disorders/therapy , Esophageal Neoplasms/complications , Esophagoscopy/instrumentation , Esophagoscopy/methods , Humans , Pain Management , StentsABSTRACT
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.