Defining Proficiency for The Society of Thoracic Surgeons Participants Performing Thoracoscopic Lobectomy
Annals of Thoracic Surgery
Background: Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. Methods: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. Results: Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p = 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p = 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. Conclusions: VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.
Puri, Varun; Gaissert, Henning A.; Wormuth, David W.; Grogan, Eric L.; Burfeind, William R.; Chang, Andrew C.; Seder, Christopher W.; Fernandez, Felix G.; Brown, Lisa; Magee, Mitchell J.; Kosinski, Andrzej S.; Raymond, Daniel P.; Broderick, Stephen R.; Welsh, Robert J.; DeCamp, Malcolm M.; Farjah, Farhood; Edwards, Melanie A.; and Kozower, Benjamin D., "Defining Proficiency for The Society of Thoracic Surgeons Participants Performing Thoracoscopic Lobectomy" (2019). Department of Surgery @SLUHN Articles & Publications. 9.