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Using logistic regression models, we compared operative mortality across surgeon subspecialties, adjusting for patient, surgeon, and hospital characteristics. Patient characteristics did not differ substantially by surgeon specialty. Adjusted operative mortality rates were lowest for cardiothoracic and noncardiac thoracic surgeons 7. Operative mortality with lung resection varies by surgeon specialty.
Some, but not all, of this variation in operative mortality is attributable to hospital and surgeon volume. Many believe that subspecialty training may improve surgical outcomes in high-risk surgery. Examples of this finding have been published across a wide range of surgical subspecialties.
For example, in carotid endarterectomy, vascular surgeons were found to have lower in-hospital mortality and stroke rates than neurosurgeons or general surgeons. However, the impact of surgeon specialty on outcomes with lung cancer surgery is uncertain. Surgeons that are board-certified in thoracic surgery have greater training in thoracic procedures than general surgeons. Moreover, some thoracic surgeons eschew cardiac procedures, focusing primarily on lung procedures.
Although 1 study 7 has compared outcomes by specialty, this study was relatively small, restricted to 1 state, and was limited in examination of potentially confounding variables, such as hospital setting and hospital volume in lung resection. Although many believe lung resection is best performed by board-certified thoracic surgeons, the empiric basis for this assumption has not been established. For this reason, we performed a national study comparing operative mortality rates with lung resection between noncardiac thoracic, cardiothoracic, and general surgeons.
This file contains hospital discharge abstracts for acute care hospitalizations of all US Medicare recipients under the hospital Part A insurance program. We excluded patients under age 65 or over age Further details on the database are available elsewhere. We linked patients and surgeons using the unique provider identifier number in each patient record in the Medicare database. We then categorized surgeons into 3 distinct, mutually exclusive subspecialty categories: To ensure that we accurately designated thoracic surgeons, we obtained a list of board-certified thoracic surgeons from the American Board of Thoracic Surgery ABTS , the certifying body for thoracic surgeons.
This list was merged with our Medicare file to identify thoracic surgeons. We further characterized thoracic surgeons as cardiothoracic surgeons or noncardiac thoracic surgeons. The former were defined as those performing at least 1 coronary artery bypass graft CABG procedure on any Medicare patient during the study period.
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Thoracic surgeons that did not perform any CABG procedures during the study period were designated as noncardiac thoracic surgeons. Noncardiac thoracic and cardiothoracic surgeons were analyzed separately in the analysis. Determination of surgeon subspecialty. We used the patient as the unit of analysis. Our exposure variable was surgeon specialty general, cardiothoracic, or noncardiac thoracic , and our main outcome measure was operative mortality, defined as death before discharge or within 30 days of the operative procedure.
Deaths occurring after discharge but within 30 days of the operative procedure were captured by using the National Death Index. Utilizing methods previously described, 8,10 we used multiple logistic regression to study relationships between patient level variables and our main outcome measures. We adjusted for the following variables: Patient comorbidities were identified using information from both the index admission and admission occurring within the preceding 6 months.
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Comorbidities were compiled into a Charlson score 11 for each patient, a commonly used measure of comorbidity status. The Charlson score weights patients based on the number and type of comorbidities recorded in the discharge abstract. Comorbidities typically include diagnoses such as chronic obstructive pulmonary disease, coronary artery disease, or hypertension.
We also adjusted for the extent of resection lobectomy versus pneumonectomy. We also adjusted for characteristics of the hospital in which each surgeon practiced. For surgeons who operated in more than 1 hospital, we used the hospital in which he or she performed the most cases. Using the American Hospital Association file, we adjusted for the following variables: Given the well-documented association between operative mortality and hospital volume, 8,12,13 we also adjusted for hospital volume in lung resection.
To eliminate any bias introduced by assignment of high- and low-volume cut points, hospital volume was considered as a continuous variable. Given evidence 1,7,12,14 that operative mortality varies with surgeon experience, we adjusted for surgeon volume in lung resection, also considered as a continuous variable. In measuring hospital and surgeon volume, we defined volume as the total number of lung resections both Medicare and non-Medicare patients treated by the individual hospital or surgeon.
Additionally, we adjusted for the effect of clustering 15 of patients within surgeons and within hospitals. Results from these regression models were used to generate adjusted mortality rates using predicted risk estimates.
The institutional review board at Dartmouth Medical School approved our study protocol. Overall, 25, patients were included in our analysis. There were no substantial differences in mean age, sex, race, or comorbidity score or between groups Table 1. Overall, general surgeons, cardiothoracic surgeons, and noncardiac thoracic surgeons were included in our analysis Table 2.
Surgeon characteristics varied by specialty. Thoracic surgeons, on average, were slightly older, had higher procedure volumes in lung resection, and were more likely to practice in high-volume hospitals than general surgeons. Hospitals serving as the primary hospitals for cardiothoracic and noncardiac thoracic surgeons were more likely to be teaching institutions, employ residents, be affiliated with a medical school, and be a part of an American College of Surgeons cancer program than the primary hospitals for general surgeons.
Adjusted operative mortality rates varied by surgeon specialty Fig. The lowest mortality rates were seen in patients undergoing surgery by thoracic surgeons. Adjusted operative mortality rates ranged from 5. Odds ratios of operative mortality are shown in Table 3 , using the general surgery group as the referent group. Crude odds ratios are shown in the first row, while odds ratios adjusted for patient, hospital, and surgeon characteristics are shown in the latter rows. This effect changes little when adjusting for patient and hospital characteristics.
When we adjust for continuous measures of surgeon and hospital volume, the effect is only slightly attenuated for both cardiothoracic surgeons and noncardiac thoracic surgeons. Adjusted operative mortality with lung resection, by surgeon specialty, stratified by surgeon and hospital volume, at the patient level.
We then examined whether specialty-related differences persisted in analysis restricted to high-volume surgeons and high-volume hospitals.
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Only a small percentage of general and cardiothoracic surgeons were high-volume surgeons 2. Within the group of high-volume surgeons, adjusted operative mortality rates were lowest for noncardiac thoracic 5. Within high-volume hospitals, a trend similar to the subgroup analysis of surgeon volume was noted. Adjusted operative mortality rates were lowest for noncardiac thoracic surgeons 5.
Surgeon Specialty and Operative Mortality With Lung Resection
Last, we examined if the extent of resection affected the effect of surgeon specialty. While baseline risks were more than twice as high in pneumonectomy, adjusted operative mortality continued to be highest among general surgeons and lowest among thoracic surgeons Fig. Adjusted operative mortality with lung resection, by procedure type pneumonectomy or lobectomy. NCTS, noncardiac thoracic surgeons. Our study of lung resection compared operative mortality in lung resection across surgical subspecialties.
While we found that overall, board-certified thoracic surgeons have lower rates of operative mortality in lung resection than general surgeons. However, when we restricted our analysis to high-volume surgeons or high-volume hospitals, the differences in operative mortality between general and thoracic surgeons were less pronounced. Therefore, while operative volume explains some of the difference between general and thoracic surgeons, other patient, surgeon, and hospital factors are likely to influence a patient's operative risk with lung resection.
Our study has several limitations. First, our study is based on administrative data from Medicare. As the limits of administrative data for risk adjustment have been well documented, 16,17 we may not have adequately accounted for differences in case mix across surgical specialties. However, it is important to note that observed differences in patient characteristics were quite small, and what small trends there were tended to suggest increased operative risk in the patients of thoracic surgeons.