Elsevier

The Annals of Thoracic Surgery

Volume 98, Issue 6, December 2014, Pages 1976-1982
The Annals of Thoracic Surgery

Original article
General thoracic
Pneumonectomy: The Burden of Death After Discharge and Predictors of Surgical Mortality

Presented at the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.
https://doi.org/10.1016/j.athoracsur.2014.06.068Get rights and content

Background

Pneumonectomy has the highest mortality rate among resections for lung cancer, with limited literature differentiating predictors of postpneumonectomy in-hospital mortality (IHM) from early postdischarge mortality (PDM). This study aims to examine the burden of death over time and to identify potential predictive factors, including patient comorbidities and hospital and surgeon volumes.

Methods

Data were abstracted from an Ontario population-based linked database from 2005 to 2011. Proportional mortality and cumulative survival attributable to IHM and 90-day PDM is reported. Logistic and Cox regression analyses examined the role of potential factors related to death. Odds ratios (ORs) and hazard ratios (HRs) and 95% confidence intervals (CIs) were reported.

Results

Of 505 patients who underwent pneumonectomy, the median length of stay was 6 days (1–30 days). IHM was 4.4% (2.9%–6.5%), and 90-day PDM was an additional 6.4% (4.6%–9.0%). Logistic regression showed that congestive heart failure (CHF) (OR, 23.5; range, 4.0–136.0), cerebrovascular disease (OR, 12.5; range, 1.2–128.0), renal disease (OR, 8.8; range, 1.3–60.5), and previous myocardial infarction (MI) (OR, 5.4; range, 1.5–20.0) were predictive of IHM, whereas age (HR, 1.4; range, 1.1–1.7) per year and CHF (HR, 18.0; range, 4.0–79.0) were predictive of PDM. All other factors were not significant.

Conclusions

PDM represents a distinct and underrecognized burden of postoperative death. More than half of postpneumonectomy mortality occurred after discharge, and the rate remained unchanged over the study period. Patient factors play a major role in both IHM and PDM, whereas institutional and physician volume do not influence outcome, suggesting the importance of patient selection and the need for continued evaluation of mortality.

Section snippets

Patients and Methods

The dataset was assembled using databases available through the cd-link program through the Institute for Clinical Evaluative Sciences from 2005 to 2011. Data was collected from the Ontario Cancer Registry, Ontario Health Insurance Plan claims, Canadian Institutes for Health Information Discharge Abstract Database, and the National Ambulatory Care Reporting Service database. The study was reviewed and approved by the St. Joseph’s Healthcare Hamilton Research Ethics Board.

All patients in Ontario

Results

There were 505 patients undergoing pneumonectomy in the study, 300 of whom (59.4%) were men. The median age was 60 to 65 years, and the median length of stay was 6 days (range, 1–30 days). Overall patient characteristics of those who were discharged alive are summarized in Table 1, and frequencies of comorbidities are presented in Table 2. Within 90 days of the operation date, 221 (43%) patients received chemotherapy, 45 (8.9%) patients received radiation therapy, and 37 (7.3%) visited the

Comment

This study presents the prominent but overlooked burden of death that exists in the postdischarge setting among patients undergoing pneumonectomy for NSCLC. More than half of postpneumonectomy deaths occurred after discharge. Examination of all pneumonectomy procedures in Ontario from 2005 to 2011 confirmed that mortality has not improved over time, which is discordant with reports of other surgical procedures 15, 16, 17. Although mortality in the studied population is comparable to current

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