594
[2]
[3]
[4]
[5] [6]
[7]
[8]
[9]
[10]
[11]
[12]
A. Green et al. / European Journal of Cardio-Thoracic Surgery respiratory system in the nordic countries 1964-2003 followed up to the end of 2006. Acta Oncol 2010;49:608–23. Strand T, Rostad H, Møller B, Norstein J. Survival after resection for primary lung cancer: a population based study of 3211 resected patients. Thorax 2006;61:710–5. Schneider L, Farrokhyar F, Schieman C, Hanna WC, Shargall Y, Finley CJ. The burden of death following discharge after lobectomy. Eur J Cardiothorac Surg 2015;48:65–70. Schneider L, Farrokhyar F, Schieman C, Shargall Y, D’Souza J, Camposilvan I et al. Pneumonectomy: the burden of death after discharge and predictors of surgical mortality. Ann Thorac Surg 2014;98:1976–81. Nagai K, Yoshida J, Nishimura M. Postoperative mortality in lung cancer patients. Ann Thorac Cardiovasc Surg 2007;13:373–7. Jakobsen E, Palshof T, Osterlind K, Pilegaard H. Data from a national lung cancer registry contributes to improve outcome and quality of surgery: Danish results. Eur J Cardiothorac Surg 2009;35:348–52. Damhuis R, Coonar A, Plaisier P, Dankers M, Bekkers J, Linklater K et al. A case-mix model for monitoring of postoperative mortality after surgery for lung cancer. Lung Cancer 2006;51:123–9. Harichand-Herdt S, Ramalingam SS. Gender-associated differences in lung cancer: clinical characteristics and treatment outcomes in women. Semin Oncol 2009;36:572–80. Sigel K, Bonomi M, Packer S, Wisnivesky J. Effect of age on survival of clinical stage in non-small-cell lung cancer. Ann Surg Oncol 2009;16: 1912–7. Allen MS, Darling GE, Pechet TTV, Mitchell JD, Herndon JE, Landreneau RJ et al. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG z0030 trial. Ann Thorac Surg 2006;81: 1013–20. Janssen-Heijnen MLG, Smulders S, Lemmens VEPP, Smeenk FWJM, van Geffen HJAA, Coebergh JWW. Effect of comorbidity on the treatment and prognosis of elderly patients with non-small cell lung cancer. Thorax 2004; 59:602–7. Jakobsen E, Green A, Østerlind K, Riis T, Iachina M, Palshof T. Nationwide quality improvement in lung cancer care: the role of the Danish Lung Cancer Group and Registry. J Thorac Oncol 2013;8:1238–47.
[13] Pedersen CB. The Danish civil registration system. Scand J Public Health 2011;39(Suppl. 7):22–5. [14] Bjerregaard B, Larsen OB. The Danish pathology register. Scand J Public Health 2011;39(Suppl. 7):72–4. [15] Lynge E, Sandegaard JL, Rebolj M. The Danish national patient register. Scand J Public Health 2011;39(Suppl. 7):30–3. [16] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83. [17] Thygesen SK, Christiansen CF, Christensen S, Lash TL, Sørensen HT. The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish Registry of Patients. BMC Med Res Methodol 2011;11:83. [18] Fisher LD, Lin DY. Time-dependent covariates in the Cox proportionalhazards regression model. Annu Rev Public Health 1999;20:145–57. [19] Bryant AS, Rudemiller K, Cerfolio RJ. The 30- versus 90-day operative mortality after pulmonary resection. Ann Thorac Surg 2010;89: 1717–23. [20] Damhuis RA, Wijnhoven BP, Plaisier PW, Kirkels WJ, Kranse R, van Lanschot JJ. Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types. Br J Surg 2012;99:1149–54. [21] McMillan RR, Berger A, Sima CS, Lou F, Dycoco J, Rusch V et al. Thirtyday mortality underestimates the risk of early death after major resections for thoracic malignancies. Ann Thorac Surg 2014;98:1769–75. [22] Pezzi CM, Mallin K, Mendez AS, Greer Gay E, Putnam JB Jr. Ninety-day mortality after resection for lung cancer is nearly double 30-day mortality. J Thorac Cardiovasc Surg 2014;148(5):2269–77. [23] Powell HA, Tata LJ, Baldwin DR, Stanley RA, Khakwani A, Hubbard RB. Early mortality after surgical resection for lung cancer: an analysis of the English National Lung cancer audit. Thorax 2013;68:826–34. [24] Hu Y, McMurry TL, Isbell JM, Stukenborg GJ, Kozower BD. Readmission after lung cancer resection is associated with a 6-fold increase in 90-day postoperative mortality. J Thorac Cardiovasc Surg 2014;97:973–9. [25] Falcoz PE, Puyraveau M, Rivera C, Bernard A, Massard G, Mauny F et al. The impact of hospital and surgeon volume on the 30-day mortality of lung cancer surgery: a nation-based reappraisal. J Thorac Cardiovasc Surg 2014;148:841–8.
EDITORIAL COMMENT
European Journal of Cardio-Thoracic Surgery 49 (2016) 594–595 doi:10.1093/ejcts/ezv160 Advance Access publication 5 May 2015
Cite this article as: Finley CJ. When is the burden of responsibility over for the surgeon? Eur J Cardiothorac Surg 2016;49:594–5.
When is the burden of responsibility over for the surgeon? Christian J. Finley* Department of Surgery, McMaster University, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada * Corresponding author. St. Joseph’s Healthcare Hamilton, 50 Charlton Avenue East, Juravinski Tower T-2105B, Hamilton, ON, Canada L8N 4A6. Tel: +1-905-5221155; fax: +1-905-5268160; e-mail: fi[email protected] (C.J. Finley).
Keywords: Outcomes • Epidemiology • Mortality
To many, the safe conduct of an operation and the successful discharge of a patient is the summation of the surgeon’s responsibility. While this is the fundamental responsibility of a surgeon, our role in both the preoperative and postoperative periods has never been more important. One does not have to look too deeply into the literature to see that operative mortality can be defined in many ways, but when we extend the follow-up timeframe, that number becomes frighteningly higher [1, 2].
Operative mortality in most countries has fallen continuously over the last decade. Improved risk stratification, anaesthetic care, pain control and the ability to rescue critically ill patients have all incrementally pushed down our in-hospital mortality. These changes in the perioperative period can set off a cascade of events extending into the postoperative timeframe that can lead to the death of patients after they are discharged. In many cases, we have identified risk factors for those deaths, yet we still struggle
A. Green et al. / European Journal of Cardio-Thoracic Surgery
journeys, the burden of postoperative care seems to extend to the horizon. This study further emphasizes the need for further study into this area and is a rallying cry for surgeons to intensify their efforts on their postoperative care.
REFERENCES [1] Bryant AS, Rudemiller K, Cerfolio RJ. The 30- versus 90-day operative mortality after pulmonary resection. Ann Thorac Surg 2010;89: 1717–22. [2] Schneider L, Farrokhyar F, Schieman C, Shargall Y, D’Souza J, Camposilvan I et al. Pneumonectomy: the burden of death after discharge and predictors of surgical mortality. Ann Thorac Surg 2014;98:1976–82. [3] Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, Villar JC et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012;307: 2295–304. [4] Green A, Hauge J, Iachina M, Jakobsen E. The mortality after surgery in primary lung cancer: results from the Danish Lung Cancer Registry. Eur J Cardiothorac Surg 2016;49:589–94.
THORACIC
with how to minimize it [3]. In contrast, post-discharge mortality has not improved with time, and suggests that our improved perioperative care has not affected this interval. The study by Green et al. [4] published in this journal is a good example of how fastidious documentation and evaluation can both show the burden of a problem and give hints on where to focus our attention. They do a very good job of thoughtfully applying risk stratification to their patient population on a national level and using that available data to identify a high-risk group. Many of these results have face validity. I think most surgeons would worry more about older, more comorbid patients and patients with adverse events, but the findings from this study suggest that male patients with more complex surgery also warrant increased attention. The secondary benefit of this evaluation in the Danish group is the ability to benchmark themselves to ensure internal consistency and also to measure continuous improvement. This is an ability that most countries lack, but is fundamental to improvements in care. The challenge is what to do next with this information. Clearly, there is an unmet need for postoperative care. Like many
595
[2]
[3]
[4]
[5] [6]
[7]
[8]
[9]
[10]
[11]
[12]
A. Green et al. / European Journal of Cardio-Thoracic Surgery respiratory system in the nordic countries 1964-2003 followed up to the end of 2006. Acta Oncol 2010;49:608–23. Strand T, Rostad H, Møller B, Norstein J. Survival after resection for primary lung cancer: a population based study of 3211 resected patients. Thorax 2006;61:710–5. Schneider L, Farrokhyar F, Schieman C, Hanna WC, Shargall Y, Finley CJ. The burden of death following discharge after lobectomy. Eur J Cardiothorac Surg 2015;48:65–70. Schneider L, Farrokhyar F, Schieman C, Shargall Y, D’Souza J, Camposilvan I et al. Pneumonectomy: the burden of death after discharge and predictors of surgical mortality. Ann Thorac Surg 2014;98:1976–81. Nagai K, Yoshida J, Nishimura M. Postoperative mortality in lung cancer patients. Ann Thorac Cardiovasc Surg 2007;13:373–7. Jakobsen E, Palshof T, Osterlind K, Pilegaard H. Data from a national lung cancer registry contributes to improve outcome and quality of surgery: Danish results. Eur J Cardiothorac Surg 2009;35:348–52. Damhuis R, Coonar A, Plaisier P, Dankers M, Bekkers J, Linklater K et al. A case-mix model for monitoring of postoperative mortality after surgery for lung cancer. Lung Cancer 2006;51:123–9. Harichand-Herdt S, Ramalingam SS. Gender-associated differences in lung cancer: clinical characteristics and treatment outcomes in women. Semin Oncol 2009;36:572–80. Sigel K, Bonomi M, Packer S, Wisnivesky J. Effect of age on survival of clinical stage in non-small-cell lung cancer. Ann Surg Oncol 2009;16: 1912–7. Allen MS, Darling GE, Pechet TTV, Mitchell JD, Herndon JE, Landreneau RJ et al. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG z0030 trial. Ann Thorac Surg 2006;81: 1013–20. Janssen-Heijnen MLG, Smulders S, Lemmens VEPP, Smeenk FWJM, van Geffen HJAA, Coebergh JWW. Effect of comorbidity on the treatment and prognosis of elderly patients with non-small cell lung cancer. Thorax 2004; 59:602–7. Jakobsen E, Green A, Østerlind K, Riis T, Iachina M, Palshof T. Nationwide quality improvement in lung cancer care: the role of the Danish Lung Cancer Group and Registry. J Thorac Oncol 2013;8:1238–47.
[13] Pedersen CB. The Danish civil registration system. Scand J Public Health 2011;39(Suppl. 7):22–5. [14] Bjerregaard B, Larsen OB. The Danish pathology register. Scand J Public Health 2011;39(Suppl. 7):72–4. [15] Lynge E, Sandegaard JL, Rebolj M. The Danish national patient register. Scand J Public Health 2011;39(Suppl. 7):30–3. [16] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83. [17] Thygesen SK, Christiansen CF, Christensen S, Lash TL, Sørensen HT. The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish Registry of Patients. BMC Med Res Methodol 2011;11:83. [18] Fisher LD, Lin DY. Time-dependent covariates in the Cox proportionalhazards regression model. Annu Rev Public Health 1999;20:145–57. [19] Bryant AS, Rudemiller K, Cerfolio RJ. The 30- versus 90-day operative mortality after pulmonary resection. Ann Thorac Surg 2010;89: 1717–23. [20] Damhuis RA, Wijnhoven BP, Plaisier PW, Kirkels WJ, Kranse R, van Lanschot JJ. Comparison of 30-day, 90-day and in-hospital postoperative mortality for eight different cancer types. Br J Surg 2012;99:1149–54. [21] McMillan RR, Berger A, Sima CS, Lou F, Dycoco J, Rusch V et al. Thirtyday mortality underestimates the risk of early death after major resections for thoracic malignancies. Ann Thorac Surg 2014;98:1769–75. [22] Pezzi CM, Mallin K, Mendez AS, Greer Gay E, Putnam JB Jr. Ninety-day mortality after resection for lung cancer is nearly double 30-day mortality. J Thorac Cardiovasc Surg 2014;148(5):2269–77. [23] Powell HA, Tata LJ, Baldwin DR, Stanley RA, Khakwani A, Hubbard RB. Early mortality after surgical resection for lung cancer: an analysis of the English National Lung cancer audit. Thorax 2013;68:826–34. [24] Hu Y, McMurry TL, Isbell JM, Stukenborg GJ, Kozower BD. Readmission after lung cancer resection is associated with a 6-fold increase in 90-day postoperative mortality. J Thorac Cardiovasc Surg 2014;97:973–9. [25] Falcoz PE, Puyraveau M, Rivera C, Bernard A, Massard G, Mauny F et al. The impact of hospital and surgeon volume on the 30-day mortality of lung cancer surgery: a nation-based reappraisal. J Thorac Cardiovasc Surg 2014;148:841–8.
EDITORIAL COMMENT
European Journal of Cardio-Thoracic Surgery 49 (2016) 594–595 doi:10.1093/ejcts/ezv160 Advance Access publication 5 May 2015
Cite this article as: Finley CJ. When is the burden of responsibility over for the surgeon? Eur J Cardiothorac Surg 2016;49:594–5.
When is the burden of responsibility over for the surgeon? Christian J. Finley* Department of Surgery, McMaster University, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada * Corresponding author. St. Joseph’s Healthcare Hamilton, 50 Charlton Avenue East, Juravinski Tower T-2105B, Hamilton, ON, Canada L8N 4A6. Tel: +1-905-5221155; fax: +1-905-5268160; e-mail: fi[email protected] (C.J. Finley).
Keywords: Outcomes • Epidemiology • Mortality
To many, the safe conduct of an operation and the successful discharge of a patient is the summation of the surgeon’s responsibility. While this is the fundamental responsibility of a surgeon, our role in both the preoperative and postoperative periods has never been more important. One does not have to look too deeply into the literature to see that operative mortality can be defined in many ways, but when we extend the follow-up timeframe, that number becomes frighteningly higher [1, 2].
Operative mortality in most countries has fallen continuously over the last decade. Improved risk stratification, anaesthetic care, pain control and the ability to rescue critically ill patients have all incrementally pushed down our in-hospital mortality. These changes in the perioperative period can set off a cascade of events extending into the postoperative timeframe that can lead to the death of patients after they are discharged. In many cases, we have identified risk factors for those deaths, yet we still struggle
A. Green et al. / European Journal of Cardio-Thoracic Surgery
journeys, the burden of postoperative care seems to extend to the horizon. This study further emphasizes the need for further study into this area and is a rallying cry for surgeons to intensify their efforts on their postoperative care.
REFERENCES [1] Bryant AS, Rudemiller K, Cerfolio RJ. The 30- versus 90-day operative mortality after pulmonary resection. Ann Thorac Surg 2010;89: 1717–22. [2] Schneider L, Farrokhyar F, Schieman C, Shargall Y, D’Souza J, Camposilvan I et al. Pneumonectomy: the burden of death after discharge and predictors of surgical mortality. Ann Thorac Surg 2014;98:1976–82. [3] Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, Villar JC et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012;307: 2295–304. [4] Green A, Hauge J, Iachina M, Jakobsen E. The mortality after surgery in primary lung cancer: results from the Danish Lung Cancer Registry. Eur J Cardiothorac Surg 2016;49:589–94.
THORACIC
with how to minimize it [3]. In contrast, post-discharge mortality has not improved with time, and suggests that our improved perioperative care has not affected this interval. The study by Green et al. [4] published in this journal is a good example of how fastidious documentation and evaluation can both show the burden of a problem and give hints on where to focus our attention. They do a very good job of thoughtfully applying risk stratification to their patient population on a national level and using that available data to identify a high-risk group. Many of these results have face validity. I think most surgeons would worry more about older, more comorbid patients and patients with adverse events, but the findings from this study suggest that male patients with more complex surgery also warrant increased attention. The secondary benefit of this evaluation in the Danish group is the ability to benchmark themselves to ensure internal consistency and also to measure continuous improvement. This is an ability that most countries lack, but is fundamental to improvements in care. The challenge is what to do next with this information. Clearly, there is an unmet need for postoperative care. Like many
595
