Department of Surgery, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular and Thoracic Surgery, Loyola University, Chicago, Illinois.
Department of Surgery, Mayo Clinic, Rochester, Minnesota.
Ann Thorac Surg. 2021 Sep;112(3):952-960. doi: 10.1016/j.athoracsur.2020.08.058. Epub 2020 Nov 5.
Contemporary data on lung volume reduction surgery (LVRS) is sparse, particularly in regard to utilization and surgical outcomes. In this context, we analyzed the practice patterns and outcomes of LVRS nationally.
We identified all patients (n = 1617) undergoing LVRS at 165 hospitals between 2001 and 2017 from The Society of Thoracic Surgeons (STS) General Thoracic Database. Practice patterns were assessed at the hospital and STS regional levels. In addition, we obtained regional chronic obstructive pulmonary disease prevalence data from the Centers for Disease Control. We used hierarchical logistic regression to estimate associations with each outcome of interest and calculate risk- and reliability-adjusted outcome rates.
Since 2011, national LVRS utilization has been increasing with decreasing mortality rates (3.1% risk-adjusted mortality in 2016). There is wide regional variation in LVRS average caseload that is not congruent with national chronic obstructive pulmonary disease prevalence (Pearson correlation coefficient -0.11). On multivariable analysis, only older age (adjusted odds ratio 1.05, P < .001), male sex (adjusted odds ratio 1.5, P = .007), underweight body mass index (adjusted odds ratio 1.94, P = .027), and ECOG score of 4 (adjusted odds ratio 5.17, Z-score 3.91, P = .001) were associated with the occurrence of the composite outcome of major morbidity or mortality. At the hospital level, six hospitals performed 40% of all LVRS nationally with adjusted national 30-day mortality rate of 4.3% and composite outcome rate of 15.8%. Despite this, there was minimal variation in adjusted outcome rates.
National utilization of LVRS is increasing and it has become safer overall, even at lower volume hospitals. There is regional variation in LVRS use that does not mirror national chronic obstructive pulmonary disease prevalence, suggesting access disparities. The findings have potential policy implications.
关于肺减容手术（LVRS）的当代数据较为匮乏，特别是在手术应用和结果方面。在此背景下，我们对全国范围内 LVRS 的手术实践和结果进行了分析。
我们从胸外科医师学会（STS）普通胸科数据库中确定了 2001 年至 2017 年间在 165 家医院接受 LVRS 治疗的所有患者（n=1617 例）。在医院和 STS 区域层面评估了手术实践模式。此外，我们从疾病控制中心获得了区域慢性阻塞性肺疾病流行率数据。我们使用分层逻辑回归来估计各感兴趣结局的关联，并计算风险和可靠性调整后的结局发生率。
自 2011 年以来，全国范围内 LVRS 的应用呈上升趋势，死亡率呈下降趋势（2016 年风险调整死亡率为 3.1%）。LVRS 的平均病例量存在广泛的区域差异，与全国慢性阻塞性肺疾病的流行率不一致（皮尔逊相关系数为-0.11）。多变量分析显示，只有年龄较大（调整后的优势比 1.05，P<.001）、男性（调整后的优势比 1.5，P=0.007）、体重指数不足（调整后的优势比 1.94，P=0.027）和 ECOG 评分 4 分（调整后的优势比 5.17，Z 值 3.91，P=0.001）与主要发病率或死亡率的复合结局相关。在医院层面，6 家医院完成了全国 40%的 LVRS 手术，调整后的全国 30 天死亡率为 4.3%，复合结局发生率为 15.8%。尽管如此，调整后的结局发生率变化极小。
全国范围内 LVRS 的应用正在增加，其整体安全性更高，即使在低容量医院也是如此。LVRS 的应用存在区域差异，与全国慢性阻塞性肺疾病的流行率不一致，这表明存在获得途径的差异。这些发现可能具有政策意义。
