治疗和意向治疗倾向评分分析评估电视辅助胸腔镜手术对肺癌解剖性切除术后 90 天死亡率的影响。

Treatment and intention-to-treat propensity score analysis to evaluate the impact of video-assisted thoracic surgery on 90-day mortality after anatomical resection for lung cancer.

机构信息

Department of Thoracic Surgery, Hospital Universitario Miguel Servet, Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain.

Department of Thoracic Surgery, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.

出版信息

Eur J Cardiothorac Surg. 2022 Aug 3;62(3). doi: 10.1093/ejcts/ezac122.

DOI:10.1093/ejcts/ezac122

PMID:35213711

Abstract

OBJECTIVES

The aim of this study was to know the treatment effect of video-assisted thoracic surgery (VATS) on 90-day mortality after anatomical lung resection based on a nationwide cohort.

METHODS

This is a multicentre prospective cohort of 2721 anatomical resections for lung cancer from December 2016 to March 2018. Treatment and intention-to-treat (ITT) analyses were performed after inverse probability score weighting and different propensity score matching algorithms. Covariate balance was assessed by standardized mean differences. The estimators reported were the average treatment effect, the average treatment effect on the treated and odds ratios after conditional logistic models with 95% confidence intervals. The unconfoundedness assumption was evaluated by sensitivity analysis for average treatment effect (c-dependence) and average treatment effect on the treated (Γ).

RESULTS

VATS was the initial approach in 1911 patients (70.2%), though 273 cases (14.3%) had to be converted to thoracotomy. Ninety-day mortality rates were: treatment analysis (VATS 1.16% vs open 3.9%, P < 0.001), ITT analysis (VATS 1.78% vs open 3.36%, P = 0.012). After inverse probability score weighting and propensity score matching, in the treatment analysis, VATS meant absolute risk reductions between 2.25% and 2.96% and relative risk reductions between 65% and 70% [OR = 0.34 (95% confidence interval 0.15-0.79), all P-values <0.004). However, all the estimators turned out to be non-significant in the ITT analyses. A high sensitivity to unobservable confounders was proved (c-dependence 0.135, Γ = 1.5).

CONCLUSIONS

VATS can reduce the risk of 90-day mortality after anatomical lung resection. However, the implications of conversion to thoracotomy, comparing ITT versus treatment analysis, and the potential impact of hidden bias should deserve further attention in the future.

摘要

目的

本研究旨在通过全国性队列研究，了解电视辅助胸腔镜手术（VATS）对解剖性肺切除术后 90 天死亡率的治疗效果。

方法

这是一项多中心前瞻性队列研究，纳入了 2016 年 12 月至 2018 年 3 月期间 2721 例肺癌解剖性切除术患者。采用逆概率评分加权和不同倾向评分匹配算法进行治疗和意向治疗（ITT）分析。通过标准化均数差值评估协变量平衡。报告的估计值为平均治疗效果、经处理的平均治疗效果和条件逻辑模型的比值比（OR），置信区间为 95%。通过敏感性分析评估平均治疗效果（c-依赖性）和经处理的平均治疗效果（Γ）评估无混杂假设。

结果

273 例（14.3%）患者需转为开胸手术，VATS 是初始手术方式，但有 1911 例患者（70.2%）接受了 VATS 治疗。90 天死亡率为：治疗分析（VATS 组为 1.16%，开胸组为 3.9%，P<0.001），ITT 分析（VATS 组为 1.78%，开胸组为 3.36%，P=0.012）。经逆概率评分加权和倾向评分匹配后，在治疗分析中，VATS 可使绝对风险降低 2.25%~~2.96%，相对风险降低 65%~~70%[OR=0.34（95%可信区间 0.15~0.79），所有 P 值均<0.004]。然而，所有的估计值在 ITT 分析中均不显著。研究结果表明，该模型对不可观测的混杂因素高度敏感（c-依赖性为 0.135，Γ为 1.5）。