Invited Commentary

Abstract

The adoption rate of thoracoscopic lobectomy varies widely throughout the world, and some of this variation can be attributed to economic and cultural issues. The variation in the adoption rate of thoracoscopic lobectomy in the United States is equally large, and it can be attributed only to resistance to innovation. This study by Abdelsattar and colleagues [1Abdelsattar Z.M. Allen M.S. Shen K.R. et al.Variation in hospital adoption rates of video-assisted thoracoscopic lobectomy for lung cancer and the effect on outcomes.Ann Thorac Surg. 2017; 103: 454-461Abstract Full Text Full Text PDF Scopus (24) Google Scholar] analyzes the National Cancer Database to assess the variation in adoption of thoracoscopic lobectomy and to identify factors that might explain this variation. In this study, adoption rates in the highest and lowest quintiles were 76% versus 0.6%, respectively. This finding is similar to a recent publication using the National Inpatient Sample Database, demonstrating that the mean hospital utilization of thoracoscopic lobectomy ranged from 3% to 66%, that discordance (actual versus predicted utilization) was as high as 250%, and that complications were less common with the thoracoscopic approach versus open (17% versus 25%; p < 0.05) [2Cooper M.A. Hutfless S. Segev D.L. et al.Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review.BMJ. 2014; 349: g4198Crossref PubMed Scopus (61) Google Scholar]. In the Society of Thoracic Surgeons General Thoracic Surgery Database, the most recent publication demonstrated that approximately 50% of lobectomies are performed thoracoscopically [3Ceppa D.P. Kosinski A.S. Berry M.F. Tong B.C. et al.Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons database analysis.Ann Surg. 2012; 256: 487-493Crossref PubMed Scopus (193) Google Scholar]; in the European Society of Thoracic Surgery Database, less than 25% of lobectomies are performed thoracoscopically [4Falcoz P.-E. Puyraveau M. Thomas P.-A. Decaluwe H. et al.Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer; a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database.Eur J Cardiothorac Surg. 2016; 49: 602-609Crossref PubMed Scopus (269) Google Scholar]. Considering that the adoption rate of thoracoscopic lobectomy since introduction approximately 20 years ago is so low in the United States and worldwide, it can be concluded that we have not yet made it through the “early majority” phase of adoption, with the “late majority” barely on the horizon. In light of the overwhelming evidence of outcome advantages of thoracoscopic lobectomy, continued focus on teaching and training is paramount—in training programs, in regional courses, and in national and international meetings [5Zwischenberger B. D’Amico T.A. Tong B.C. How I teach it: thoracoscopic lobectomy.Ann Thorac Surg. 2016; 101: 846-849Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. It is possible that the development of improved instrumentation, alternate robotic platforms, and three-dimensional optics will improve the conversion of surgeons to “minimally invasive” and increase the adoption rate of thoracoscopic lobectomy and other minimally invasive approaches. The advent of publicly reported outcomes will expose the surgeons “late majority” and “laggard” phases to patients, referring physicians, and payors, which unfortunately may be the most effective force to reduce the practice variation and to improve the outcomes associated with thoracoscopic lobectomy. Variation in Hospital Adoption Rates of Video-Assisted Thoracoscopic Lobectomy for Lung Cancer and the Effect on OutcomesThe Annals of Thoracic SurgeryVol. 103Issue 2PreviewThis study examined the variation in the adoption of video-assisted thoracoscopic surgery (VATS) for lobectomy across United States hospitals from a population-based national database. Full-Text PDF