Mortality Classification System Research Articles

Comparative Analysis of Short-Term Outcomes of Anatomical Lung Resections Using Video-Assisted Thoracoscopic Surgery and Thoracotomy Approaches

Objective: To analyze short-term outcomes of anatomical lung resections using video-assisted thoracoscopic surgery (VATS) and thoracotomy approaches.Materials and methods: Our retrospective study included 530 patients who underwent surgery for various lung diseases in the thoracic surgery unit of City Multidisciplinary Hospital No. 2 (Saint Petersburg, Russian Federation) between 2014 and 2021. The patients were grouped based on the surgical approach: group 1 for patients who underwent VATS (n = 378), group 2 for patients who underwent thoracotomy (n = 120), and group 3 for patients who underwent conversion from VATS to thoracotomy (n = 32).Results: Tumor size, paranodal and peribronchial changes were unfavorable prognostic factors for conversion from VATS to thoracotomy (odds ratio [OR] = 1.032, CI: 1.013-1.051, P < .001; OR = 4.416, CI: 2.100-9.283, P < .0005; OR = 3.109, CI: 1.496-6.462, P < .002). Patients from group 1 and group 3 mostly had minor complications, whereas 32 patients (53%) from group 2 developed grade III-V complications according to Thoracic Morbidity and Mortality classification system. High Charlson Comorbidity Index (CCI), thoracotomy approach, emphysematous changes, adhesions, and absence of interlobar fissures were independent unfavorable prognostic factors for complications in the early postoperative period (OR = 1.665, CI: 1.031-2.691, P < .05; OR = 1.874, CI: 1.1433.070, P < .05; OR = 1.8803, CI: 1.126-2.888, P < .05; OR = 1.548, CI: 1.010-2.370, P < .05; OR = 1.612, CI: 1.053-2.466, P < .05).Conclusions: VATS is an effective and safe approach for anatomical lung resection. Tumor size above 40 mm, significant paranodal and peribronchial changes were risk factors for conversion from VATS to thoracotomy. CCI above 5, thoracotomy approach, emphysematous changes, adhesions, and absence of interlobar fissures were independent unfavorable prognostic factors for complications in the early postoperative period.

Multicentre positive deviance seminar to generate best practice recommendations to reduce anastomotic leak and length of stay for patients undergoing oesophagectomy

BackgroundWe describe a novel process using positive deviance (PD) with the Canadian Association of Thoracic Surgeons members, to identify perioperative best practice to minimise anastomotic leak (AL) and length of...

Epidemiological Study on the Causes of Mortality Among Children Aged 5-14 Years in the Northeast of Iran in 2013- 2019: A Descriptive Study

Background and aims: To identify the pattern and causes of death and to deal with them are among the most appropriate strategies to increase human life expectancy. The pattern of death in society must be identified to cope with the causes of premature deaths. The aim of this study was to epidemiologically investigate the causes of death in people aged 5-14 years in northeastern Iran. Methods: Data on the deaths of people aged 5-14 years from Khorasan Razavi province during 2013- 2019, drawn from the Causes of Mortality Classification System of the Ministry of Health and Medical Education, were used to conduct the study. Results: Data on 2084 deaths were examined, of which 824 (40.04%) occurred in girls. The number of deaths was 976 (53.83%) and 1108 (46.17%) in the age group of 5-9 and 10-14, respectively. Traffic accidents, cancers, external causes (unexpected events), and circulatory system diseases were found as the main causes of death. Among the cancers, lymphoid leukemia, malignant brain tumors, and myeloid leukemia (18%, 12%, and 7%, respectively) were the most common cancers, leading to death. In rural areas, unexpected events (20%) were the leading cause of death, followed by traffic accidents and cancers (19% and 13%, respectively). Conclusion: Overall, the mortality rate in children aged 5-14 years due to traffic accidents and unexpected events (suffocation, burns, and the like) seems to be substantially higher in Iran compared to some developing countries and some neighboring countries such as Turkey. Given the possibility of taking preventive measures in this regard, it is necessary to develop policies to reduce the mortality rate in the age group.

Salvage Lung Resections After Definitive Chemoradiotherapy: A Safe and Effective Oncologic Option

Patients with locally advanced, non-small cell lung cancer treated with definitive chemoradiotherapy alone often demonstrate persistent or recurrent disease. In the absence of systemic progression, salvage lung resection after definitive chemoradiotherapy has been used as a treatment option. Given the paucity of data, we sought to evaluate the safety and efficacy of salvage pulmonary resections occurring greater than 90 days after definitive chemoradiotherapy. Retrospective institutional database review identified patients undergoing salvage lung resection at least 90 days after the completion of definitive chemoradiotherapy. Primary outcomes evaluated were overall survival and recurrence-free survival. Thirty patients met inclusion criteria between January 1, 2004 and December 31, 2015. Median time to surgery after definitive radiotherapy was 279 days (interquartile range, 168-474 days). Extended resections were performed in 11 patients (37%). Ottawa Thoracic Morbidity and Mortality Classification System grade IIIA or greater complications occurred in 12 patients (40%). Thirty-day mortality was 6.7% (2 patients). Median overall survival after salvage resection was 24 months. Median overall survival for an R1 resection was 5.3 months vs 108 months for an R0 resection (P= .001). Persistent pN1-positive salvage resections also did lesswell compared with pN0 (8.9 vs 28.2 months; P=.06). For patients who underwent nonextended salvage resection (simple lobectomy or simple pneumonectomy), median overall survival was 108.4 months, vs 8.9 months for extended salvage resections (P= .02). With proper patient selection, salvage lung resections can be performed with acceptable morbidity, mortality, and oncologic outcomes, particularly when a ypN0R0 resection can be achieved by nonextended surgical means.

EP1.17-31 30 Days Major Morbidity and Mortality After Lung Cancer Surgery. Outcomes of Five Years in a Single Center Experience

Lung cancer is the leading cause of cancer-related death in the world. Surgery offers the best potential cure, but as in any surgery there are some complications that will be minimized with the improvement of surgical practice and treatment protocols. The aim of this study was to clarify the level of service we are providing in order to improve it and to add more information in the global database on the Thoracic Morbidity and Mortality classification system for patients undergoing lung resection. This is a retrospective study that included all patients who underwent lung resection in our department from January 2011 to January 2015. The parameters examined were postoperative mortality thirty days and postoperative complications. Both patients were evaluated prior to surgery according to the Karnofsky score and the intervention was performed by postero-lateral thoracotomy. There were 216 patients who were operated on for lung cancer in which 37 (17%) of them underwent pneumonectomy meanwhile the rest lobectomies, bilobectomies and anatomical segmentectomies. The average age was 62.4 years (± 12SD). 12% of patients were women and 88% males. 79% were smokers and 21% non-smokers. According to TNM classification, 10.2% of cases were in the first stage, 44% in the second stage, 21.3% in the third stage and 5.6% in the fourth stage. 40.4% of cases had another illness (cardiovascular disease 24.2%, COPD 11.8%, diabetes mellitus 3.7% and other diseases 0.6%). 17% of patients had complications 30 days after surgery and only 2.3% died. As for pneumonectomy, the complication rate was 24% and the mortality rate was 8%. The main complications that have been observed were 19 cases of empyema, 4 cases of broncho-pleural fistula, 4 cases of pneumonia, 3 cases of prolonged air loss, 3 cases of heart attack and in 4 cases different complications were observed. 2 of mortality occurred due to a heart attack, in 2 cases occurred due to severe pneumonia and in one case a vascular accident occurred during the operation. Hospital stay was 8.5±3 days. In our specialty, the complication rate following a surgical operation is a parameter very often used to check the quality level provided by health professionals. Our results show average mortality and morbidity after lung cancer surgery. However, patients with reduced lung capacity and undergoing pneumonectomy should be treated with the utmost care, since they run a considerable risk of major complications or death during the first 30 days after surgery.

Applying the international classification of diseases to perinatal mortality data, South Africa.

ObjectiveTo examine the feasibility of applying the International Classification of Diseases-perinatal mortality (ICD-PM) coding to an existing data set in the classification of perinatal deaths.MethodsOne author, a researcher with a non-clinical public health background, applied the ICD-PM coding system to South Africa’s national perinatal mortality audit system, the Perinatal Problem Identification Program. The database for this study included all perinatal deaths (n = 26 810), defined as either stillbirths (of birth weight > 1000 g and after 28 weeks of gestation) or early neonatal deaths (age 0–7 days), that occurred between 1 October 2013 and 31 December 2016. A clinical obstetrician verified the coding.FindingsThe South African classification system does not include the timing of death; however, under the ICD-PM system, deaths could be classified as antepartum (n = 15 619; 58.2%), intrapartum (n = 3725; 14.0%) or neonatal (n = 7466; 27.8%). Further, the South African classification system linked a maternal condition to only 40.3% (10 802/26 810) of all perinatal deaths; this proportion increased to 68.9% (18 467/26 810) under the ICD-PM system.ConclusionThe main benefit of using the clinically relevant and user-friendly ICD-PM system was an enhanced understanding of the data, in terms of both timing of death and maternal conditions. We have also demonstrated that it is feasible to convert an existing perinatal mortality classification system to one which is globally comparable and can inform policy-makers internationally.

The feasibility of a clinical audit tool to investigate stillbirth in Australia - a single centre experience.

The stillbirth rate in Australia is 7 per 1000 births (Australia's Mothers and Babies 2014-in brief. Perinatal Statistics Series no. 32. Cat no. PER 87, Canberra, AIHW, 2016). The Perinatal Society of Australia and New Zealand (PSANZ) developed guidelines to standardise the investigations into stillbirth. To identify causes of stillbirths and stillbirth care using the National Perinatal Death Clinical Audit Tool (National Perinatal Death Clinical Audit Tool, Australian and New Zealand Stillbirth Alliance [ANZSA]/Perinatal Society of Australia and New Zealand [PSANZ]) and compare it to the PSANZ recommendations. Documentation of examination findings and follow-up after stillbirth were also reviewed. From the total of 515 registered stillbirths at a Queensland hospital, 170 stillbirths were considered unexplained after chart review between July 2004 and September 2014. The National Perinatal Death Clinical Audit Tool was applied and resulting underlying causes of stillbirths were classified using the PSANZ perinatal mortality classification system. The stillbirth rate for this centre was 11.2 per 1000 births. A cause of fetal death was established in 55.4% (93/168) and 75 cases (44.6%) remained unexplained corresponding to 14.6% of all registered stillbirths (75/515). Over half of the women (52.7%) were nulliparous. High rates of autopsy (47.3%), bereavement support (99.4%) and placental histopathology (98.8%) were noted. The general practitioner was notified in 98.7% of cases at the time of stillbirth; 34.1% of babies were small for gestational age at birth, 18.9% were growth-restricted at birth and 21.4% of women were current smokers. The National Perinatal Death Clinical Audit Tool facilitates and streamlines stillbirth investigations and thus helps to identify underlying causes of stillbirth.

Performance criteria for verbal autopsy-based systems to estimate national causes of death: development and application to the Indian Million Death Study

BackgroundVerbal autopsy (VA) has been proposed to determine the cause of death (COD) distributions in settings where most deaths occur without medical attention or certification. We develop performance criteria for VA-based COD systems and apply these to the Registrar General of India’s ongoing, nationally-representative Indian Million Death Study (MDS).MethodsPerformance criteria include a low ill-defined proportion of deaths before old age; reproducibility, including consistency of COD distributions with independent resampling; differences in COD distribution of hospital, home, urban or rural deaths; age-, sex- and time-specific plausibility of specific diseases; stability and repeatability of dual physician coding; and the ability of the mortality classification system to capture a wide range of conditions.ResultsThe introduction of the MDS in India reduced the proportion of ill-defined deaths before age 70 years from 13% to 4%. The cause-specific mortality fractions (CSMFs) at ages 5 to 69 years for independently resampled deaths and the MDS were very similar across 19 disease categories. By contrast, CSMFs at these ages differed between hospital and home deaths and between urban and rural deaths. Thus, reliance mostly on urban or hospital data can distort national estimates of CODs. Age-, sex- and time-specific patterns for various diseases were plausible. Initial physician agreement on COD occurred about two-thirds of the time. The MDS COD classification system was able to capture more eligible records than alternative classification systems. By these metrics, the Indian MDS performs well for deaths prior to age 70 years. The key implication for low- and middle-income countries where medical certification of death remains uncommon is to implement COD surveys that randomly sample all deaths, use simple but high-quality field work with built-in resampling, and use electronic rather than paper systems to expedite field work and coding.ConclusionsSimple criteria can evaluate the performance of VA-based COD systems. Despite the misclassification of VA, the MDS demonstrates that national surveys of CODs using VA are an order of magnitude better than the limited COD data previously available.

Measuring Surgical Quality: Comparison of Postoperative Adverse Events with the American College of Surgeons NSQIP and the Thoracic Morbidity and Mortality Classification System

Monitoring surgical outcomes is critical to quality improvement; however, different data-collection methodologies can provide divergent evaluations of surgical outcomes. We compared postoperative adverse event reporting on the same patients using 2 classification systems: the retrospectively recorded American College of Surgeons (ACS) NSQIP and the prospectively collected Thoracic Morbidity and Mortality (TM&M) system. Using the TM&M system, complications and deaths were documented daily by fellows and reviewed weekly by staff for all thoracic surgical cases conducted at our institution (April 1, 2010 to December 31, 2011). The ACS NSQIP recording was performed 30 to 120 days after index surgery by trained surgical clinical reviewers on a systemic sampling of major cases during the same time period. Univariate analyses of the data were performed. During the study period, 1,788 thoracic procedures were performed (1,091 were designated "major," as per ACS NSQIP inclusion criteria). The ACS NSQIP evaluated 182 of these procedures, representing 21.1% and 16.7% of patients and procedures, respectively. Mortality rates were 1.4% in TM&M vs 2.2% in ACS NSQIP (p = 0.42). Total patients and procedures with complications reported were 24.4% and 31.1% by TM&M vs 20.2% and 39.0% by ACS NSQIP (p = 0.23 and 0.03), respectively. Rates of reported cardiac complications were higher in TM&M vs ACS NSQIP (5.8% vs 1.1%; p = 0.01), and wound complications were lower (2.5% vs 6.0%; p = 0.01). Although overall rates were similar, significant differences in collection, definitions, and classification of postoperative adverse events were observed when comparing TM&M and ACS NSQIP. Although both systems offer complementary value, harmonization of definitions and severity classification would enhance quality-improvement programs.

Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection

Postoperative atrial fibrillation (PAF) occurs commonly following pulmonary resection. Our aims were to quantify the incidence and severity of PAF using the Thoracic Morbidity & Mortality classification system, and identify risk factors for PAF. All consecutive patients undergoing pulmonary resection at a single centre (January 2008 - April 2010) were enrolled. PAF was defined as postoperative, electrocardiographically documented and requiring initiation of pharmacological therapy. Univariate and multivariate analyses of risk factors associated with the development of PAF were conducted. The incidence of PAF was 11.8% (n = 43) of 363 pulmonary resections (open: n = 173; 47.7%; video-assisted: n = 177; 48.8%; converted: n = 13; 3.6%): sublobar (n = 93; 25.6%), lobectomy (n = 237; 65.3%), bilobectomy (n = 7; 1.9%) and pneumonectomy (n = 24; 6.6%). Twenty-eight cases (65.1%) were uncomplicated/transient, and 15 cases (34.9%) were complicated/persistent PAF, defined as lasting for >7 days (40.0%), requiring cardioversion (13.3%), vasopressors (33.3%), in-hospital use of anticoagulants (46.7%) and/or anticoagulants on discharge (26.7%). Patients with PAF had increased mean lengths of hospital stay (10.5 days vs 6.9 days; P = 0.04). Peak onset of PAF occurred 2.5 (standard deviation (SD) ± 1.3) days after pulmonary resection, lasting for 1.8 ± 2.8 (mean, ±SD) days. Multivariate analysis identified (relative risk; 95% confidence interval): age ≥70 years (2.3; 1.1-5.1), history of angioplasty/stents/angina (4.0; 1.4-11.3), thoracotomy (3.6; 1.4-9.3), conversion to open thoracotomy (16.5; 2.2-124.0) and extent of surgery/stage (7.1; 1.0-49.4) as predictors of PAF. While the majority of PAF is uncomplicated and transient, one-third of cases lead to persistence or major intervention. Age, coronary artery disease and extent of surgery/stage increase the risk of PAF following pulmonary resection. Identifying patients with elevated risk may lead to targeted prophylaxis to reduce the incidence of PAF.

Quantifying the incidence and impact of postoperative prolonged alveolar air leak after pulmonary resection

Prolonged alveolar air leak (PAAL) is a frequent occurrence after lobectomy or lesser resections. The resulting complications and their impact are not well understood. Our aims are to prospectively determine the incidence and severity of PAAL after pulmonary resection using the Thoracic Morbidity & Mortality classification system and to identify risk factors. A prospective collection of Thoracic Morbidity & Mortality data was performed for all consecutive pulmonary resections (n = 380; January 2008 to April 2010). Demographics, comorbidities, and preoperative cardiopulmonary assessment were retrospectively identified. The incidence and severity (grades I-V) of burden from PAAL were quantified using the Ottawa Thoracic Morbidity & Mortality system. Risk factors for PAAL and severe PAAL (defined as leading to major intervention, organ failure, or death) were sought with univariate and multivariate analyses. The incidences of PAAL and severe PAAL were 18% and 4.8%, respectively. PAAL prolonged the median hospital stay by 4 days. The majority of complications associated with PAAL were limited to pulmonary and pleural categories (90%). Significant predictors of PAAL from multivariate analysis include severe radiologic emphysema (odds ratio [OR], 2.8; confidence interval [CI], 1.2-6.2), histopathologic emphysema (OR, 1.9; CI, 1.1-3.6), percentage of predicted value for forced expiratory volume in 1 second less than 80% (OR, 1.9; CI, 1.1-3.3), and lobectomy (OR, 4.9; CI, 1.-14.1). Risk factors for severe PAAL include radiologic emphysema, percentage of predicted value for forced expiratory volume in 1 second less than 80%, forced expiratory volume in 1 second/forced vital capacity ratio less than 70%, and intraoperative difficulties (P < .05). PAAL leads to longer hospital stays, and approximately 4.8% of patients undergoing pulmonary resection experience PAAL that necessitates placement of additional chest drains, bronchoscopy, reoperation, or life support. Further study is required to assess the cost-effectiveness of measures to reduce PAAL.

O6-5.1 Million death study mortality classification (MDS-MC) system for verbal autopsies

IntroductionThe Global Burden of Disease (GBD) disease classification system, based on ICD-10, is mostly based on hospitalised patients and medically-certified causes of death in developed countries. However, most deaths in...

Evaluating the Reliability and Reproducibility of the Ottawa Thoracic Morbidity and Mortality Classification System

Minimizing adverse events after surgery is widely recognized as an important indicator of quality; yet no consensus has been reached on how to standardize the reporting of adverse events after surgical procedures. Our objectives were to develop a standardized classification system to monitor both the presence and severity of thoracic morbidity and mortality, and to evaluate its reliability and reproducibility among a national cohort of thoracic surgeons. To assess the Thoracic Morbidity and Mortality classification system (based on the Clavien-Dindo classification of adverse events), a 31-item questionnaire was sent to all members of the Canadian Association of Thoracic Surgeons in August 2009, consisting of a general description of the Thoracic Morbidity and Mortality severity grades, 20 case-based questions of postoperative adverse events to be classified, and questions regarding personal judgments. We derived descriptive and quantitative information using weighted Kappa statistics. Fifty-two (54.7%) thoracic surgeons completed the questionnaire; 41 (78.8%) of the respondents were affiliated with an academic teaching hospital. A total of 1,326 individual weighted Kappa statistics were calculated for all distinct pairs of raters, of which 1,152 (87%) were greater than 0.81, a range that is interpreted as "almost perfect agreement." A further 174 (13%) were in the range between 0.61 and 0.8, interpreted as "substantial agreement." All results were statistically significant (p < 0.0001). The classification system was regarded as straightforward (98% of the respondents), reproducible (94%), logical (92%), and useful (98%). The modified classification system appears to offer objective, reliable, and reproducible reporting of thoracic morbidity and mortality, and thus may assist continuous quality improvement in thoracic surgery.