Society Of Thoracic Surgeons General Thoracic Surgery Database Research Articles

2024 Update of The Society of Thoracic Surgeons Short-term Esophagectomy Risk Model: More Inclusive and Improved Calibration

BackgroundThe Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) previously reported short-term risk models for esophagectomy for esophageal cancer. We sought to update existing models using more inclusive contemporary cohorts, with consideration of additional risk factors based on clinical evidence. MethodsThe study population consisted of adult patients in the STS-GTSD who underwent esophagectomy for esophageal cancer between January 2015 and December 2022. Separate esophagectomy risk models were derived for 3 primary end points: operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used, with predictors retained in models if P < .10. All derived models were validated using 9-fold cross-validation. Model discrimination and calibration were assessed for the overall cohort and specified subgroups. ResultsA total of 18,503 patients from 254 centers underwent esophagectomy for esophageal cancer. Operative mortality, morbidity, and composite morbidity or mortality rates were 3.4%, 30.5%, and 30.9%, respectively. Novel predictors of short-term outcomes in the updated models included body surface area and insurance payor type. Overall discrimination was similar or superior to previous STS-GTSD models for operative mortality (C statistic = 0.72) and for composite morbidity or mortality (C statistic = 0.62), Model discrimination was comparable across procedure- and demographic-specific subcohorts. Model calibration was excellent in all patient subgroups. ConclusionsThe newly derived esophagectomy risk models showed similar or superior performance compared with previous models, with broader applicability and clinical face validity. These models provide robust preoperative risk estimation and can be used for shared decision making, assessment of provider performance, and quality improvement.

Initial Assessment of the Effect of ProvenCare on Lung Cancer Surgical Quality

BackgroundProvenCare is a joint initiative of the American College of Surgeons Commission on Cancer, Geisinger, and The Society of Thoracic Surgeons (STS) to standardize evidence-based practices in the delivery of surgical lung cancer care. This study compares outcomes of ProvenCare patients with the STS Database. MethodsBest practice elements were agreed on through expert consensus meetings. ProvenCare elements were used to direct care. Compliance was monitored while clinical outcomes were collected within the STS General Thoracic Surgery Database (GTSD). ProvenCare patient outcomes were compared with outcomes in all other STS GTSD patients. Univariable and multivariable logistic regression models compared morbidity and mortality. ResultsA total of 2026 patients at 23 ProvenCare hospitals were compared with 71 565 control patients at 311 hospitals from 2010 to 2016. ProvenCare patients were more likely to receive guideline-recommended staging evaluations and more likely to have mediastinal staging performed during resection (63.4% vs 49.4%; P < .001). There was no difference in 30-day mortality (1.4% vs 1.3% lobectomy [P = .84]; 3.4% vs 2.0% all other resections [P = .054]) or STS indicator complications (10.8% vs 9.9% lobectomy [P = .21]; 9.2% vs 9.4% all other resections [P = .92]). When controlling for patient-level clinical and demographic risk factors, the likelihood of perioperative morbidity and mortality was not significantly different (odds ratio [OR], 1.07 [95% CI, 0.77-1.47] lobectomy; OR, 0.97 [95% CI, 0.62-1.50] all other resections). ConclusionsVariability in preoperative evaluation of patients with lung cancer represents an opportunity to improve quality of care. ProvenCare increased use of guideline-recommended preoperative processes, which may improve cancer outcomes and survival, without resulting in differences in short-term surgical outcomes.

Community Size and Lung Cancer Resection Outcomes: Studying The Society of Thoracic Surgeons Database

Socioeconomic factors play key roles in surgical outcomes. Socioeconomic data within The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) are limited. Therefore, we utilized community size as a surrogate to understand socioeconomic differences in lung cancer resection outcomes. We retrospectively reviewed all lung cancer resections from January 2012 to January 2017 in the STS GTSD. This captured 68,722 patients from 286 centers nationwide. We then linked patient zip codes with 2013 Rural-Urban Continuum Codes to understand the association between community size and postoperative outcomes. Demographic and clinical variables were evaluated for relationships with 30-day mortality, major morbidity, and readmission. Zip codes were included in 47.2% of patients. Zip-coded patients were older, were more comorbid, had less advanced disease, and were more commonly treated with minimally invasive approaches than were those without zip code classification. For geocoded patients, multivariable analyses demonstrated that sex, insurance payor, and hospital region were associated with all 3 major endpoints. Community size, based on Rural-Urban Continuum Codes coding, was not associated with any primary endpoint. Invasive mediastinal staging was related to morbidity, greater pathological stage predicted mortality, and worsened clinical stage was associated with readmission. More invasive surgery and greater extent of lung resection were associated with all primary endpoints. Incomplete data capture can promote selection bias within the STS GTSD and skew outcomes reporting. Moreover, community size is an insufficient surrogate, compared with sex, insurance payor, hospital region, for understanding socioeconomic differences in lung cancer resection outcomes.

The Society of Thoracic Surgeons Composite Score Rating for Pulmonary Resection for Lung Cancer

The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has developed composite quality measures for lobectomy and esophagectomy. This study sought to develop a composite measure including all resections for lung cancer. The STS lung cancer composite score is based on 2 outcomes: risk-adjusted mortality and morbidity. GTSD data were included from January 2015 to December 2017. "Star ratings" were created for centers with 30 or more cases by using 95% Bayesian credible intervals. The Bayesian model was performed with and without inclusion of the minimally invasive approach to assess the impact of approach on the composite measure. The study population included 38,461 patients from 256 centers. Overall operative mortality was 1.3% (495 of 38,461). The major complication rate was 7.9% (3045 of 38,461). The median number of nodes examined was 10 (interquartile range, 5 to 16); the median number of nodal stations sampled was 4 (interquartile range, 3 to 5). Positive resection margins were identified in 3.7% (1420 of 38,461). A total of 214 centers with 30 or more cases were assigned star ratings. There were 7 1-star, 194 2-star, and 13 3-star programs; 70.6% of resections were performed through a minimally invasive approach. Inclusion of minimally invasive approach, which was adjusted for in previous models, altered the star ratings for 3% (6of 214) of the programs. Participants in the STS GTSD perform lung cancer resection with low morbidity and mortality. Lymph node data suggest that participants are meeting contemporary staging standards. There is wide variability among participants in application of minimally invasive approaches. The study found that risk adjustment for approach altered ratings in 3% of participants.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2019 Update on Research

The Society of Thoracic Surgeons (STS) Workforce on Research Development and the STS Research Center currently offer 3 outcomes research platforms using the STS General Thoracic Surgery Database: (1) the traditional Access and Publications Program supports STS-sponsored projects with data analysis conducted at an STS-approved data analytic center, (2) the STS Task Force for FundedResearch supports STS investigators pursuing extramural research funding for projects incorporating STS National Database data linked to other data sets suchas Centers for Medicare and Medicaid Services, and (3) the Participant User File (PUF) program that provides deidentified patient-level data files from the STS General Thoracic Surgery Database to investigators with approved projects to be analyzed at their institution. This report includesan updated review of each program in addition to an outline of 2019-based articles published or accepted.

Blazing new trails: initial efforts to create a joint Society of Thoracic Surgeons-European Society of Thoracic Surgeons (STS-ESTS) dataset.

Over the past 5 years, there has been an increased focus on international database collaboration between the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) and European Society of Thoracic Surgeons (ESTS) Registry Task Forces. To this end, a joint STS-ESTS database Task Force meeting is held each year at the STS annual meeting, during which current and future projects are discussed. As this relationship has evolved, various issues have been encountered that must be overcome to maximize the potential of this collaborative effort. This article provides an overview of the STS GTSD and ESTS Registry, past projects, and the challenges faced by the Societal Task Forces as future projects are envisioned.

Invasive Mediastinal Staging for Lung Cancer by The Society of Thoracic Surgeons Database Participants

Prior studies suggest underutilization ofinvasive mediastinal staging for lung cancer. We hypothesized that The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) participants would have higher rates of invasive staging compared with previous reports. We conducted a retrospective cohort study (2012 to 2016) of lung cancer patients staged by computed tomography and positron-emission tomography and first treated with an anatomic resection. We defined invasive staging by the use of mediastinoscopy, endosonography, or thoracoscopy. Standardized incidence ratios were used to compare participant-level rates of invasive staging, and Poisson regression was used to identify factors associated with invasive staging. Among 29,015 patients across 256 participating STS-GTSD sites, 34% (95% confidence interval: 33% to 34%) underwent invasive staging. The overall rate of invasive staging did not change between 2012 and 2016 (ptrend= 0.16). Increasing clinical stage and features suggestive of a central tumor were associated with invasive staging (p < 0.001). Rates of invasive staging among patients with clinical stage IB or greater or features suggestive of a central tumor were 43% (95% confidence interval: 42% to 44%) and 52% (95% confidence interval: 50% to 54%), respectively. There was a more than 40-fold variation in rates of invasive staging across 251 centers contributing at least 10 cases (standardized incidence ratio: lowest= 0.08; highest= 3.26); 66 sites (26%) performed invasive mediastinal staging less often than average and 77 sites (31%) performed invasive staging more often than average. The STS-GTSD participants performed invasive mediastinal staging more frequently than prior reports, and yet only in a minority of patients. Rates of invasive mediastinal staging vary widely across STS-GTSD participants.

Author's response to invited commentary "a perspective on the Society of Thoracic Surgeons Composite Score for evaluating esophagectomy for esophageal cancer".

The Society of Thoracic Surgeons (STS) launched its Adult Cardiac Surgery database in 1989 as a prospective clinical outcomes database for enhancing quality improvement and improving patient safety. Participation in ACSD is voluntary but includes more than 90% of centers performing cardiac surgery in the United States (1). In contrast the penetrance of the STS General Thoracic Surgery Database (GTSD), established in 2002, is far lower.

The Society of Thoracic Surgeons National Database 2017 Annual Report

The Society of Thoracic Surgeons (STS) National Database has three major component databases: the STSAdult Cardiac Surgery Database (ACSD), the STS Congenital Heart Surgery Database (CHSD), and the STS General Thoracic Surgery Database (GTSD). Beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article summarizes the status of the STS National Database as of October 2017 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2017 series "Outcomes Analysis, Quality Improvement, and Patient Safety."

Surgically Managed Clinical Stage IIIA–Clinical N2 Lung Cancer in The Society of Thoracic Surgeons Database

The role of surgical resection in patients with clinical stage IIIA-N2 positive (cIIIA-N2) lung cancer is controversial, partly because of the variability in short- and long-term outcomes. The objective of this study was to characterize the management of cIIIA-N2 lung cancer in The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD). The STS-GTSD was queried for patients who underwent operations for cIIIA-N2 lung cancer between 2002 and 2012. A subset of patients aged older than 65 years was linked to Medicare data. Identified were 3,319 surgically managed, cIIIA-N2 patients, including 1,784 (54%) treated with upfront resection (treatment naïve upfront surgery group, and 1,535 (46%) with induction therapy. A positron emission tomography scan was documented in 93% of patients, and 51% of patients were coded in STS-GTSD as having undergone invasive mediastinal staging. Nodal overstaging (cN2→pN0/N1) was observed in 43% of upfront surgery patients. Lobectomy was performed in 69% of patients and pneumonectomy in 11%. Operative mortality was similar between patients treated with upfront surgery (1.9%) and induction therapy (2.5%, p= .2583). The unadjusted Kaplan-Meier estimate of 5-year survival of cIII-N2 patients treated with induction therapy then resection was 35%. STS surgeons achieve excellent short- and long-term results treating predominantly lobectomy-amenable cIIIA-N2 lung cancer. However, prevalent overstaging and abstention from induction therapy suggest "overcoding" of false positives on imaging or variable compliance with current guidelines for cIIIA-N2 lung cancer. Efforts are needed to improve clinical stage determination and guideline compliance in the GTSD for this cohort.

The Society of Thoracic Surgeons Composite Score for Evaluating Esophagectomy for Esophageal Cancer

The Society of Thoracic Surgeons (STS) has developed composite quality measures for cardiac surgical procedures and lobectomy for lung cancer. This study sought to develop a composite measure for esophagectomy for esophageal cancer. The STS esophagectomy composite score is derived from two risk-adjusted outcomes: mortality and major complications. General Thoracic Surgery Database data were included from 2012 to 2014, and 95% Bayesian credible intervals were established to determine "star" ratings. STS participants were compared with the National Inpatient Sample as a national benchmark (including non-STS participants). The study population included 4,321 patients who underwent esophagectomy from 167 participating centers. The operative mortality rate was 3.1% (N= 135), and the major complication rate was 33.1% (N= 1,429). Of the 167 participants, 70 reported an average yearly volume of five or more esophagectomies during the study period. With this threshold, reliability for the composite score was 0.58 (95% credible interval, 0.41 to 0.72). Of these 70 participants, 5 (7.1%) were three star, 63 (90.0%) were two star, and 2 (2.9%) were one star. A majority of STS participants, 58.1% (N= 97), did not have sufficient volume to receive a reliable composite score. Benchmarked to the 2012 National Inpatient Sample cohort, STS General Thoracic Surgery Database participants have comparable discharge mortality rates and shorter postoperative lengths of stay. STS has developed a quality measure for esophageal cancer surgical procedures based on a composite score of risk-adjusted operative mortality rates and major complications. The composite rating for esophagectomy has good reliability for programs performing an average of five procedures annually, although almost 60% of participants are not eligible for a star rating because of lower procedure volumes.

Trends and controversies in multidisciplinary care of the patient with breast cancer

<dm:abstracts xmlns:dm="http://www.elsevier.com/xml/dm/dtd"><ce:abstract xmlns:ce="http://www.elsevier.com/xml/common/dtd" xml:lang="en" id="abs0010" view="all" class="author"><ce:section-title id="sectitle0010">Abstract</ce:section-title><ce:abstract-sec id="abssec0010" view="all"><ce:simple-para id="abspara0010" view="all">Through the leadership of the Society of Thoracic Surgeons (STS) Workforce on Research Development, the STS Research Center now offers three programs that facilitate outcomes research utilizing the STS General Thoracic Surgery Database (GTSD). (1) The Access and Publications Program supports STS-sponsored projects with data analysis conducted at an STS approved data analytic center, (2) the STS Task Force for Funded Research (TFR) helps STS investigators pursue extramural research funding for projects analyzing STS National Database data, and (3) the Participant User File (PUF) research program that provides investigators with approved projects de-identified patient-level data files from the STS GTSD to be analyzed at their institution. A synopsis of the processes and goals of each program in addition to 2017 based articles published or accepted in 2017 and works in progress are outlined.</ce:simple-para></ce:abstract-sec></ce:abstract></dm:abstracts>

Fifty-Second Annual Meeting, The Society of Thoracic Surgeons

Fifty-Second Annual Meeting, The Society of Thoracic Surgeons

The Society of Thoracic Surgeons Lung Cancer Resection Risk Model: Higher Quality Data and Superior Outcomes

The Society of Thoracic Surgeons (STS) creates risk-adjustment models for common cardiothoracic operations for quality improvement purposes. Our aim was to update the lung cancer resection risk model utilizing the STS General Thoracic Surgery Database (GTSD) with a larger and more contemporary cohort. We queried the STS GTSD for all surgical resections of lung cancers from January 1, 2012, through December 31, 2014. Logistic regression was used to create three risk models for adverse events: operative mortality, major morbidity, and composite mortality and major morbidity. In all, 27,844 lung cancer resections were performed at 231 centers; 62% (n= 17,153) were performed by thoracoscopy. The mortality rate was 1.4% (n= 401), major morbidity rate was 9.1% (n= 2,545), and the composite rate was 9.5% (n= 2,654). Predictors of mortality included age, being male, forced expiratory volume in 1 second, body mass index, cerebrovascular disease, steroids, coronary artery disease, peripheral vascular disease, renal dysfunction, Zubrod score, American Society of Anesthesiologists rating, thoracotomy approach, induction therapy, reoperation, tumor stage, and greater extent of resection (all p < 0.05). For major morbidity and the composite measure, cigarette smoking becomes a risk factor whereas stage, renal dysfunction, congestive heart failure, and cerebrovascular disease lose significance. Operative mortality and complication rates are low for lung cancer resection among surgeons participating in the GTSD. Risk factors from the prior lung cancer resection model are refined, and new risk factors such as prior thoracic surgery are identified. The GTSD risk models continue to evolve as more centers report and data are audited for quality assurance.

Longitudinal Follow-up of Lung Cancer Resection From the Society of Thoracic Surgeons General Thoracic Surgery Database in Patients 65 Years and Older

The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) does not capture long-term survival after lung cancer surgery. Our objective was to provide longitudinal follow-up to the STS GTSD through linkage to Centers for Medicare and Medicaid Services (CMS) data for patients 65 years of age or older. Lung cancer operations reported in the STS GTSD from 2002 through 2012 were linked to CMS data for patients 65 years of age or older using variables common to both databases with a deterministic matching algorithm. Mortality data were abstracted for each linked patient from the CMS data. The Kaplan-Meier method was used to estimate long-term survival for lung cancer surgery patients based on tumor stage. From 2002 through 2012, 60,089 lung cancer resections were identified in the GTSD, and 37,009 (61.7%) were in patients 65 years or older. Of these, 26,055 of 37,099 lung cancer resections (70%) in patients 65 years or older were successfully linked to CMS data. Failure to link was most commonly related to having a health maintenance organization or commercial insurance as the primary payer: 40.5% (5,290 of 13,065) of such patients were not linked from 2009 to 2012 (years payer data available). Median survival after lung cancer resection was 6.7 years for pathologic stage I, 3.5 years for stage II, 2.4 years for stage III, and 2.2 years for stage IV. The CMS data complement the STS GTSD data by enabling examination of long-term survival and resource utilization in patients 65 years or older. Linked data from the STS GTSD and the CMS will allow for longitudinal analyses of comparative effectiveness among different surgical approaches for the treatment of lung cancer.

Introduction to the STS National Database Series: Outcomes Analysis, Quality Improvement, and Patient Safety

The Society of Thoracic Surgeons (STS) National Database is the foundation for most of the Society's quality, research, and patient safety activities. Beginning in January 2016 and repeating each year, The Annals of Thoracic Surgery will publish a monthly Database series of scholarly articles on outcomes analysis, quality improvement, and patient safety. Six articles will be directly derived from the STS National Database and will be published every other month: three articles on outcomes and quality (one each from the STS Adult Cardiac Surgery Database, the STS Congenital Heart Surgery Database, and the STS General Thoracic Surgery Database), and three articles on research (one from each of these three specialty databases). These six articles will alternate with five additional articles on topics related to patient safety. The final article, to be published in December, will provide a summary of the prior 11 manuscripts. This series will allow STS and its Workforces on National Databases, Research Development, and Patient Safety to convey timely information aimed at improving the quality and safety of cardiothoracic surgery.

Differences in reported esophageal cancer resection outcomes between national clinical and administrative databases

The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) is the largest clinical thoracic surgical database in the United States. The purpose of the present study was to determine whether the GTSD esophagectomy outcomes are representative of nationwide outcomes by comparing them with other national clinical and administrative databases. From 2002 to 2008, esophageal cancer resection outcomes from the GTSD were compared with those from the National Surgery Quality Improvement Program (NSQIP) and Nationwide Inpatient Sample (NIS). The observed differences in patient characteristics and postoperative events were also analyzed. Annual esophageal resection volumes have increased over time. However, as of 2008, the GTSD and NSQIP only capture a small proportion of resections performed nationally (36% and 11%, respectively). The median patient age and female gender were similar in all 3 databases. Mortality was significantly lower within the GTSD (3.2%) and NSQIP (2.6%) compared with the NIS (6.1%, P < .001). The median length of stay was lower in the GTSD (10 days) than in either the NSQIP (12 days) and NIS (12 days, P < .001). The STS GTSD reports outstanding mortality results and hospital length of stay for esophageal cancer resection. However, the surgical outcomes from the STS GTSD are not representative of the national results from programs not participating in the database. These results establish a reference for future esophagectomy comparisons and highlight the importance of increased participation and use of the STS GTSD.