title: The burden of death following discharge after lobectomy†.
abstract: OBJECTIVE
  Pulmonary lobectomy is the most commonly performed surgery for lung cancer and remains the gold standard operative treatment. The reported surgical mortality from this procedure rarely differentiates between in-hospital mortality (IHM) and early post-discharge mortality (PDM). We aimed to examine the IHM and 90-day PDM over time and identify outcome predictors including patient characteristics, comorbidity and system-level factors.
  
  
  METHODS
  Data for patients who underwent lobectomy from 2005 to 2011 were acquired from a linked Ontario population-based database. Exclusions included patients undergoing sleeve lobectomy, resections for synchronous lesions, previous lung malignancy and extended length of stay (LOS) over 30 days. We reported proportional mortality and cumulative survival attributable to IHM and PDM with confidence intervals. Multivariate logistic and Cox regression analyses were performed to examine the role of variables associated with IHM and 90-day PDM.
  
  
  RESULTS
  For 5389 patients who underwent lobectomy for non-small-cell lung cancer, the median LOS was 6 (1-30) days. IHM (n = 73) was 1.4% (1.1-1.6%) and PDM (n = 101) was an additional 1.9% (1.6-2.3%) within 90 days post-lobectomy discharge. Logistic regression suggested that age [odds ratio (OR): 1.5 (1.3-1.8)], myocardial infarction [OR: 3.6 (1.8-7.0)], congestive heart failure [OR: 5.8 (2.4-13.8)], chronic obstructive pulmonary disease [OR: 1.9 (1.1-3.2)], preoperative positron emission tomography [OR: 2.7 (1.1-7.0)], peptic ulcer disease [OR: 22.1 (4.1-117.4)], hemiplegia [OR: 15.8 (1.8-141.1)], other primary cancer [OR: 0.5 (0.3-0.8)] and year of surgery [OR: 1.0 (0.8-1.0)] were potential predictors of IHM. Length of hospital stay [hazard ratio (HR): 1.1 (1.0-1.1)], male gender [HR: 1.5 (1.0-2.3)], age [HR: 1.1 (1.0-1.3)] and metastatic cancer [HR: 2.6 (1.7-4.0)] were potential predictors of PDM.
  
  
  CONCLUSIONS
  PDM represents a substantive, under-reported burden of mortality due to lobectomy. More than half of post-lobectomy mortality occurs post-discharge and the annual rate remained unchanged, while IHM decreased with time, suggesting that the improvement seen in mortality might be exclusive to the smaller IHM. Patient factors play a significant role in both IHM and PDM. We emphasize that this identifies the importance of appropriate patient selection, further investigation of risk factors and particular attention to these risk factors during regular follow-up visits to improve PDM in this high-risk patient population.
authors.affiliation: Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
authors.forename: Laura
authors.initials: L
authors.lastname: Schneider
authors.affiliation: Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Forough
authors.initials: F
authors.lastname: Farrokhyar
authors.affiliation: Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
authors.forename: Colin
authors.initials: C
authors.lastname: Schieman
authors.affiliation: Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
authors.forename: Waël C
authors.initials: WC
authors.lastname: Hanna
authors.affiliation: Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
authors.forename: Yaron
authors.initials: Y
authors.lastname: Shargall
authors.affiliation: Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada finleyc@mcmaster.ca.
authors.forename: Christian J
authors.initials: CJ
authors.lastname: Finley
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality* / Q000601:surgery; D005260:Female; D006801:Humans; D016015:Logistic Models; D008175:Lung Neoplasms / Q000401:mortality* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data*; D011013:Pneumonectomy / Q000401:mortality*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors
keywords: Epidemiology; Lobectomy; Mortality; Non-small-cell lung cancer; Outcomes