Real-time monitoring of a video-assisted thoracoscopic surgery lobectomy programme using a specific cardiopulmonary complications risk-adjusted control chart†.
OBJECTIVE
To implement internal monitoring using a risk-adjusted model specific for video-assisted thoracoscopic surgery (VATS) lobectomy.


METHODS
Retrospective analysis on prospectively collected data of 348 patients submitted to VATS lobectomy (August 2012-August 2014). Baseline and surgical variables were tested for a possible association with postoperative cardiopulmonary complications. Logistic regression and bootstrap resampling analyses were used to develop the risk-adjusted model to obtain the predicted morbidity of 50 consecutive patients (September 2014-November 2014). A risk-adjusted control chart was constructed to track down practice variation during this period. Patients were ordered by date of operation and assigned a score represented by the individual predicted morbidity: the plotted line goes up in case of absence of complications and goes down by the predicted morbidity minus 1 in case of complications. Over time, if outcomes are as expected based on the risk-adjusted model, the plotted line will tend to be close to zero.


RESULTS
Cardiopulmonary complications and in-hospital/30-day mortality rates were 14% (47 cases) and 1.8% (6 cases), respectively. Age (P = 0.006, coefficient 0.55, bootstrap frequency 76%) and predicted postoperative forced expiratory volume in 1 s (ppoFEV1) (P < 0.001, coefficient -0.38, bootstrap frequency 98%) remained independently associated with cardiopulmonary morbidity after logistic regression and bootstrap analyses. The following risk logit model for cardiopulmonary morbidity after VATS lobectomy was generated: -3.17 -0.038XppoFEV1 +0.55Xage. The risk-adjusted control chart showed a downward trend indicating a worse than expected performance in the audited period.


CONCLUSIONS
The present analysis offers a methodological template for VATS lobectomy that helps to evaluate the surgical programme. It aims to give a real-time monitoring with the possibility to confront the performance of the centre with the population-specific expectancies. Moreover, being reactive with time, this method allows early detection of underperformance and implementation of critical change in clinical practice.
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK miripat_6@yahoo.it.
Miriam
M
Patella
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK.
Alberto
A
Sandri
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK.
Cecilia
C
Pompili
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK.
Kostas
K
Papagiannopoulos
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK.
Richard
R
Milton
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK.
Nilanjan
N
Chaudhuri
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK.
Emmanuel
E
Kefaloyannis
Department of Thoracic Surgery, St James's University Hospital, Leeds, UK.
Alessandro
A
Brunelli
D000368:Aged; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D008168:Lung / Q000503:physiopathology / Q000601:surgery; D008175:Lung Neoplasms / Q000503:physiopathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D011013:Pneumonectomy / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data*
Lung cancer; Risk modelling; Thoracoscopic lobectomy; Variable life-adjusted display chart