Clinical impact of lung age on postoperative readmission in non–small cell lung cancer

doi:10.1016/j.jss.2014.08.028

Journal of Surgical Research

Volume 193, Issue 1, January 2015, Pages 442-448

https://doi.org/10.1016/j.jss.2014.08.028 Get rights and content

Abstract

Background

Recently, the Japanese Respiratory Society (JRS) proposed using lung age (LA) as an indicator of lung function; however, reports regarding the association of LA with the risk of postoperative readmission within 90 d after surgical treatment for non–small cell lung cancer (NSCLC) are limited. Here, we analyze the clinical relationship between LA and readmission within 90 d after surgical treatment for NSCLC.

Methods

A total of 979 patients underwent curative resections for NSCLC from January 2000–September 2012 at the Kitasato University Hospital. We selected patients who required readmission because of surgical complications within 90 d of surgery and retrospectively analyzed various clinical data. LA was calculated based on the formula given by the Japanese Respiratory Society, which relies on preoperative respiratory function. We also calculated the age gap (AG) between the calculated LA and the true age (TA).

Results

There were 216 patients who needed to be readmitted within 90 d of surgery, 33 (3%) of whom were hospitalized for surgical complications. Twenty-four patients (73%) had respiratory complications, and 7 patients (21%) died. There were significant differences between the readmitted and no readmitted patients in terms of preoperative factors, such as gender, LA, AG, smoking status, and smoking index (P < 0.05). In addition, there were significant differences in intraoperative blood loss, postoperative complications, histologic type, duration of hospitalization, and hospitalization after surgery (P < 0.05). Multivariate analysis using logistic regression indicated that LA, AG, blood loss, and postoperative complications were independent factors that predicted readmission. Additionally, the 5-y survival rates were 78% and 44% for the no readmitted and readmitted groups, respectively (P < 0.001).

Conclusions

The AG between TA and LA was significantly associated with postoperative complications and remained an independent predictive factor after multiple regressions. LA was shown to be a useful factor for predicting the risk of surgery-related readmission within 90 d after surgery for NSCLC.

Introduction

The ultimate goal of thoracic oncological surgery is the curative resection of the cancer without significant surgery-associated postoperative morbidity or mortality. Although rare, early, unplanned, surgery-related hospital readmission after curative lung resection for non–small cell lung cancer (NSCLC) can result in surgery-associated death. Preoperative intervention to decrease the risk of postoperative readmission could therefore be of substantial benefit. However, there is a paucity of information on readmission rates among surgical patients, with most existing studies focusing on procedure-specific readmission rates within specific patient populations [1], [2], [3], [4].

For this study, we considered the novel concept of whether an association existed between lung age (LA) and readmission [5]. LA is based on an original formula developed by Morris and Temple that allows an individual's age to be calculated by rearranging the regression equation that was constructed to predict the normal reference value of forced expiratory volume at 1 s (FEV₁) [6]. This LA calculation was first reported at the lung physiology special-member meeting of the Japanese Respiratory Society (JRS) in 2001 [5]. The respiratory function test (RFT) for measuring individual FEV₁ values is routinely performed preoperatively on lung cancer patients to assess surgical risk. Additionally, not only is LA easily understood by both clinicians and patients, but assessing the difference between LA and true age (TA) is useful and convenient for predicting both respiratory complications and prognosis [7]. Few studies, however, have reported on the suitability of using this new concept in lung cancer surgery.

A previous report suggested that hospital length of stay, comorbidities, and postoperative complications are each significantly associated with rates of readmission [8]. Therefore, we retrospectively analyzed the relationship between surgical results and the risk factors for surgery-related readmission in patients who underwent curative resection for NSCLC, and evaluated whether LA was related to clinical outcomes. The purpose of the study was to better understand which factors are most commonly associated with readmission.

Section snippets

Patients

A total of 3269 cases involving patients who presented with lung cancer at the Kitasato University Hospital from January 2000–September 2012 were reviewed. Of these, 979 patients underwent curative pulmonary resection inducing lobectomy, bilobectomy, and pneumonectomy with open thoracotomy for NSCLC. Preoperative risk factors, intraoperative variables, and the 90-d postoperative morbidity and mortality outcomes were analyzed in these cases to identify unplanned readmissions within 90 d of

Results

Of the 979 patients who underwent surgical treatment, there were a total of 216 patients who needed to be readmitted within 90 d of surgery. The reason for readmission included adjuvant therapy, other diseases, or surgical complications. Thirty-three patients (28 males and 5 females) were readmitted to our hospital within 90 d of curative surgery for NSCLC. In most cases, readmission was caused by respiratory symptoms (respiratory disorder, 24 cases; fever up, 4 cases; surgical site infection,

Discussion

This study revealed that the AG between TA and LA may be a useful predictor of readmission within 90 d of surgical treatment in NSCLC patients undergoing curative lung resection. In multiple logistic regressions, LA, AG, blood loss, and postoperative complications were independent factors for surgery-related readmission within 90 d after NSCLC surgery. The readmission rate was 3.4% after major thoracic oncological surgery, and these patients had a hospital mortality rate of 21.2% for

Conclusions

In conclusion, the AG between TA and LA was significantly associated with readmission within 90 d after curative lung resection and remained an independent predictor in a preoperative routine survey after multiple logistic regressions. We propose that LA and AG deserve greater consideration as preoperative predictors of readmission within 90 d of curative lung resection and of prognoses in NSCLC patients. We also suggest that these parameters are simple, noninvasive, and can assist both

Acknowledgment

Authors' contributions: F.O. wrote the article and collected references. M.M. coordinated the work of all authors. F.O., Y.S., A.I., and H.A. performed the operations and provided all necessary clinical support. F.O. conducted the statistical analyses for the article. Y.K. and M.M. helped draft the article. All authors read and approved the final article.

The authors declare that they have no conflicts of interest.

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Readmissions after lung resection in France: The PMSI database
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Les réadmissions dans les 30 jours constituent un indicateur de la qualité des soins, car elles reflètent souvent une prise en charge après la sortie qui n’est pas optimale. L’objectif de ce travail est de mesurer au cours du temps d’une part le taux de réadmissions, et d’autre part le nombre d’hôpitaux ayant un taux standardisé de réadmission au-delà des limites par rapport à la moyenne nationale.
Tous les patients ayant une résection pulmonaire majeure pour un cancer du poumon en France ont été extraits de la base de données nationale du Programme de médicalisation des systèmes d'information (PMSI). La réadmission dans les 30 jours était définie comme toute nouvelle hospitalisation soit dans le même hôpital soit dans un autre établissement.
Du 1^er janvier 2005 au 31 décembre 2018, 110 603 patients ont été inclus. Le taux de réadmissions toutes causes confondues à 30 jours était de 24,9 % (n = 27 540). Les patients après une pneumonectomie avaient un taux de réadmission de 37 % (n = 4918) et 23 % après une lobectomie (n = 2684) (p < 0,0001). Pour la première période, nous avons comptabilisé 10 hôpitaux avec un taux standardisé de réadmissions se situant au-delà de la limite de 99,8 % et 10 hôpitaux au-delà de la limite de 95 %. Pour la deuxième période, 8 hôpitaux avaient un taux standardisé de réadmissions se situant au-delà de la limite de 99,8 % et 11 hôpitaux au-delà de la limite de 95 %. Pour la troisième période, 7 hôpitaux avaient un taux standardisé de réadmissions se situant au-delà de la limite de 99,8 % et 6 hôpitaux au-delà de la limite de 95 %.
Les réadmissions à l’hôpital 30 jours après une résection pulmonaire majeure pour cancer en France ont peu diminué durant ces trois périodes. Des mesures pour prévenir les réadmissions devraient être instaurées en France.
Readmission within 30 days is an indicator of the quality of care, because it often reflects post-discharge care that is not optimal. The objective of this work is to measure over time on the one hand the readmission rate and on the other hand the number of hospitals with a standardized readmission rate beyond the national average.
All patients with major pulmonary resection for lung cancer in France were extracted from the PMSI national database. Readmission within 30 days was defined as any new hospitalization either in the same hospital or in another establishment.
From January 1, 2005 to December 31, 2018, 110,603 patients were included. The 30-day all-cause readmissions rate was 24.9% (n = 27,540). Patients after pneumonectomy had a readmission rate of 37% (n = 4918) and 23% after lobectomy (n = 2684) (P < 0.0001). For the first period, we counted 10 hospitals with a standardized readmissions rate above the 99.8 limit and 10 hospitals above the 95% limit. For the second period, 8 hospitals had a standardized readmission rate above the 99.8% limit and 11 hospitals above the 95% limit. For the third period, 7 hospitals had a standardized readmission rate above the 99.8% limit and 6 hospitals above the 95% limit.
Readmissions to hospital 30 days after major lung resection for cancer in France declined little during these three periods. Measures to prevent readmissions should be introduced.
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Urgent readmissions have a major impact on outcomes in patient health and healthcare costs. The associated risk factors have generally been infrequently studied. The main objective of the present work is to identify pre- and perioperative determinants of readmission; the secondary aim was to determine readmission rate, identification of readmission diagnoses, and impact of readmissions on survival rates in related analytical studies.
The review was performed through a systematic search in the main bibliographic databases. In the end, 19 papers met the selection criteria.
The main risk factors were: sociodemographic patient variables; comorbidities; type of resection; postoperative complications; long stay.
Despite the great variability in the published studies, all highlight the importance of reducing readmission rates because of the significant impact on patients and the healthcare system.
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Patients undergoing surgery for clinical stage I to III non–small cell lung cancer were abstracted from the National Cancer Database. Regression models were fitted to identify predictors of 30-day readmission and to study the association of unplanned readmission with 30-day and long-term survival.
Between 1998 and 2010, 129,893 patients underwent resection for stage I to III non–small cell lung cancer. Of these, 5624 (4.3%) were unexpectedly readmitted within 30 days. In a multivariate regression model, increasing age, male gender, preoperative radiation, and pneumonectomy (odds ratio, 1.77; 95% confidence interval, 1.56-2.00) were associated with unexpected readmissions. Longer index hospitalization and higher Charlson comorbidity score were also predictive of readmission. The 30-day mortality for readmitted patients was higher (3.9% vs 2.8%), as was the 90-day mortality (7.0% vs 3.3%, both P < .001). In a multivariate Cox proportional hazards model of long-term survival, increasing age, higher Charlson comorbidity score, and higher pathologic stage (hazard ratio, for stage III 1.81; 95% confidence interval, 1.42-2.29) were associated with greater risk of mortality. Unplanned readmission was independently associated with a higher risk of long-term mortality (hazard ratio, 1.40; 95% confidence interval, 1.34-1.47). The median survival for readmitted patients was significantly shorter (38.7 vs 58.5 months, P < .001).
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ThoracicClinical impact of lung age on postoperative readmission in non–small cell lung cancer

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Conclusions

Acknowledgment

J Gastrointest Surg: official J Soc Surg Aliment Tract

JACC Cardiovasc Interv

J Am Coll Surgeons

Prev Med

J Am Coll Surgeons

Ann Thorac Surg

Chest

Chest

Lancet

Chest

The J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

Thoracic
Clinical impact of lung age on postoperative readmission in non–small cell lung cancer