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Ann Thorac Surg 1997;63:321
© 1997 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, University of Florida Health Science Center, Jacksonville, Florida, and Emory University Clinic, Atlanta, Georgia
It has become a well-accepted fact that statistical algorithms can be used to predict important elements of clinical care. Early applications of this concept were based on Bayesian theory and focused on "computer-assisted diagnosis" [1]. Later, it became apparent that these algorithms could be used to predict patient postoperative status, spawning the relatively new field of "operative risk assessment."
The compelling need for sophisticated risk assessment in cardiac surgery has been recognized for several years and has become an integral part of the practice of cardiac surgery. The recent trend whereby managed care groups as well as various regulatory agencies require detailed reporting of operative results has further emphasized the need for refined risk-adjusted outcome analysis in cardiac surgery [2].
On the other hand, there is less of a perceived need for risk assessment in pulmonary surgery. Several important events occurring within the past year indicate that this perception should change. In his Presidential Address to The Society of Thoracic Surgeons (STS) [3], Dr John R. Benfield urged the membership to develop meaningful risk assessment techniques in general thoracic surgery. In response to this charge, selected leaders of the STS National Database Committee have formulated a protocol to gather appropriate patient data from a variety of centers performing pulmonary cancer surgery. These patient data will be analyzed to develop both diagnostic and prognostic models. Specifically, the models will be designed to assist the surgeon by providing predictions of (1) the probability of cancer in a pulmonary lesion, (2) the probability of resectability, (3) the probability of postoperative mortality, and (4) the probability of postoperative morbidity.
Certainly this represents uncharted water, and we may find that pulmonary surgery does not lend itself to this kind of statistical analysis. We consider this quite unlikely and fully anticipate that thoracic surgeons will come to find statistical diagnostic and outcome analysis to be a valuable adjunct in the assessment of patients undergoing pulmonary cancer operations.
Lung volume reduction surgery may well be another area in which outcomes analysis can be particularly valuable. Currently there is considerable debate regarding which patients benefit from this form of intervention. If significant patient risk factors can be identified and a reasonable volume of patients can be registered into an appropriate database, it should be possible to use statistical algorithms to predict both operative mortality and patient benefit. Such information could be quite useful when combined with sound clinical judgement in the evaluation of candidates for lung volume reduction surgery.
The STS National Database Committee will soon complete the module for pulmonary surgery and offer this option to participating members. As with the cardiac surgery module, a brief form should be completed for each patient undergoing operation. The form will contain information regarding patient demographics, clinical characteristics, and operative outcomes. After accumulation of an adequate amount of data, statistical models will be developed to provide subscribers with diagnostic and prognostic information for individual patients. This information may then be used for patient counseling, medical decision-making, and outcome analysis.
The STS National Database Committee recognizes that many subscribers will encounter the need to quickly reply to managed care groups and governmental agencies requiring detailed information on operative results, length of stay, and cost containment. The database will have this type of information readily available, allowing individual subscribers to respond to these organizations not only with the obligatory demographic "bean-counting" but also with comprehensive information on national norm comparisons and sophisticated risk-adjusted outcomes analysis. By taking a proactive approach, thoracic surgeons will determine the important issues to be addressed rather than have these issues dictated to us by a myriad of administrative agencies.
In addition, Dr Benfield has emphasized that the accumulation of an aggregate national experience in general thoracic surgery will likely benefit the entire thoracic surgery community [3]. Such a repository of information should provide uncontestable evidence that "patients whose operations are done by thoracic surgeons suffer fewer complications and get well more quickly and with a better outcome than do patients whose care is rendered by less well educated surgeons" [3]. This, in turn, should prompt health care agencies to "insist that thoracic surgery be done by fully educated thoracic surgeons" [3].
To obtain this information an inevitable administrative and financial obligation falls upon the surgeon, but this seems a small price to pay for the considerable benefit. As with the cardiac surgery database, the success of a pulmonary surgery database will depend on the acceptance and participation of the STS membership. Such participation deserves the serious consideration of all members. The STS Database Committee welcomes comments and suggestions dealing with both the development and the implementation of this module. To facilitate your input, the STS Web site (http://www.sts.org) will soon provide a new page devoted to important issues on this topic.
Footnotes
Address reprint requests to Dr Edwards, Division of Cardiothoracic Surgery, University of Florida Health Science Center, 653-2 W Eighth St, Jacksonville, FL 32209-6511.
References
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