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J Thorac Cardiovasc Surg 1999;117:969-979
© 1999 Mosby, Inc.

GENERAL THORACIC SURGERY

PROGNOSTIC MODELS OF THIRTY-DAY MORTALITY AND MORBIDITY AFTER MAJOR PULMONARY RESECTION

David H. Harpole, Jr, MD, Malcolm M. DeCamp, Jr, MD, Jennifer Daley, MD, Kwan Hur, MS, Charles A. Oprian, PhD, William G. Henderson, PhD, Shukri F. Khuri, MD, Participants in the National Veterans Affairs Surgical Quality Improvement Program

From the Veterans Affairs Medical Center/Harvard Medical School, Brockton/West Roxbury, Mass; the Veterans Affairs Medical Center/Duke University Medical Center, Durham, NC; and the Cooperative Studies Program Coordinating Center, Veterans Affairs Medical Center, Hines, Ill.

Supported by the Department of Veterans Affairs Office of Patient Care Services, the Health Services Research and Development Service, and the Cooperative Studies Program. Jennifer Daley, MD, is a Senior Research Associate in the Career Development Award Program of the Health Services Research and Development of the Department of Veterans Affairs.

Presented in part at the Thirtieth Annual Session of The Society of Thoracic Surgeons, Palm Springs, Calif, 1995.

Received for publication May 27, 1998. Revisions requested Sept 10, 1998. Revisions received Dec 10, 1998. Accepted for publication Jan 12, 1999. Address for reprints: David H. Harpole, Jr, MD, Chief, Cardiothoracic Surgery, Durham VA Medical Center, 10 Fulton St, Durham, NC 27705.

Background:A part of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program was developed to predict 30-day mortality and morbidity for patients undergoing a major pulmonary resection. Methods: Perioperative data were acquired from 194,319 noncardiac surgical operations at 123 Veterans Affairs Medical Centers between October 1, 1991, and August 31, 1995. Current Procedural Terminology code-based analysis was undertaken for major pulmonary resections (lobectomy and pneumonectomy). Preoperative, intraoperative, and outcome variables were collected. The 30-day mortality and morbidity models were developed by means of multivariable stepwise logistic regression with the preoperative and intraoperative variables used as independent predictors of outcome. Results: A total of 3516 patients (mean age 64 ± 9 years) underwent either lobectomy (n = 2949) or pneumonectomy (n = 567). Thirty-day mortality was 4.0% for lobectomy (119/2949) and 11.5% for pneumonectomy (65/567). The preoperative predictors of 30-day mortality were albumin, do not resuscitate status, transfusion of more than 4 units, age, disseminated cancer, impaired sensorium, prothrombin time more than 12 seconds, type of operation, and dyspnea. When the intraoperative variables were considered, intraoperative blood loss was added to the preoperative model. In the presence of these intraoperative variables in the model, do not resuscitate status and prothrombin time more than 12 seconds were only marginally significant. Thirty-day morbidity, defined as the presence of 1 or more of the 21 predefined complications, was 23.8% for lobectomy (703/2949) and 25.7% for pneumonectomy (146/567). In multivariable models, independent preoperative predictors (P < .05) of 30-day morbidity were age, weight loss greater than 10% in the 6 months before surgery, history of chronic obstructive pulmonary disease, transfusion of more than 4 units, albumin, hemiplegia, smoking, and dyspnea. When intraoperative variables were added to the preoperative model, the duration of operation time and intraoperative transfusions were included in the model and albumin became marginally significant. Conclusions: This analysis identifies independent patient risk factors that are associated with 30-day mortality and morbidity for patients undergoing a major pulmonary resection. This series provides an initial risk-adjustment model for major pulmonary resections. Future refinements will allow comparative assessment of surgical outcomes and quality of care at many institutions.




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