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Purpose of Review: Lung cancer is the leading cause of cancer-related death in the United States. Pulmonary resection, in addition to perioperative systemic therapies, is a cornerstone of treatment for operable patients with early-stage and locoregional disease. In recent years, increased emphasis has been placed on surgical quality metrics: specific and evidence-based structural, process, and outcome measures that aim to decrease variation in lung cancer care and improve long term outcomes. These metrics can be divided into potential areas of intervention or improvement in the preoperative, intraoperative, and postoperative phases of care and form the basis of guidelines issued by organizations including the National Cancer Center Network (NCCN) and Society of Thoracic Surgeons (STS). This review focuses on established quality metrics associated with lung cancer surgery with an emphasis on the most recent research and guidelines., Recent Findings: Over the past 18 months, quality metrics across the peri-operative care period were explored, including optimal invasive mediastinal staging preoperatively, the extent of intraoperative lymphadenectomy, surgical approaches related to minimally invasive resection, and enhanced recovery pathways that facilitate early discharge following pulmonary resection., Summary: Quality metrics in lung cancer surgery is an exciting and important area of research. Adherence to quality metrics has been shown to improve overall survival and guidelines supporting their use allows targeted quality improvement efforts at a local level to facilitate more consistent, less variable oncologic outcomes across centers., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Pulmonary metastasectomy (PM) for colorectal cancer may provide respite from systemic therapy and prolonged disease-free intervals. We sought to identify factors associated with PM and to characterize the differential impact on overall survival for those offered lung resection., Methods: The National Cancer Database was queried for stage IV colorectal cancer patients with lung-limited metastatic disease between 2010 and 2016. Among patients who underwent primary tumor resection, those who underwent PM were compared with those who did not. Penalized regression with the least absolute selection and shrinkage operator was used to determine factors associated with receiving metastasectomy as well as overall survival., Results: In total, 867 (15.1%) patients underwent resection of both primary tumor and pulmonary metastases whereas 4864 (84.8%) had primary tumor resection alone. In unadjusted analyses, metastasectomy patents were younger, more often privately insured, more educated, and traveled farther to receive care (all P < .001). In multivariable analyses, younger age, traveling >25 miles, and care at high-volume hospitals were associated with PM (P < .01). In addition, primary site surgery without PM was associated with worse overall survival (hazard ratio, 1.35; confidence interval, 1.23-1.49), even after adjusting for patient, tumor, and hospital-related factors., Conclusions: Patients who were older, who received care closer to home, and who were treated at low-volume hospitals were less likely to receive metastasectomy for lung-limited colorectal cancer after definitive resection of their primary tumor. Failure to receive PM resulted in worse overall survival, emphasizing the strong need for efforts to provide uniform, equitable care to all patients., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We have previously demonstrated that Enhanced Recovery After Surgery protocols are associated with a reduction in pulmonary complications. As a component of enhanced recovery pathways, intercostal nerve blocks with liposomal bupivacaine are increasingly utilized, but the extent to which this element may contribute to such outcomes has not been evaluated., Methods: Patients undergoing lung resection for stage I to III non-small cell lung cancer at a single institution from 2006 to 2017 were examined for major postoperative pulmonary morbidity, defined as pneumonia, acute respiratory distress syndrome, respiratory arrest, reintubation, bronchoscopy, or need for discharge with oxygen. Pharmacy records were queried for administration of liposomal bupivacaine via posterior intercostal nerve block. Patients treated with and without liposomal bupivacaine were compared in a logistic regression to determine the impact on pulmonary morbidity., Results: A total of 2865 patients were identified, including 860 (30%) who were treated with liposomal bupivacaine via posterior intercostal block. Pulmonary morbidity occurred in 455 (16%). Adoption of liposomal bupivacaine analgesia occurred over several years, beginning in 2012 to full adoption by 2017. Liposomal bupivacaine management was associated with a reduction in pulmonary complications, as compared with nonuse (odds ratio, 0.63; P = .006). Additional factors associated with the occurrence of pulmonary morbidity were age, body mass index, smoking, spirometry values, and operative blood loss., Conclusions: As a component of an active enhanced recovery program, liposomal bupivacaine is associated with a reduction in major pulmonary complications, and utilization should be evaluated on a hospital-by-hospital basis., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Websites are primary sources of information for prospective trainees. However, little is known regarding the information deemed most important to cardiothoracic (CT) surgery interviewees when evaluating a program. The objectives of this study were to (1) report informational content important to CT surgery interviewees on a fellowship website and (2) improve the quality of a specific program's website., Methods: Study investigators conducted a survey of interviewees at a traditional 2-year CT surgery fellowship program. Questions were asked to elicit what information interviewees considered important to include in a program website and to identify gaps in the website's content. After administering the survey to 2018 fellowship interviewees, the website was redesigned, and the survey was readministered to 2019 fellowship interviewees., Results: A total of 49 interviewees completed the survey (response rate, 90.7%); 45 (91.8%) of these interviewees had previously visited the program's website. Interviewees reported that the most important information they sought when accessing fellowship websites included faculty profiles (n = 47), rotation schedules (n = 33), current fellows' profiles (n = 29), and past fellows' profiles (n = 26). The website was revamped to include content across each of these domains. After website redesign, there was significant improvement in interviewees reporting that they found the information they sought (mean score, 3.56 to 4.64; P < .001) and that the website was useful (mean score, 3.67 to 4.77; P < .001) compared with the previous year., Conclusions: CT surgery fellowship websites are accessed by the majority of interviewees and are a critical source of program information. Optimizing website design and content on the basis of survey feedback objectively improved the usefulness of the program website to interviewees., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) expanded restrictions on resident duty hours. While studies have shown no association between these restrictions and improved outcomes, process-of-care and patient experience measures may be more sensitive to resident performance, and thus may be impacted by duty hour policies. The objective of this study was to evaluate the association between the 2011 resident duty hour reform and measures of processes-of-care and patient experience., Methods: Hospital Consumer Assessment of Healthcare Providers and Systems survey data and process-of-care scores were obtained from the Centers for Medicare and Medicaid Services Hospital Compare website for 1 year prior to (1 July 2010 to 30 June 2011) and 1 year after (1 July 2011 to 30 June 2012) duty hour reform implementation. Using a difference-in-differences model, non-teaching and teaching hospitals were compared before and after the 2011 reform to test the association of this policy with changes in process-of-care and patient experience measure scores., Results: Duty hour reform was not associated with a change in the five patient experience measures evaluated, including patients rating a hospital 9 or 10 (coefficient -0.003, 95% CI -0.79 to 0.79) or stating they would 'definitely recommend' a hospital (coefficient -0.28, 95% CI -1.01 to 0.44). For all 10 process-of-care measures examined, such as antibiotic timing (coefficient -0.462, 95% CI -1.502 to 0.579) and discontinuation (0.188, 95% CI -0.529 to 0.904), duty hour reform was not associated with a change in scores., Conclusions: The 2011 ACGME duty hour reform was not associated with improvements in process-of-care and patient experience measures. These data should be considered when considering reform of resident duty hour policies., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Localized hepatocellular carcinoma (HCC) in patients with adequate liver function is typically treated with resection. Non-surgical modalities including trans-arterial embolization have emerged as options for intermediate/advanced HCC. Hypothesizing that non-surgical techniques have expanded to localized disease, we examined treatment patterns, factors associated with surgical therapy, and the impact of modality on survival., Methods: Non-cirrhotic, localized HCC patients were identified from the National Cancer Data Base (2003-2011). Trends were examined using average annual percent change (AAPC). Regression models were developed to determine factors associated with treatment and assess the association of modality with survival., Results: Of 10,187 patients (median tumor size: 3.7 cm), 6,387 (62.7%) underwent surgery and 3,800 (37.3%) non-surgical therapy. Surgery declined from 61.6% to 44.5% (AAPC, -3.7%; 95%CI, -4.9% to -2.6%, P < 0.001). Non-surgical therapies increased from 17.2% to 39.2% (AAPC 11.4%; 95%CI, 8.8-14.1%, P < 0.001). White race, higher income, and treatment in an academic center (OR = 1.37, 95%CI 1.13-1.66) were associated with surgery. Patients selected for non-surgical therapy had worse adjusted 5-year survival (HR=2.05, 95%CI 1.85-2.26)., Conclusions: Non-surgical therapy has become as common as surgery in the treatment of non-cirrhotic, localized HCC. Randomized studies are needed to compare the effectiveness of treatments for this disease., (© 2015 Wiley Periodicals, Inc.)

Objectives: Our objectives were to (1) assess readmission rates and timing after pulmonary resection, (2) report the most common reasons for rehospitalization, and (3) identify risk factors for unplanned readmission after pulmonary resection., Methods: Patients who underwent pulmonary resection were identified from the 2011 American College of Surgeons National Surgical Quality Improvement Program database. We examined readmission within 30 days of surgery for all resections and 3 subgroups: open lobectomy, video-assisted thoracoscopic lobectomy, and pneumonectomy. Regression models were developed to identify factors associated with readmission., Results: In 1847 patients, there were 899 open lobectomies (49%), 724 video-assisted thoracoscopic lobectomies (39%), and 85 pneumonectomies (5%). The overall readmission rate was 9.3% with no significant difference found among patients undergoing open lobectomy (9.1%), video-assisted thoracoscopic lobectomy (8.4%), or pneumonectomy (11.8%) (P = .576). The median time from operation to readmission was similar among patients undergoing open (14 days) or video-assisted thoracoscopic lobectomy (13 days). The most common cause of readmission for all groups examined was pulmonary related. In multivariable analyses, the strongest factor associated with readmission was an inpatient complication after the initial surgery in all resections (hazard ratio [HR], 4.29; 95% confidence interval [CI], 3.05-6.04), open lobectomy (HR, 4.36; 95% CI, 2.75-6.94), and video-assisted thoracoscopic lobectomy (HR, 4.60; 95% CI, 2.65-7.97). Surgical approach was not associated with readmission (video-assisted thoracoscopic vs open lobectomy: HR, 1.07; 95% CI, 0.75-1.52)., Conclusions: Experiencing a postoperative complication was strongly associated with unplanned readmission. Increased attention toward reducing postoperative complications and earlier outpatient follow-up in these patients may be a viable strategy for decreasing readmissions after pulmonary resection., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: In fiscal year (FY) 2015, the Centers for Medicare & Medicaid Services (CMS) instituted the Hospital-Acquired Condition (HAC) Reduction Program, which reduces payments to the lowest-performing hospitals. However, it is uncertain whether this program accurately measures quality and fairly penalizes hospitals., Objective: To examine the characteristics of hospitals penalized by the HAC Reduction Program and to evaluate the association of a summary score of hospital characteristics related to quality with penalization in the HAC program., Design, Setting, and Participants: Data for hospitals participating in the FY2015 HAC Reduction Program were obtained from CMS' Hospital Compare and merged with the 2014 American Hospital Association Annual Survey and FY2015 Medicare Impact File. Logistic regression models were developed to examine the association between hospital characteristics and HAC program penalization. An 8-point hospital quality summary score was created using hospital characteristics related to volume, accreditations, and offering of advanced care services. The relationship between the hospital quality summary score and HAC program penalization was examined. Publicly reported process-of-care and outcome measures were examined from 4 clinical areas (surgery, acute myocardial infarction, heart failure, pneumonia), and their association with the hospital quality summary score was evaluated., Exposures: Penalization in the HAC Reduction Program., Main Outcomes and Measures: Hospital characteristics associated with penalization., Results: Of the 3284 hospitals participating in the HAC program, 721 (22.0%) were penalized. Hospitals were more likely to be penalized if they were accredited by the Joint Commission (24.0% accredited, 14.4% not accredited; odds ratio [OR], 1.33; 95% CI, 1.04-1.70); they were major teaching hospitals (42.3%; OR, 1.58; 95% CI, 1.09-2.29) or very major teaching hospitals (62.2%; OR, 2.61; 95% CI, 1.55-4.39; vs nonteaching hospitals, 17.0%); they cared for more complex patient populations based on case mix index (quartile 4 vs quartile 1: 32.8% vs 12.1%; OR, 1.98; 95% CI, 1.44-2.71); or they were safety-net hospitals vs non-safety-net hospitals (28.3% vs 19.9%; OR, 1.36; 95% CI, 1.11-1.68). Hospitals with higher hospital quality summary scores had significantly better performance on 9 of 10 publicly reported process and outcomes measures compared with hospitals that had lower quality scores (all P ≤ .01 for trend). However, hospitals with the highest quality score of 8 were penalized significantly more frequently than hospitals with the lowest quality score of 0 (67.3% [37/55] vs 12.6% [53/422]; P < .001 for trend)., Conclusions and Relevance: Among hospitals participating in the HAC Reduction Program, hospitals that were penalized more frequently had more quality accreditations, offered advanced services, were major teaching institutions, and had better performance on other process and outcome measures. These paradoxical findings suggest that the approach for assessing hospital penalties in the HAC Reduction Program merits reconsideration to ensure it is achieving the intended goals.

Importance: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training., Objective: To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance., Design, Setting, and Participants: Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period., Exposures: National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs., Main Outcomes and Measures: Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance., Results: In the main analysis, 204,641 patients were identified from 23 teaching (n = 102,525) and 31 nonteaching (n = 102,116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period., Conclusions and Relevance: Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.

Background: In October 2012, The Centers for Medicare and Medicaid Services (CMS) began publicly reporting American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical outcomes on its public reporting website, Hospital Compare. Participation in this CMS-NSQIP initiative is voluntary. Our objective was to compare CMS-NSQIP participating hospitals with ACS NSQIP hospitals that elected not to participate., Study Design: Hospital Compare and American Hospital Association Annual Survey data were merged to compare CMS-NSQIP participants with nonparticipants. Regression models were developed to assess predictors of participation and to assess if hospitals differed on 32 process, 10 patient experience (Hospital Consumer Assessment of HealthCare Providers and Systems [HCAHPS]), and 16 outcomes (Hospital Compare and Agency for Healthcare Research Quality) measures. Additionally, performance on 2 waves of publicly reported ACS NSQIP surgical outcomes measures was compared., Results: Of the 452 ACS NSQIP hospitals, 80 (18%) participated in CMS-NSQIP public reporting. Participating hospitals had more beds, admissions, operations, and were more often accredited (Commission on Cancer and the Council of Teaching Hospitals [COTH] [p < 0.05]). Only COTH membership remained significant in adjusted analyses (odds ratio 2.45, 95% CI 1.12 to 5.35). Hospital performance on process, HCAHPS, and outcomes measures were not associated with CMS-NSQIP participation for 54 of 58 measures examined. Hospitals with "better-than-average" performance were more likely to publicly report the Elderly Surgery measure (p < 0.05). In wave 2, an increased proportion of new participants reported "worse-than-average" outcomes., Conclusions: There were few measurable differences between CMS-NSQIP participating and nonparticipating hospitals. The decision to voluntarily publicly report may be related to the hospital's culture of quality improvement and transparency., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the performance of the American-European Consensus Group (AECG) and the newly proposed American College of Rheumatology (ACR) classification criteria for Sjögren's Syndrome (SS) in a well-characterised sicca cohort, given ongoing efforts to resolve discrepancies and weaknesses in the systems., Methods: In a multidisciplinary clinic for the evaluation of sicca, we assessed features of salivary and lacrimal gland dysfunction and autoimmunity as defined by tests of both AECG and ACR criteria in 646 participants. Global gene expression profiles were compared in a subset of 180 participants., Results: Application of the AECG and ACR criteria resulted in classification of 279 and 268 participants with SS, respectively. Both criteria were met by 244 participants (81%). In 26 of the 35 AECG+/ACR participants, the minor salivary gland biopsy focal score was ≥1 (74%), while nine had positive anti-Ro/La (26%). There were 24 AECG-/ACR+ who met ACR criteria mainly due to differences in the scoring of corneal staining. All patients with SS, regardless of classification, had similar gene expression profiles, which were distinct from the healthy controls., Conclusions: The two sets of classification criteria yield concordant results in the majority of cases and gene expression profiling suggests that patients meeting either set of criteria are more similar to other SS participants than to healthy controls. Thus, there is no clear evidence for increased value of the new ACR criteria over the old AECG criteria from the clinical or biological perspective. It is our contention, supported by this report, that improvements in diagnostic acumen will require a more fundamental understanding of the pathogenic mechanisms than is at present available.