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Objectives: This study assessed the validity of surveys for identifying the best coronary artery bypass surgeons., Methods: Data on physicians who performed coronary artery bypass surgery were available from New York, Pennsylvania, and Wisconsin. Data on physicians' reputation were obtained from one national and five city surveys. The measure of surgical performance was the mortality ratio (MR), that is, the ratio of the observed to the predicted patient mortality rate., Results: Mortality ratios were very similar for the 10,722 patients treated by the 31 surgeons defined as "best" doctors in the surveys (MR = 98) and for the 74,854 patients treated by 243 other surgeons who had more than a minimal number of cases (MR = .96). The mortality ratio was 1.34 for the patients treated by surgeons with the lowest volumes and .87 for the surgeons who performed more than 400 coronary artery bypass surgeries in 3 years., Conclusions: These results suggest that the quality of a coronary artery bypass surgeon may be more closely associated with patient volume than with the surgeon's reputation among peers.

The factors that influence decision making among surgeons are not well understood. We evaluated how tumor stage in patients subjected to potentially curative surgery for lung cancer affects the self-reported follow-up strategies employed by practicing surgeons. Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to the 3,700 members of the Society of Thoracic Surgeons. The effect of TNM stage on the surveillance strategies chosen by the respondents was analyzed. All of the ten most commonly employed surveillance modalities were ordered significantly more frequently with increasing TNM stage, although the differences are small. Only 23% of respondents modified their strategies according to the patient's TNM stage. This effect persisted through 5 years of follow-up. We conclude that most surgeons performing surveillance after potentially curative surgery for otherwise healthy patients with lung cancer use the same follow-up strategy irrespective of TNM stage. These data should help in the design of prospective trials of this topic.

Bronchoplastic procedures involving the main carina are declared as central bronchoplasties. A nation-wide collection of these interventions performed between 1980 and 1993 is analysed. The study is on a total of 154 operations, that were 16 bifurcation resections and 14 stem bronchus resections without parenchyma sacrifice, 61 sleeve or wedge pneumonectomies and 63 tracheal sleeve or wedge right upper lobectomies or carina-plasties. Surgery alone-without multimodality therapy-was the choice of treatment almost exclusively. About 90% of these interventions were performed for highly malignant, histologically peripheral-type, but centrally located bronchial cancers. The hospital mortality and morbidity were found up to 30% (an average of appr. 17%), depending on surgical subsets. Cause of death were surgical at 11% (leakage, anastomotic dehiscence and bleeding) and non surgical at 5.8% respectively. Complications at another 9% were related to surgery. Data of survival suggest, that nodal state is the strongest predictor, but the unfavourable N2 group comprises longer survivors as well. Certain part of this kind of interventions is to be chosen without alternatives (isolated tracheobronchial resections without parenchyma-resection, extended pneumonectomies) while extended lobectomies are alternatives of the extended pneumonectomies in strict conditions. A central bronchoplastic procedure is justified only with hope of complete resection for its high complication rate.

Background: Reports on the comparative performance of physicians are becoming increasingly common. Little is known, however, about the credibility of these reports with target audiences or their influence on the delivery of medical services., Methods: Since 1992, Pennsylvania has published the Consumer Guide to Coronary Artery Bypass Graft Surgery, which lists annual risk-adjusted mortality rates for all hospitals and surgeons providing such surgery in the state. In 1995, we surveyed a randomly selected sample of 50 percent of Pennsylvania cardiologists and cardiac surgeons to find out whether they were aware of the guide and, if so, to determine their views on its usefulness, limitations, and influence on providers., Results: Eighty-two percent of the cardiologists and all the cardiac surgeons were aware of the guide. Only 10 percent of these respondents reported that its mortality rates were "very important" in assessing the performance of a cardiothoracic surgeon. Less than 10 percent reported discussing the guide with more than 10 percent of their patients who were candidates for a coronary-artery bypass graft (CABG). Eighty-seven percent of the cardiologists reported that the guide had a minimal influence or none on their referral recommendations. For both groups, the most important limitations of the guide were the absence of indicators of quality other than mortality (cited by 78 percent), inadequate risk adjustment (79 percent), and the unreliability of data provided by hospitals and surgeons (53 percent). Fifty-nine percent of the cardiologists reported increased difficulty in finding surgeons willing to perform CABG surgery in severely ill patients who required it, and 63 percent of the cardiac surgeons reported that they were less willing to operate on such patients., Conclusions: The Consumer Guide to Coronary Artery Bypass Graft Surgery has limited credibility among cardiovascular specialists. It has little influence on referral recommendations and may introduce a barrier to care for severely ill patients. If publicly released performance reports are intended to guide the choice of providers without impeding access to medical care, a collaborative process involving physicians may enhance the credibility and usefulness of the reports.

Background: The purpose of this communication is to demonstrate the feasibility of a voluntary national cardiac surgical database., Methods: The genesis of the Society of Thoracic Surgeons (STS) National Cardiac and General Thoracic Surgery Databases in the interval of 1986 to 1990 is described. The issues facing the Committee in the initial decision making processes are discussed choosing a society-based, in-house activity versus using an outside vendor, private practice needs versus academic ones; open versus closed membership and vendors, risk stratification; data quality; audit; and access to data., Results: In the 6 years of operation the STS cardiac surgical database has grown from 41,000 to 706,000 patients. The number of practice groups, hospitals, and surgeons has increased from 26 to 624, 32 to 750, and 120 to 1850, respectively. All but one state is represented, as are more than 400 teaching hospitals, including 28 Veterans Administration hospitals and 60 university centers., Conclusions: The STS database system has become firmly established and is a model for other societies and associations. The data placed yearly in the public domain have become a national standard.

United States physicians are grappling with a fundamental reorganization of the healthcare system. Although many remain skeptical of governmental efforts at reform, they seem to take as given an industrial efficiency model of change, including large and integrated managed care arrangements and performance measurement based on outcomes such as quality. This uncharacteristic acquiescence seems to derive in part from a confounding of concepts. This article makes three distinctions: among knowledge about practice, knowledge about quality, and outcomes research; between outcomes research and the outcomes movement; and between the outcomes movement and other options for healthcare reform. The suggestion that statistical measurement of specific variables ought not to have a priori precedence over other ways of thinking--and doing something--about healthcare is made.

The criteria by which healthcare is judged or measured are quality, accessibility, and cost effectiveness. To evaluate these criteria it is important to have a database. There are many strengths and weakness to large databases. They can be used as an indicator of the level of performance or quality, for clinical decision making, and as a measurement of cost effectiveness. They can also be useful in the evaluation and development of treatment algorithms and critical pathways for patients with entry level disease. In addition, they can measure patient access to healthcare and the appropriateness of care. It is important for these databases to appropriately adjust for preoperative risk factors that may influence outcome. Outcome in most of the databases is measured by mortality, but morbidity, functional status, quality of life, cost of care, length of stay, return to work, and patient satisfaction are also important outcomes. Factors that can influence the quality of the outcome data are the methods by which the data are collected, standardization of definitions, the currentness of the database, adequate numbers of patients and outcomes, and appropriate analytic techniques. It is important to feed back the data to the healthcare providers in a timely enough fashion so that processes and structures of care can be modified to improve treatment and results. The reliability of the databases and the validity must be substantiated for the healthcare provider to have confidence in the database.(ABSTRACT TRUNCATED AT 250 WORDS)

Many efforts to improve the quality of care focus on information drawn from databases. Such information can be very useful; however, the acquisition and analysis of data must be undertaken with caution. Six issues related to quality of care and the acquisition and analysis of data that pose problems for thoracic surgeons are the limitations and dangers of the right to know, the inadequacy of current databases, outcomes analysis and whether they help or hurt us, increased scrutiny of our practices, practice guidelines and the standards of care, and credentialing. To maximize the benefits of databases, physicians must participate in the process of data acquisition and analysis and the formation of practice guidelines. Speaking out against the misuse of incomplete or inaccurate data and supporting Society initiatives that address these concerns will help us as we strive to maintain a strong physician-patient relationship and to deliver optimal care to our patients.

Based on a simple register for thoracic and cardiovascular operations a modulated system has been built up at Department of Surgery A. The register covers waiting list, a basic patient record, extensive operative data, the postoperative course and the final outcome. A local area network includes 36 microcomputers with approximately 75 users. Owing to lack of commercially available programs, local applications based on dBase have been developed. In this article we discuss our positive experiences from use of the local system with respect to administration, quality assurance and local research, its future place within a larger hospital system interconnected via a backbone, the need for better support and graphic user interface.

Primary care physicians who encourage patients to interact in the medical interview receive high ratings of patient satisfaction with art of care. To determine if this finding holds true in specialty medicine, we designed a two-factor [art of care (high/low); heart specialty (cardiology/cardiovascular surgery)] four-group analogue study. Videotapes for each of the four conditions depicted the first interview between (actor) patient with coronary artery disease and (actor) specialist. The high art of care physicians elicited the patient's story in his own words and encouraged questions and feedback during the interview; the low art of care physicians did not encourage patient interaction. The cardiologists discussed medical treatment and the cardiovascular surgeons discussed surgical treatment. A pilot study of the instrument we developed indicated that the Art of Care Scale, Technical Quality of Care Scale, and Willingness to be Treated Scale demonstrated high internal consistency and that the Art of Care Scale and the Technical Quality of Care Scale defined two dimensions. In the final study, 124 graduate students in education in a midwestern United States university each viewed one videotape and used the instrument to evaluate the physician. Subjects rated the specialists who encouraged patients to interact higher on the Art of Care Scale than specialists who did not encourage interaction. Art of Care Scale Scores predicted subjects' willingness to be treated by the physician they viewed on the videotape. No significant differences in ratings of Art of Care could be attributed to specialty.

Objective: To examine the longitudinal relationship between surgeon volume and in-hospital mortality for coronary artery bypass graft (CABG) surgery in New York State and to explain changes in mortality that occurred over time., Design: Observation of clinically risk-adjusted operative mortality over time., Setting: All 30 New York State hospitals in which CABG surgery was performed for 1989 through 1992., Patients: All 57,187 patients undergoing isolated CABG surgery in New York State in 1989 through 1992 in the 30 hospitals., Main Outcome Measures: Actual, expected, and risk-adjusted mortality., Results: Risk-adjusted in-hospital mortality decreased for all categories of surgeons. Low-volume surgeons (< or = 50 operations per year) experienced a 60% reduction in risk-adjusted mortality in the 4-year period, whereas the highest-volume surgeons (> 150 operations per year) experienced a 34% reduction. The percentage of patients undergoing CABG surgery by low-volume surgeons decreased from 7.6% in 1989 to 5.7% in 1992, a 25% decrease., Conclusions: The overall decline in risk-adjusted mortality could not be explained by shifts in patients away from low-volume surgeons to high-volume surgeons. The proportionately larger decrease in risk-adjusted mortality for low-volume surgeons could not be explained by changes in patient case mix or by improvements in the performance of surgeons with persistently low volumes. Part of the decrease was a result of the exodus of low-volume surgeons with high risk-adjusted mortality (in all years studied), the markedly better performance of surgeons who were new to the system (especially in 1991 and 1992), and the performance of surgeons who were not consistently low-volume surgeons (especially in 1992).

Between January 1991 and February 1996, and February 1996, 222 videothoracoscopic operations were conducted in 215 patients. Indications for video-assisted thoracic surgery (Vats) have included management of pneumothorax, (91), pleural effusion (59), lung nodules (41), mediastinal biopsy (8), need for lung biopsy (10), small endothoracic masses (6), haemothorax (4), gangliectomy in Raynaud syndrome (1), the removal of jugular vein catheter (1), and middle lobectomy for A-V fistula (1). Fifteen procedures were converted to thoracotomy; nine conversions were made for more extensive resection after a diagnosis of primary lung malignancy. Other reasons for conversion were adhesions (6). There was one complication (haemothorax). There were no intraoperative deaths. Mean operative time was 60 min. (median line); the median chest tube duration was three days and hospital stay five days. The video-assisted thoracic surgery procedures were safe, and for patients the advantages included less pain and earlier post-operative mobilization.

Restrictions on the operative domain of general surgeons threaten the viability of trauma surgery as a career choice. Our study hypothesis is that an experienced trauma surgeon can provide definitive care for life-threatening thoracic trauma. This analysis is based on clinical outcomes at an ACS-verified level I center in which there are more than 3000 trauma admissions managed annually under the direction of four academic trauma surgeons. We selected penetrating cardiac wounds and blunt tears of the thoracic aorta because these injuries are managed exclusively by the trauma service and the endpoints are distinct. During the past 4 years, 40 patients with cardiac wounds were delivered to the ED; 23 patients arrived dead. In the remaining 17, injury mechanisms were 15 stab wounds (SW), one gunshot wound (GSW), and one shotgun (SGW). Four of these patients required ED thoracotomy, and the remaining 13 underwent some form of prethoracotomy pericardial decompression. Survival rate without neurologic deficit was 94% (16 of 17). During this same period, 19 patients with a torn thoracic aorta from blunt injuries arrived with signs of life. In this group the injury mechanisms were automobile crash in 15, and the mean ISS was 39.7 +/- 2.3. One patient was transferred for total cardiopulmonary bypass; 17 of the remaining patients underwent aortic repair employing partial left heart bypass. Sixteen of our 18 patients lived and none developed paraplegia. In summary, excluding patients who arrived dead, survival for penetrating cardiac wounds was 94% and for blunt thoracic aortic tears 89%. In conclusion, these data support our contention that trauma surgeons can render definitive care for thoracic injuries with survival rates comparable to those reported by cardiothoracic surgeons.

The need for accurate risk assessment has become an indispensable element in the practice of cardiac surgery. The Society of Thoracic Surgeons National Cardiac Surgery Database allows subscribing institutions to perform sophisticated patient risk assessment using traditional statistical tools and a newly developed risk model of operative mortality. The database experience with isolated coronary artery bypass grafting has been studied most closely at this point and serves as the basis for this report. The approach to operative risk assessment is presented along with an analysis of important risk factors in the practice of coronary artery surgery from 1980 through 1990. The database contains records of 80,881 patients undergoing coronary artery bypass grafting in numerous institutions from 1980 through 1990. These records were used to conduct a detailed analysis of risk factors associated with coronary operations in this time interval and to present statistical methods used to formulate a risk equation that allows one to predict the probability of operative death. In the course of this decade, there were clearly defined trends showing a statistically significant increase in adverse patient risk factors. The risk model has proven to be a reliable tool for predicting the probability of operative death in an individual patient and may be valuable in both patient counseling and medical decision making. Large multi-institutional databases of this type are key ingredients of modern operative risk assessment. A database containing a broad national experience of this type can represent an aggregate experience that may well approximate a universally accepted standard of care.

Unlabelled: Primary solitary plasmacytoma and Ewing's sarcoma of the chest wall are relatively uncommon tumors, and data concerning treatment and results are sparse. To assess the results of therapy we reviewed our 40-year experience., Methods: Records of 24 patients with solitary plasmacytoma and 62 with Ewing's sarcoma arising in the chest wall who were admitted to our institution from 1949 to 1989 were reviewed., Results: In the group with plasmacytoma (n = 24), ages ranged from 35 to 75 years (median 59 years); male/female ratio was 2.4:1. The presenting complaint was pain or mass or both in 92% (22/24). Primary therapy was local only in 5 (resection in 3, radiotherapy in 2), chemotherapy in 16 (resection in 5, radiotherapy in 10, and chemotherapy alone in 1); 3 patients did not receive therapy. Multiple myeloma developed subsequently in 75% (18/24). Overall 5-year survival was 38% (median 56 months). Age, sex, site of primary tumor, and local therapy did not significantly impact on survival. Ages in the patients who had Ewing's sarcoma (n = 62) ranged from 2 to 39 years (median 16 years); male/female ratio was 1.6:1. Presenting complaint was pain or mass or both in 98% (61/62). Primary therapy was local in 17 (resection in 7, radiotherapy in 7, resection plus radiotherapy in 3) and chemotherapy in 45 (plus resection in 29, resection and radiotherapy in 10, and radiation therapy alone in 3). Overall 5-year survival was 48% (median 57 months). Age, sex, and site of primary tumor did not significantly impact on survival. Patients in whom distant metastases developed (n = 48) had a significantly decreased survival (5 year, 28%) compared with those who did not have metastases (n = 14; 5 year, 100%)., Conclusion: Plasmacytoma of the chest wall, even if solitary at presentation, should be considered a systemic disease, and therapy should be directed as such. For Ewing's sarcoma, although resection or radiotherapy may offer local control, because of the prevalence of distant metastases (77%), systemic therapy should be considered an integral part of treatment.

This article presents findings from the Abt Associates survey, commissioned by The Society of Thoracic Surgeons and other cooperating organizations, used to collect data to develop a resource-based relative value scale for cardiothoracic and vascular surgery. The methodology used by Abt Associates to measure the total work of surgical procedures is described, and differences between the Abt methodology and that used in the Harvard study are highlighted. The report also compares the total work measured by the Harvard and Abt studies for several specific operations. Discrepancies in relative total work measures between the two studies are shown to result primarily from differences in the measurement of preoperative and postoperative work. Background information on responding physicians is summarized. Physicians asked to respond to the survey were randomly selected from a combined list of all members of the six cardiothoracic and vascular organizations as well as those physicians included on the American Medical Association Masterfile with a primary specialty indication of cardiovascular, general thoracic, or peripheral vascular surgery. Therefore, these data should be reasonably representative of the cardiothoracic and vascular surgery profession as a whole. Information provided includes board certification status, age, sex, practice type, reimbursement source, hours worked per week, and number of operations performed. In addition, data describe the types of hospitals at which cardiothoracic and vascular surgeons typically practice. The survey also provides data on current surgical practice. Statistics are available on the average number of various types of operations surgeons perform, and on what percentage are reoperations. Finally, the work of reoperations and emergency procedures relative to primary elective operations is compared directly.(ABSTRACT TRUNCATED AT 250 WORDS)

Local recurrence of breast cancer is a relatively common entity. Occasionally, the management of such recurrences necessitates full-thickness chest wall resection. Although the chance for cure in such circumstances is small, achieving local control remains a desirable goal to maintain comfort and hygiene. This study evaluates the utility and morbidity of full-thickness chest wall resection in the control of symptomatic local recurrence of breast carcinoma. Twelve patients, undergoing such resections, were identified from hospital records. The resections included an average of three ribs (range, two to five) and, in seven cases, part or all of the sternum. A variety of rigid and soft tissue chest wall reconstructive techniques were utilized. Of the 11 patients available for follow-up, ten reported good overall function postoperatively. There were no postoperative deaths and only one patient developed a major complication requiring prolonged hospital stay. The patients spent an average of 6.6 hours in surgery, 14.6 hours intubated, and 20 days in the hospital. There were ten patients available for long-term follow-up. At the time of this study, 70 per cent were still alive, with or without disease, with a mean survival of 27 months (range, 3-71 months). Forty per cent were alive, disease-free, with a mean survival of 36 months (range, 3-71 months). This series demonstrates low morbidity, improved quality of life, and the possibility of long-term, disease-free survival after full-thickness chest wall resection for recurrent breast carcinoma.

In the 1970s and 1980s the measures for providing the inhabitants of the FRG with regionally distributed facilities in thoracic and cardiovascular surgery took almost only heart surgery into account. In the field of thoracic surgery, by contrast, several centers were closed or used for other purposes. This development was due to the decline in tuberculosis, but also partly to the lack of exact statistics concerning thoracic surgery. The result has been a considerable deficit in the provision of specialized care for the population and stagnation in research. A nationwide questionnaire in 1989 showed that in 78.4% of the surgery departments asked general thoracic surgery was undertaken only occasionally (less than 100 interventions a year); 42.8% of the operations were undertaken by non-specialized surgeons. Malignant diseases dominated the case-load. Because of the lack of sufficient thoracic surgery departments with appropriate specialized knowledge, it must be assumed that many patients with cancer of the thoracic organs are receiving either no, inefficient, or too late a treatment of their disease. Reorganisation of general thoracic surgery is necessary in order to provide the population with adequate facilities in this field. The existing thoracic surgery centers should be enlarged and attached to the universities in order to ensure research and teaching. Specialized treatment of thoracic surgical diseases can be achieved by reorganizing general surgery departments in the regional hospitals which already undertake thoracic interventions and by establishing additional thoracic surgery departments under qualified leadership.

The use of prophylactic antimicrobials in cardiothoracic surgery has become an accepted medical practice. The choice of drug and the duration of therapy varies among institutions. In 1985, we conducted a telephone survey to determine the choice of prophylactic antimicrobials in cardiothoracic surgery programs across the U.S. We recently conducted this survey for a second time. In our 1988 survey, 51 hospitals responded, with 34 (67%) having a standard antimicrobial regimen. Of all hospitals surveyed, first-generation cephalosporins were the most commonly used agents. First-generation cephalosporins were employed in 33 (48.4%) hospitals, cefamandole in 13 (19.1%), cefuroxime in nine (13.2%), vancomycin in three (4.4%), and vancomycin plus gentamicin in two (2.9%). A variety of other agents were employed by one of the remaining hospitals. Fourteen (27%) hospitals had automatic stop orders for antimicrobial prophylaxis in this indication. Ten (19.6%) institutions had changed the antimicrobial agent(s) used for prophylaxis in the last year. The results of this survey indicate that most hospitals continue to use first-generation cephalosporins for antimicrobial prophylaxis in cardiothoracic surgery, but there is considerable variation among institutions.