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• 13080

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  E13 - High Risk Patients and Low Risk Surgeons (ID 13)

  • Event: WCLC 2013
  • Type: Educational Session
  • Track: Surgery
  • Presentations: 1
  • Moderators:H. Date, R. Calhoun
  • Coordinates: 10/30/2013, 14:00 - 15:30, Parkside Ballroom A, Level 1

  • 13083

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    E13.2 - Standards and Benchmarking of Surgery (ID 433)

    14:00 - 15:30  |  Author(s): A. Brunelli
    • Abstract
    • Presentation
    • Slides

    Abstract
    Managed care system, public accountability, cost containment, pay-for-performance and ranking culture demand Quality of care to be monitored through appropriate instruments. Outcome endpoints (i.e. morbidity and mortality) are still the most widely used quality indicators in thoracic surgery. Outcomes however should be reported in the most correct way to prevent risk-averse behaviours and misleading information. They need risk-adjustment, as different case-mixes at different institutions may influence outcome and those units operating on older and sicker patients would be penalized without an appropriate risk-adjustment. Therefore, risk-modelling must become the logical and necessary approach for provider profiling and comparative audit. The most important tool of any quality assessment endeavour is a database that is made up of a representative sample of the study group of interest. The gold standard for data should be a specialty-specific, procedure-specific, prospectively maintained, periodically audited, electronic database that contain, at the minimum, a core set of variables that has been demonstrated to be associated with outcome. The practical steps that should be planned and possibly recorded to construct a solid clinical database are a clear definition of the data sources and the creation of a list of variables (and their definitions) that will constitute the database. These steps will permit that 1) the database can be used even by subjects that did not participate to its construction, 2) the database can be audited by external data managers to assess quality of data, 3) changes in data collection or variables recording may be adequately planned. The importance of the source and the quality of data cannot be overemphasized enough. Most of the data that are of clinical interest derive from clinical records or other attached documents, such as laboratory exams or PFTs. One of the most critical aspects of the database construction is the extraction of the data from the medical record to the database. Wherever possible, data should be entered in real time, at the point of capture; to this end a networked database should be accessible in the operating theatre, the ward, the clinic and the multidisciplinary team meeting room. When possible this data should be used to generate documents such as operation notes, MDT report, correspondence, so that data capture becomes integral to routine patient care. The person in charge of capturing or transferring data into a database should be properly qualified and adequately trained. A Clinical Audit Lead should be selected within each unit who will be responsible for the accuracy and quality of data collection. The data should be periodically checked for discrepancies, inconsistencies, missing values, in order to ensure a high quality database. In fact no model or predictive equation can be better than the data upon which it is based. If any underperformance in data collection would be detected this should be reported to all persons involved in the process of data recording with the final objective of continuously improving the quality of the database. The European Society of Thoracic Surgeons (ESTS) appointed a Database Committee responsible to develop and maintain an online clinical Database with the aim to collect clinical data from thoracic surgery units across Europe. The ESTS Database is an online database, which is free to members and directly accessible from the link on the ESTS homepage. The main purpose of the ESTS database is for quality monitoring and improving activities. Several outcome and process indicators are included in the dataset. These indicators have been used to construct a Composite Performance Score, which is used as one of the parameters necessary for the European Institutional Accreditation System (EIAS). The EIAS is a process aimed at standardization of thoracic surgery practice across European units. It is currently based on the information submitted to the ESTS Database and focused on major lung resections for lung cancer, the prevalent activity in our specialty. In the construction of the CPS, indicators covering all three temporal domains of our practice (preoperative, intraoperative and postoperative) were selected. These indicators included risk-adjusted hospital mortality and morbidity (outcomes) and 3 process measures derived from published guidelines: the proportion of lung resection candidates with measured DLCO, the proportion of candidates to lung resection for NSCLC with clinically suspicious nodal disease submitted to preoperative invasive mediastinal staging and the proportion of patients with a intraoperative mediastinal staging according to the ESTS published guidelines. The final composite score combined 3 processes and 2 outcomes indicators into a single comprehensive quality score which was able to discriminate between the units entering in the comparison process. Units eligible for the accreditation process are then inspected by a team of auditors appointed by the ESTS to verify a sample of data submitted to the ESTS database and the structural, procedural and qualification characteristics of the unit and surgeons working in that unit. Most recently the ESTS Executive Committee revised the structural characteristics of general thoracic surgery unit in Europe with the aim to provide a comprehensive document in line with the quality initiatives of the Society and serving as a guide for harmonizing the general thoracic surgical practice in Europe. That document will be used as a reference for future quality initiatives and educational activities of the society

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• 13033

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  MS16 - ESTS/IASLC Thymic Session (ID 33)

  • Event: WCLC 2013
  • Type: Mini Symposia
  • Track: Thymoma & Other Thoracic Malignancies
  • Presentations: 1
  • Moderators:P. Goldstraw, E. Lim
  • Coordinates: 10/30/2013, 10:30 - 12:00, Bayside Gallery A, Level 1

  • 13036

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    MS16.3 - Surgery for Thymic Tumours: Outcomes from the ESTS Data Base (ID 532)

    10:30 - 12:00  |  Author(s): A. Brunelli
    • Abstract
    • Presentation
    • Slides

    Abstract
    Introduction: Thymic tumors are rare malignancies and most of the current literature is composed of single-institutional series collecting small number of patients spanned over short time periods. The European Society of Thoracic Surgeons (ESTS) thymic working group developed a retrospective database among its members collecting patients with thymic tumors submitted to surgical resection between 1990 and 2010. Methods: A total of 2151 patients were collected from 35 Institutions, including 1798 thymomas, 191 thymic carcinomas (TC), and 41 Neuroendocrine Thymic Tumors (NETT)). 1709 patients (89%) received a complete resection. Myasthenia Gravis (MG) was present in 629 patients (35%). Different clinical-pathologic characteristics were analyzed for their impact on survival and recurrence. Primary outcome was overall survival (OS); secondary outcomes were the proportion of incomplete resections, disease-free survival (DFS) and the cumulative incidence of recurrence (CIR). Results: Ten-year OS and DFS rates were 73% and 70%. The risk of mortality increased with age and with the stage. It also increased in the presence of TC, NETT and incomplete resection. Ten-year CIR was 12%. Predictors of incomplete resection included male gender, tumor size, the absence of MG, non-thymoma categories (TC and NETT) and high-risk thymomas (B2-B3). The risk of recurrence increased with tumor size, increased stage and NETT. Finally, our analysis indicates that the overall effect of adjuvant therapy after complete resection on OS was significantly beneficial (p=0.05) using a propensity score. Conclusions: Masaoka stages III-IV, incomplete resection and non-thymoma histology showed a significant impact in increasing recurrence and in worsening survival. The administration of adjuvant therapy after complete resection is associated with improved survival.

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