Variation in Hospital Adoption Rates of Video-Assisted Thoracoscopic Lobectomy for Lung Cancer and the Effect on Outcomes

Background This study examined the variation in the adoption of video-assisted thoracoscopic surgery (VATS) for lobectomy across United States hospitals from a population-based national database. Methods We used the National Cancer Data Base to identify patients undergoing lobectomy between 2010 and 2012 and used hierarchical regression to estimate case-mix–adjusted VATS lobectomy rates using patient and tumor characteristics. We stratified hospitals into quintiles by adjusted VATS lobectomy rates. To account for lack of equipment to perform minimally invasive thoracoscopic operations, we also obtained data on VATS wedge resections. Results Of 55,972 cancer lobectomies performed at 905 hospitals, 17,072 (30.5%) were VATS. Crude hospital VATS use varied widely (mean was 25.5% of all lobectomies per hospital; interquartile range, 4.4% to 42.3%). Variation persisted after case-mix adjustment. For example, VATS rates at the highest and lowest quintiles were 76% vs 0.6%, respectively. Differences in patient and tumor characteristics across quintiles were negligible, and there was no indication that those hospitals lacked VATS equipment. The risk-adjusted same-hospital readmission (6.7% vs 7%; p > 0.2), 30-day mortality (1.5% vs 1.5%; p > 0.2), and 90-day mortality (2.9% vs 2.7%; p = 0.038) rates were similar between the highest and lowest quintiles. Length of stay was shorter at hospitals in the highest VATS quintile (6.6 vs 7.4 days; p < 0.001). Conclusions Adoption of VATS lobectomy varies widely across United States hospitals. This variation cannot be explained by patient or tumor characteristics or by a shortage of VATS equipment. Efforts to reduce this variation will require the dissemination and implementation of novel training techniques and learning opportunities for surgeons.