Department of Cardiothoracic Surgery
Making the “Efficiency”
Case For New TechnologyThe Example of “Digital
Pleural Drainage
Systems”
Katie S. Nason, MD MPH
2014 Focus on Thoracic Surgery:
Novel Technologies in Lung Cancer
November 22nd, 2014
No disclosures
Department of Cardiothoracic Surgery
Efficiency is concerned with the relation
between resource inputs (costs, in the
form of labor, capital, or equipment) and
either intermediate outputs (numbers
treated, waiting time, etc) or final health
outcomes (lives saved, life years gained,
quality adjusted life years (QALYs)).
Palmer, S. and D. J. Torgerson (1999). "Economic notes: definitions of efficiency." BMJ 318(7191): 1136.
Department of Cardiothoracic Surgery
Definitions
• Technical efficiency refers to the physical
relation between resources (capital and
labor) and health outcome.
• Productive efficiency refers to a situation
where one intervention produces the same
(or better) health outcome with less of one
resource and more of another.
• “Avoiding waste, including equipment,
supplies, ideas, and energy” IOM
Department of Cardiothoracic Surgery
Are health care resources being used
to get the best value for the money in
the management of prolonged air leak
• Problem: Prolonged air leak after lung
resection
• Resource input: Pleural drainage device
• Health outcomes:
– Duration of chest tube drainage
– Need for reinsertion of chest tube
– Hospital length of stay
Department of Cardiothoracic Surgery
Analogue Pleural Drainage Systems
• Static analogue system for estimating volume
of air leak
– Inter- and intra-observer variability Varela G, et al, Eur J
Cardiothorac Surg 2009;35:28—31.
– Highly subjective
– Dependent on patient cooperation/understanding
– Single snap-shot with each observation
– Cost ~ $600
Department of Cardiothoracic Surgery
Digital Drainage Systems
• Quantify air leak continuously
• Quantify volume of air leak (ml/min) and
aggregate data over time
• Measure intrapleural pressures
Department of Cardiothoracic Surgery
Randomized comparisons:
Digital vs analogue
• 4 randomized trials (2 with lobectomy only)
– Bertolaccini, L., et al. (2011). Eur J Cardiothorac Surg
39(5): e128-132
– Cerfolio, R. J. and A. S. Bryant (2008) Ann Thorac Surg
86(2): 396-401
– Brunelli, A., et al. (2010). Eur J Cardiothorac Surg 37(1):
56-60.
– Filosso, PL et al (2010). J Cardiovasc Surg 51: 1-5.
Department of Cardiothoracic Surgery
Do digital drainage systems give the best
value for the money with regard to
TECHNICAL efficiency?
Maximum possible improvement in outcome is obtained from a
set of resource inputs.
Surgery
Total n
CT days
LOS
DPV
APV
DPV
APV
Bertolaccini (2011)
*FEV1>70%
n=98
(49/49)
Wedge/seg
/lobectomy
3.1/5.5
3.5/6.1
6.5
7.1
Cerfolio (2008)
*all PFTs
n=100
(50/50)
Wedge/seg
/lobectomy
3.1
3.9
3.3
4.0
Filosso (2010)
*FEV1 50-70%
n=31
(15/16)
Lobectomy
3/5
3/4
9
6.5
Brunelli (2010)
n=166
(82/77)
Lobectomy
4
4.9
5.4
6.3
Department of Cardiothoracic Surgery
Do digital drainage systems give the best
value for the money with regard to
PRODUCTIVE efficiency?
One intervention produces the same (or better) health outcome
with less of one resource and more of another.
Air leak D1
Air leak D2
Air leak D3
Total
DPV
APV
Total
DPV
APV
Total
DPV
APV
Bertolaccini
(2011)
47
(48)
26
(53)
21
(43)
22
(22)
12
(24)
10
(20)
11
(11)
6
(12)
5
(10)
Cerfolio
(2008)
44
(48)
23
(46)
21
(42)
21
(21)
11
(22)
10
(20)
11
(11)
6
(12)
5
(10)
Filosso
(2010)
not reported
not reported
not reported
Brunelli
(2010)
not reported
not reported
not reported
Department of Cardiothoracic Surgery
Which patient may benefit?
Predictors of postoperative prolonged air leak
– Reduced predicted
postoperative forced
expiratory volume in
1 second <80%
– Upper resections
– Presence of pleural
adhesions
– Steroid use
– Older age (>65 yrs)
– Lobectomy
– Male sex
– Normal BMI
Brunelli, A., et al. (2004). Ann Thorac Surg 77(4): 1205-1210; Cerfolio, R. J., et al. (2002). Ann Thorac Surg 73(6): 17271730; Brunelli, A., et al. (2010). Ann Thorac Surg 90(1): 204-209.
Department of Cardiothoracic Surgery
% PAL
Which patient
may benefit?
Predicting risk
40
30
20
10
0
29
1.4
0
Class A (score 0)
5
6.7
12.5
25.7
10.9
Class B (score 1) Class C (score 1.5- Class D (score >3)
3)
Risk Classification
Development
Validation
Brunelli, A., et al. (2010). Ann Thorac Surg 90(1): 204-209.
Department of Cardiothoracic Surgery
Improving risk stratification
• Age, FEV1%, FEV1/FVC
ratio, DLCO%, COPD, Side
of operation, upper vs lower,
air leak flow (ml/min),
maximum pleural pressure
and minimum pleural
pressure
• Digital measurements 6
hours postoperative
• Flow and ∆p independently predictive
• Validated in an external dataset
Brunelli, A., et al. (2011). Eur J Cardiothorac Surg 39(4): 584-588.
Department of Cardiothoracic Surgery
Summary
• The majority of patients do not have
prolonged air leak after lung resection
• Likelihood of prolonged postoperative air
leak can be estimated intraoperatively
– Suboptimal; 1 or more present in most patients
• Air flow and pressure differential
independently predictive of prolonged air
leak in early postoperative period
Department of Cardiothoracic Surgery
Conclusions
• Routine use of digital systems provides
technical but not productive efficiency
• Data suggest that Thoracic Surgeons can
improve postoperative efficiency after lung
resection through risk stratification.
• Selective use of digital drainage systems in
high-risk patients may be justified
Department of Cardiothoracic Surgery
Making the “Efficiency”
Case For New TechnologyThe Example of “Digital
Pleural Drainage
Systems”
Katie S. Nason, MD MPH
2014 Focus on Thoracic Surgery:
Novel Technologies in Lung Cancer
November 22nd, 2014
No disclosures