Metric 12

Use of Minimally Invasive Lung Surgery for Lung Cancer

Metric Category: Appropriateness

About the Metric

Definition

The percentage of all lung and thymus resection procedures performed that were minimally invasive.

Background

Minimally Invasive surgery (MIS) is a safe and effective option for lung and thymus surgery. Minimally invasive lobectomy and thymectomy procedures performed through a video-assisted thoracoscopic surgical approach are associated with fewer postoperative complications and a shorter length of stay compared to open resection. Minimally invasive surgeries may also be associated with lower costs, a shorter hospital stay, reduced opiate use, and an overall quicker recovery.

Metric Ratings

Evidence
5/5
Expert Consensus
5/5
Clinician Buy-in
4/5
Economic Impact
3.5/5
Reduction in Avoidable Harm
4.5/5
Applicability to Medicare Data
5/5
Applicability to Medicaid
4/5

Applicable to EHR Data?

Requires Pharmacy Data?

How It Works

Numerator

The number of procedures from the denominator that were minimally invasive lung resection procedures (CPT codes: 32663, 32666, 32667, 32668, 32669, 32670, 32671) or minimally invasive thymus resection procedures (CPT codes: 32673)

Denominator

The number of all lung resection procedures (CPT codes: 32440, 32442, 32445, 32480, 32484, 32486, 32505, 32506, 32507, 32608, 32663, 32666, 32667, 32668, 32669, 32670, 23671) or thymus resection procedures (CPT codes: 60521, 60522, 23673) by a given physician during the study period.

Inclusion Criteria

All patients who underwent a lung or thymus resection procedure.

Exclusion Criteria

1. If a look back period of data is available prior to the study period, exclude patients who had any history of a lung (CPT codes: 32440, 32442, 32445, 32480, 32484, 32486, 32505, 32506, 32507, 32608, 32663, 32666, 32667, 32668, 32669, 32670, 23671) or thymus resection procedure (CPT codes: 60521, 60522, 23673)

Attribution

The surgeon performing the procedure.

GAM Thresholds™

GAM establishes clinical thresholds using the input of key physician leaders within a specialty and the GAM clinical team. GAM utilizes an elaborate consensus building process with final adjudication by our leadership team.

  • Sample Size: 5-10

    This threshold applies to a clinician with a minimum of 11 cases.

  • Pattern of Concern: 21-40%

    This constitutes the clinical threshold for a "pattern of concern."

  • Outlier: <21%

    This constitutes the clinical threshold for an "outlier."

  • Sample Size: 11+

    This threshold applies to a clinician with a minimum of 11 cases.

  • Pattern of Concern: 30-50%

    This constitutes the clinical threshold for a "pattern of concern."

  • Outlier: <30%

    This constitutes the clinical threshold for an "outlier."

Cases Pattern of Concern Outlier
5-10
21-40%
<21%
11+
30-50%
<30%

Supporting Literature

1. Bendixen M, Kronborg C, Jørgensen OD, Andersen C, Licht PB. Cost-utility analysis of minimally invasive surgery for lung cancer: a randomized controlled trial. Eur J Cardiothorac Surg. 2019;56(4):754-761. doi: 10.1093/ejcts/ezz064. https://academic.oup.com/ejcts/article-abstract/56/4/754/5369803

  • Describes six-year study which evaluated the cost-effectiveness of minimally invasive video-assisted thoracic surgery (VATS) versus thoracotomy for lobectomy and concluded that VATS was more cost effective overall.

 

2. Long H, Tan Q, Luo Q, et al. Thoracoscopic surgery versus thoracotomy for lung cancer: short-term outcomes of a randomized trial. Ann Thorac Surg. 2018;105(2):386-392. doi: 10.1016/j.athoracsur.2017.08.045. https://www.sciencedirect.com/science/article/abs/pii/S0003497517311918

  • Details a six-year study which aimed to assess safety and efficacy of video-assisted thoracic surgery (VATS) versus axillary thoracotomy for lobectomy for early-stage non-small lung cancer. The study demonstrated VATS was equally safe and reliable as thoracotomy and potentially superior for operation time and intraoperative blood loss.

 

3. Cooper MA, Segev DL, Makary MA. Hospital level under-utilization of minimally invasive surgery in the United States: retrospective review. BMJ. 2014;349:g4198. doi: https://doi.org/10.1136/bmj.g4198. https://www.bmj.com/content/349/bmj.g4198

  • Authors evaluate US hospital utilization of minimally invasive surgical approach for appendectomy, colectomy, total abdominal hysterectomy, and lung lobectomy.

 

4. Friedant AJ, Handorf EA, Su S, Scott WJ. Minimally invasive versus open thymectomy for thymic malignancies: systematic review and meta-analysis. J Thorac Oncol. 2016;11(1):30-8. doi: 10.1016/j.jtho.2015.08.004. https://pubmed.ncbi.nlm.nih.gov/26762737/

  • Authors performed systematic review and meta-analysis of 19 years of studies to evaluate minimally invasive versus open thymectomy for thymic malignancies and found that, for selective patients, minimally invasive thymectomy was safe and achieved similar oncologic outcomes to open thymectomy.

 

5. Boffa DJ, Kosinski AS, Furnary AP, et al. Minimally invasive lung cancer surgery performed by thoracic surgeons as effective as thoracotomy. J Clin Oncolo. 2018; 36(23):2378-2385. doi: 10.1200/JCO.2018.77.8977. https://pubmed.ncbi.nlm.nih.gov/29791289/

  • Publication details retrospective study of more than ten thousand patients over age 65 years who underwent lobectomy for stage I lung cancer between 2002 and 2013 and concluded that long-term efficacy of lobectomy performed by video-assisted thoracic surgery (VATS) were noninferior to thoracotomy.

 

6. Manerikar A, Querrey M, Cerier E, et al. Comparative effectiveness of surgical approaches for lung cancer. Journal of Surgical Research. 2021;263:274-284. https://doi.org/10.1016/j.jss.2020.10.020. https://www.sciencedirect.com/science/article/abs/pii/S0022480420307563

  •  Authors describe their meta-analysis to evaluate minimally invasive techniques, including video-assisted thoracoscopic surgery (VATS) and robot-assisted throacoscopic surgery (RATS), compared to open thoracotomy for non-small cell lung cancer and found minimally invasive approaches may be superior in near-term mortality and no difference in long-term outcomes.