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The Incidence and Clinical Burden of Air Leak Complications in Lung Surgeries: a Retrospective Analysis of a U.S. Hospital Database
Andrew Yoo1, Sudip Ghosh2, Walter Danker2, Edmund Kassis3, Iftekhar Kalsekar1.
1Epidemiology, Medical Devices, Johnson and Johnson, New Brunswick, NJ, USA, 2Global Health Economics and Market Access, Ethicon, Inc., Cincinnati, OH, USA, 3Medical Affairs, Ethicon, Inc., Cincinnati, OH, USA.

Objective: Prolonged Air Leaks (>5 days) are a commonly studied complication with significant patient morbidity, but the impact of any air leak is less well understood. This study assesses the incidence, risk factors, and clinical impact of air leaks during the hospital episode of care.
Methods: The Premier Perspective® Database contains billing data from over 600 hospitals in the U.S. All elective primary lobectomy, segmentectomy, and wedge resections from 2012-2014 were identified. During the index hospitalization, Air Leak Complications (ALC) were identified as a composite of air leak and pneumothorax ICD-9 diagnosis codes. Patient, procedure, and hospital factors were identified (Table 1) and included in multivariate models evaluating ALC risk factors and the impact of ALC on index hospitalization mortality and length of stay (LOS). The multivariate models accounted for the clustering of patients within hospitals; p values of <0.05 were considered to be statistically significant.
Results: A total of 21,150 patients undergoing lung surgery were included in the analysis: lobectomy (n=10,946), segmentectomy (n=1,788), and wedge (n=8,416). The overall incidence of ALC was 24.26% (95%CI[23.68,24.83]) and varied with resection type: lobectomy 29.20% (95%CI[28.35,30.05]), segmentectomy 22.04% (95%CI[20.11,23.96]) , and wedge 18.30% (95%CI[17.47,19.12]). Relevant risk factors for ALC included (Table 1): resection type, thoracotomy surgical approach, male gender, indication for surgery, and presence of chronic obstructive pulmonary disease (COPD). The overall mortality in the study sample was 1.06% (95%CI[0.92,1.20]), and the mean LOS was 5.7 (SE=0.04) days. After controlling for patient, procedure and hospital factors, ALC was associated with increased mortality OR 1.90 (95%CI[1.42,2.55]) and increased mean LOS of 2.5 days (p<0.01).
Conclusion: This analysis shows that multiple patient, procedural, and provider characteristics increase the risk for ALC. Air Leak Complications after lung resections are not only a frequent complication but are associated with increased mortality and hospital LOS.
Table 1: Logistic Regression Model for occurrence of ALC (N=21,150)
VariableEffectOR95% CI
Resection Type (REF: Lobectomy)Segmentectomy0.7690.6680.885
Wedge0.7260.6610.798
Approach (REF: VATS*)Thoracotomy1.1321.0081.271
Race (REF: Caucasian)African American0.9580.8351.100
Other1.0550.9021.234
Gender (REF: Female)Male1.1081.0371.184
Age (REF: >74 years)18-441.3691.0981.705
45-540.9280.7861.096
55-640.8990.7891.026
65-741.0120.9261.105
Marital Status (REF: Single)Married0.9280.8581.004
Other1.0350.8051.331
Payer (REF: Other)Commercial0.9150.7081.182
Medicaid0.9230.6991.219
Medicare0.9480.7341.225
Year of Surgery (REF:2014)20120.8540.7510.971
20130.9600.8661.064
Primary Indication (REF: Cancer)Pulmonary Fibrosis0.8030.6870.938
Other1.1771.0261.351

Table 1 cont: Logistic Regression Model for occurrence of ALC (N=21,150)
Teaching Status (REF: Non Teaching)Teaching0.9960.8291.197
Hospital Bed Size (REF: >500 beds)1-3001.0780.8321.397
301 - 5001.0840.8421.395
Provider Region (REF: West)Midwest1.0650.7921.430
South0.9050.7071.158
Northeast0.6910.4970.963
Provider Urbanicity (REF: Urban)Rural1.0880.8541.385
Hospital Volume of Lung Resections1 to 500.9270.6011.429
(REF: >300 surgeries)51 to 1500.9270.5891.460
151 to 3001.2030.7401.955
Provider Costing Type (REF: RCC**)Procedural1.0670.8941.274
Physician SpecialtyCardiac Surgeon1.0460.8951.222
(REF: Thoracic Surgeon)General Surgeon0.9390.7671.148
Other0.9960.8121.221
Charlson Comorbidity IndexScore of 00.6480.5550.758
(REF: >4)Score of 1-21.0240.9231.136
Score of 3-41.2601.1561.373
Specific Comorbid ConditionsCOPD1.8031.6301.994
Depression0.9630.8651.073
Hypertension0.9110.8520.975
Diabetes0.8210.7460.903
Obesity0.6310.5540.719
* Video Assisted Thoracic Surgery (VATS)
**Ratio of cost to charge (RCC) method


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