Mortality predictors in complicated patients after anatomical lung resection

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Teresa Gómez Hernández, Nuria Novoa Valentín, Marta Fuentes Gago, José Luis Aranda Alcaide, Gonzalo Varela Simó, Marcelo F. Jiménez López" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M. 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"apellidos" => "Jiménez López" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variables predictivas de muerte en pacientes complicados tras resección pulmonar anatómica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1094 "Ancho" => 1502 "Tamanyo" => 96855 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "ROC curve for FTR according to the study model." ] ] ] "textoCompleto" => "IntroductionThe term “failure to rescue” (FTR) was first coined in 1992 by Silber et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and refers to patient mortality after major postoperative complication. The FTR of complicated patients has been proposed as an alternative parameter to postoperative morbidity and mortality rates to measure quality of care and assess the functioning of a surgical or hospital facility. According to Silber et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>, while patient characteristics determine the occurrence of postoperative complications, hospital characteristics are associated with FTR. Thus, several studies<a class="elsevierStyleCrossRefs" href="#bib0010">2–4</a> have linked high rates of FTR with hospital factors, such as low volume of surgeries or low nurse-patient ratios. Furthermore, according to Farjah et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>, the variation in mortality rates between different hospitals is more strongly related to the ability to rescue complicated patients than to the occurrence of complications. The FTR parameter, then, offers a perspective that complements the conventional postoperative morbidity and mortality outcomes used to assess the quality of surgical units<a class="elsevierStyleCrossRef" href="#bib0030">6</a>. For this reason, some hospitals and departments have already introduced FTR as an additional indicator of quality.Although FTR is closely related to the ability to promptly detect and treat complications, and is based mainly on hospital characteristics, some studies have investigated whether there are intrinsic patient factors that could increase the risk of FTR after complex surgeries with high complication rates<a class="elsevierStyleCrossRefs" href="#bib0035">7–10</a>, although none of these analyses included patients undergoing lung resection surgeries.Our hypothesis was that certain high-risk patients are more likely to die of a major postoperative complication after lung resection, compared to the general population. The aim of the study was to investigate FTR among patients undergoing anatomical lung resection and to determine whether certain patient or surgical characteristics are predictors of FTR.MethodStudy populationWe retrospectively analyzed the records of all patients consecutively undergoing scheduled anatomical lung resection (standard segmentectomy, lobectomy, bilobectomy, or pneumonectomy) for any cause between October 1994 and February 2018 at our center. All patients with at least one major postoperative complication, defined as grade IIIa or higher according to the standardized Clavien-Dindo morbidity classification, were included in the study<a class="elsevierStyleCrossRef" href="#bib0055">11</a>. Patients with missing data at discharge were excluded from the analysis.Patient selection criteria were consistent throughout the study period and were based on the preoperative functional assessment guidelines in place at the time of the intervention<a class="elsevierStyleCrossRefs" href="#bib0060">12–15</a>. The patients were operated on by 5 expert surgeons. The surgical approach was via axillary thoracotomy without muscle section or video-assisted thoracoscopic surgery (VATS) in all cases. The patients were extubated in the operating room, and after 6h in the reanimation unit were transferred to the hospital ward. Postoperative analgesia consisted of an epidural catheter with bupivacaine and fentanyl in patients undergoing thoracotomy or a paravertebral catheter with the same medication in cases of VATS approach for 48h and paracetamol and non-steroidal anti-inflammatory drugs thereafter. Postoperative physiotherapy was initiated the day before surgery and continued after patient discharge. During the first 2 years of the study, patients were supervised by nursing staff during physiotherapy. However, in November 2002, the current intensive physiotherapy protocol based on physical exercise on a static bike was implemented. These sessions are supervised by an expert physiotherapist who also assists patients with breathing maneuvers using an incentive spirometer and helps them achieve effective coughing.Patient data were prospectively collected in an institutional database. To improve the quality of the data included in the registry, the completeness and accuracy of the data entries was monitored by a data manager at 2 different timepoints: first, upon discharge from the hospital, and then at the time the last histological result was included in the final medical reports.Statistical analysisThe outcome variable was FTR, defined as mortality (in-hospital or 30-day) among patients who experienced a major postoperative complication. In the event of death after hospital discharge, patient records were re-evaluated to determine if the patient died as a result of an in-hospital complication.Postoperative complication was defined as any adverse event that occurred during admission or within 30 days of surgery, including: respiratory failure (need for mechanical ventilation for more than 24h or need for re-intubation at any time), acute respiratory distress syndrome, atrial arrhythmia, ventricular arrhythmia, atelectasis requiring bronchoscopy, pneumonia, pulmonary embolism, acute myocardial infarction, renal failure, cerebrovascular accident (CVA), prolonged air leak (defined as persistent air leak through the pleural tube for more than 5 days after surgery), hemothorax, pneumothorax with or without air leak requiring drainage, bronchial fistula, wound dehiscence, wound hematoma, empyema, chylothorax, recurrent paralysis, and phrenic nerve paralysis. These complications were defined in advance according to the definition of variables published jointly by the American (STS) and European (ESTS) Societies of Thoracic Surgeons<a class="elsevierStyleCrossRef" href="#bib0080">16</a> and subsequently reclassified retrospectively according to the standardized Clavien-Dindo classification of postoperative morbidity as major (grade III: complications requiring endoscopic or radiological reintervention with or without general anesthesia; grade IV: life-threatening complications requiring treatment in intensive or intermediate care; grade V: complications leading to patient death) or minor (grade I: any deviation from the normal postoperative period that does not require reintervention, while allowing the administration of electrolytes, antiemetics, antipyretics, analgesics, and physiotherapy; grade II: complications requiring pharmacological treatment with drugs other than those allowed for grade I complications, including blood products and parenteral nutrition).The variables considered as risk factors for postoperative morbidity and mortality, mostly specified in the Eurolung 1 and 2 risk models<a class="elsevierStyleCrossRef" href="#bib0085">17</a>, were used as independent predictors in multivariate binary logistic regression analysis: age, body mass index (BMI), cardiac, renal, cerebrovascular comorbidity (CVA), expiratory volume in 1s predicted postoperatively (ppoFEV1%), video-assisted thoracoscopy (VATS) approach, extensive resection, pneumonectomy, and reintervention.A logistic regression model was created for the occurrence of FTR. A backward stepwise logistic regression test was used to select the variables. Only variables with p value <0.05 remained in the final model.To estimate the predictive capacity of the model, a non-parametric ROC curve was constructed and the area under the curve (AUC) and its 95% confidence interval (95% CI) were calculated.Statistical analysis was carried out using the STATA/IC 15.1 statistical software package.ResultsDuring the study period, 2569 cases underwent lung resection. In total, 53 patients (2.1%) were excluded due to incomplete data. The demographic and clinical variables of the series are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Overall, 223 (8.9%) had major complications and, of these, 49 (22%) could not be rescued.<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the stepwise logistic regression analysis (dependent variable: failure to rescue). In the final model, the variables associated with FTR were: age, history of stroke, pneumonectomy, and reintervention.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The ROC curve obtained, that estimates the predictive capacity of the model, can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The AUC was 0.82 (95% CI: 0.77–0.88).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>DiscussionReproducible indicators that accurately reflect the quality of medical care are essential for health systems. However, traditional parameters, such as complication rate, appear to have a poor correlation with in-hospital mortality due, mainly to differences in the characteristics and risk factors for death after complications among the different patient populations<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a>. Moreover, the occurrence of postoperative complications is more strongly related to patient-related factors than to hospital characteristics and quality of care<a class="elsevierStyleCrossRefs" href="#bib0005">1,18</a>. These circumstances mean that the complication rate is a suboptimal indicator of quality of care. A more precise parameter is the measure of the effectiveness of the response to a complication in preventing mortality. Therefore, the use of the FTR index as a measure of the quality of healthcare, understood as the number of deaths among patients experiencing an adverse event such as a postoperative complication, is increasing significantly.According to the latest report of the European Society of Thoracic Surgeons (ESTS), the rate of mortality and cardiorespiratory morbidity after anatomical lung resection is estimated to be 2.3% and 14.9%, respectively<a class="elsevierStyleCrossRef" href="#bib0100">20</a>; according to our results, the prevalence of major complications after anatomical lung resection is 8.9%, with the FTR index reaching 22%. This is similar to the data recorded by Ahmed et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> after cardiac surgery (RTF: 19.8%), although greater than the 6% published by Liou et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> after esophagectomy.In this study, we identified several patient- and surgery-related factors that predict FTR after anatomical lung resection. To date, studies that have evaluated FTR have focused only on hospital characteristics such as size, patient volume, technological facilities, educational level, and nurse-patient ratios<a class="elsevierStyleCrossRefs" href="#bib0010">2,22</a>. In thoracic surgery literature, FTR has been studied in lung and esophageal cancer, and findings regarding hospital qualities have been similar<a class="elsevierStyleCrossRefs" href="#bib0025">5,23,24</a>.Although modifying certain hospital characteristics may help improve outcomes, our aim was to assess whether any specific patient- or surgery-related factors were associated with a higher probability of mortality after a major postoperative complication, so that by identifying patients at high risk for FTR, we could focus efforts on how to prevent complications in these patients or how to rescue them after a complication does occur.Our data show that age, history of cerebrovascular disease, pneumonectomy, and need for reintervention increase the risk of failure to rescue after lung resection. The logistic regression model based on these variables accurately predicts FTR (AUC: 0.82). All the variables listed by the risk models of cardiorespiratory morbidity and postoperative mortality (Eurolung 1 and 2) were included as independent variables in multivariate binary logistic regression analysis but, of the patient-related factors, only age and history of stroke emerged as predictors of FTR, while for the surgical procedure, pneumonectomy and the need for reintervention increased the risk of FTR. The effect of the latter, furthermore, is very significant, to the extent that a pneumonectomized patient with a major complication is 6.6 times more likely to die than a patient with a smaller resection. Similarly, a patient who needs a reintervention is 12 times more likely to die than a patient who does not need a reintervention.These findings are consistent with previous studies. Elderly patients have higher FTR rates after urgent surgical interventions than younger patients<a class="elsevierStyleCrossRef" href="#bib0125">25</a>. Liou et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and Varley et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> found that older age was a predictor of FTR after esophagectomy and duodenopancreatectomy, respectively. Our findings of a high risk after complex surgery such as pulmonary resection are therefore not unexpected, as the patient is subjected to extreme physiological stress in all 4 situations.Numerous studies have shown that pneumonectomy is associated with significant postoperative mortality that can be as high as 8.4% at 30 days and reach 18.5% within 6 months of the intervention<a class="elsevierStyleCrossRef" href="#bib0130">26</a>. The factors that determine these results include patient age, the laterality of the procedure, and the occurrence of postoperative cardiorespiratory complications, so it stands to reason that pneumonectomy is a predictor for FTR.However, a recent British study comparing high-mortality hospitals versus low-mortality hospitals after esophagectomy showed that low-mortality hospitals performed more reinterventions for complications but had lower rates of FTR. Our results contradict these findings, and can be explained by the fact that reinterventions after lung resection are usually the consequence of a serious initial complication (hemorrhagic or infectious) from which additional complications arise (prolonged intubation, pneumonia, etc.). It is, therefore, the accumulation of complications associated with the intervention that leads to FTR, as occurs in other similar scenarios<a class="elsevierStyleCrossRef" href="#bib0050">10</a>.Our study has some limitations: as in any retrospective analysis, causality cannot be determined from the different variables analyzed; mortality was only determined in-hospital and at 30 days after discharge; deaths related to postoperative complications that occurred beyond 30 days were not included in the analysis; finally, in terms of the type of anatomical resection performed, although the study included all patients undergoing standard segmentectomy, lobectomy, bilobectomy, or pneumonectomy, only procedures that were found in previous studies to constitute a potential risk of postoperative morbidity and mortality (extended resection and pneumonectomy) were taken into account and included in the multivariate analysis as independent risk variables.In conclusion, our results show that 22% of patients with a major complication did not survive discharge. Factors that predict mortality after major complications include age, history of stroke, pneumonectomy, and reintervention. Although failed rescue efforts may be the result of certain hospital deficiencies, our results confirm the hypothesis that some patients are more likely to die after a major postoperative complication. Further studies are needed to determine how complications could be detected earlier and treated more effectively in this group of high-risk patients.Source of fundingThis study has not received specific grants from public sector agencies, the commercial sector, or non-profit organizations.Conflict of interestsThe authors state that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1581719" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423764" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1581718" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1423763" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Method" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Source of funding" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-02-07" "fechaAceptado" => "2020-04-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423764" "palabras" => array:4 [ 0 => "Rescue failure" 1 => "Surgical risk" 2 => "Postoperative mortality" 3 => "Lung resection" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1423763" "palabras" => array:4 [ 0 => "Fallo en el rescate" 1 => "Riesgo quirúrgico" 2 => "Mortalidad postoperatoria" 3 => "Resección pulmonar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionFailure to rescue (FTR), defined as the mortality rate among patients suffering from postoperative complications, is considered an indicator of the quality of surgical care. The aim of this study was to investigate the risk factors associated with FTR after anatomical lung resections. MethodPatients undergoing anatomical lung resection at our center between 1994 and 2018 were included in the study. Postoperative complications were classified as minor (grade I and II) and major (grade IIIA to V), according to the standardized classification of postoperative morbidity. Patients who died after a major complication were considered FTR. A stepwise logistic regression model was created to identify FTR predictors. Independent variables included in the multivariate analysis were age, body mass index, cardiac, renal, and cerebrovascular comorbidity, ppoFEV1%, VATS approach, extended resection, pneumonectomy, and reintervention. A non-parametric ROC curve was constructed to estimate the predictive capacity of the model. ResultsA total of 2.569 patients were included, of which 223 (8.9%) had major complications and 49 (22%) could not be rescued. Variables associated with FTR were: age (OR: 1.07), history of cerebrovascular accident (OR: 3.53), pneumonectomy (OR: 6.67), and reintervention (OR: 12.26). The area under the ROC curve was 0.82 (95% CI: 0.77–0.88). ConclusionsOverall, 22% of patients with major complications following anatomical lung resection in this series did not survive until discharge. Pneumonectomy and reintervention are the most significant risk factors for FTR." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl fallo en el rescate (FTR) definido como la tasa de fallecimientos entre los pacientes que sufren una complicación postoperatoria, es considerado un indicador de la calidad de los cuidados quirúrgicos. El objetivo de este estudio es investigar los factores de riesgo asociados al FTR después de resecciones pulmonares anatómicas. MétodoSe incluyeron en el estudio pacientes sometidos a resección pulmonar anatómica en nuestro centro entre 1994 y 2018. Las complicaciones postoperatorias se clasificaron en menores (grados I y II) y mayores (grados IIIa a V) según la clasificación estandarizada de morbilidad postoperatoria. Los casos que fallecieron tras una complicación mayor fueron considerados FTR. Se creó un modelo de regresión logística por pasos para identificar los factores predictores de FTR. Se consideraron variables independientes en el análisis multivariante la edad, índice de masa corporal, comorbilidad cardiaca, renal, cerebrovascular, VEF1ppo%, abordaje VATS, resección extendida, neumonectomía y reintervención. Se construyó una curva ROC no paramétrica para estimar la capacidad predictiva del modelo. ResultadosSe analizaron 2.569 pacientes. En total, 223 casos (8,9%) tuvieron complicaciones mayores y 49 (22%) no pudieron ser rescatados. Las variables asociadas con FTR fueron: edad (OR: 1,07), antecedente de ACV (OR: 3,53), neumonectomía (OR: 6,67) y reintervención (OR: 12,26). El área bajo la curva de la curva ROC fue 0,82 (IC 95%: 0,77–0,88). Conclusiones22% de los pacientes que presentan complicaciones mayores tras la resección pulmonar anatómica en esta serie no sobreviven al alta. La neumonectomía y la reintervención son los factores de riesgo más potentes para FTR." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez Hernández MT, Novoa Valentín N, Fuentes Gago M, Aranda Alcaide JL, Varela Simó G, Jiménez López MF. Variables predictivas de muerte en pacientes complicados tras resección pulmonar anatómica. Arch Bronconeumol. 2021;57:625–629." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1094 "Ancho" => 1502 "Tamanyo" => 96855 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "ROC curve for FTR according to the study model." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BMI: body mass index; ppoFEV1%: predicted postoperative forced expiratory volume in 1s; VATS: video-assisted thoracoscopy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex (male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2058 (81.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 (1.83) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (2.38) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary artery disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">380 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Approach (VATS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">480 (19.08) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extended resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">367 (14.59) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumonectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">307 (12.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reintervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81 (3.22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean±standard deviation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.28±9.98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.4±4.16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ppoFEV1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.41±18.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2709411.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical variables." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "95% CI: 95% confidence interval." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Odds ratio \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.076 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.040–1.113 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary artery disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.531 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.440–8.662 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumonectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.668 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.638–12.222 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reintervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.257 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.706–26.332 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2709410.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Logistic regression analysis results." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hospital and patient characteristics associated with death after surgery. 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Original Article

Mortality predictors in complicated patients after anatomical lung resection

Variables predictivas de muerte en pacientes complicados tras resección pulmonar anatómica

M. Teresa Gómez Hernándeza,b,

Corresponding author

mteresa.gomez.hernandez@gmail.com

Corresponding author.

, Nuria Novoa Valentína,b, Marta Fuentes Gagoa,b, José Luis Aranda Alcaidea,b, Gonzalo Varela Simób, Marcelo F. Jiménez Lópeza,b

a Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain

b Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain

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        "titulo" => "Variables predictivas de muerte en pacientes complicados tras resecci&#243;n pulmonar anat&#243;mica"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">ROC curve for FTR according to the study model&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term &#8220;failure to rescue&#8221; &#40;FTR&#41; was first coined in 1992 by Silber et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and refers to patient mortality after major postoperative complication&#46; The FTR of complicated patients has been proposed as an alternative parameter to postoperative morbidity and mortality rates to measure quality of care and assess the functioning of a surgical or hospital facility&#46; According to Silber et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; while patient characteristics determine the occurrence of postoperative complications&#44; hospital characteristics are associated with FTR&#46; Thus&#44; several studies<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> have linked high rates of FTR with hospital factors&#44; such as low volume of surgeries or low nurse-patient ratios&#46; Furthermore&#44; according to Farjah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#44; the variation in mortality rates between different hospitals is more strongly related to the ability to rescue complicated patients than to the occurrence of complications&#46; The FTR parameter&#44; then&#44; offers a perspective that complements the conventional postoperative morbidity and mortality outcomes used to assess the quality of surgical units<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; For this reason&#44; some hospitals and departments have already introduced FTR as an additional indicator of quality&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although FTR is closely related to the ability to promptly detect and treat complications&#44; and is based mainly on hospital characteristics&#44; some studies have investigated whether there are intrinsic patient factors that could increase the risk of FTR after complex surgeries with high complication rates<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a>&#44; although none of these analyses included patients undergoing lung resection surgeries&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our hypothesis was that certain high-risk patients are more likely to die of a major postoperative complication after lung resection&#44; compared to the general population&#46; The aim of the study was to investigate FTR among patients undergoing anatomical lung resection and to determine whether certain patient or surgical characteristics are predictors of FTR&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0020" class="elsevierStylePara elsevierViewall">We retrospectively analyzed the records of all patients consecutively undergoing scheduled anatomical lung resection &#40;standard segmentectomy&#44; lobectomy&#44; bilobectomy&#44; or pneumonectomy&#41; for any cause between October 1994 and February 2018 at our center&#46; All patients with at least one major postoperative complication&#44; defined as grade IIIa or higher according to the standardized Clavien-Dindo morbidity classification&#44; were included in the study<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; Patients with missing data at discharge were excluded from the analysis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patient selection criteria were consistent throughout the study period and were based on the preoperative functional assessment guidelines in place at the time of the intervention<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a>&#46; The patients were operated on by 5 expert surgeons&#46; The surgical approach was via axillary thoracotomy without muscle section or video-assisted thoracoscopic surgery &#40;VATS&#41; in all cases&#46; The patients were extubated in the operating room&#44; and after 6<span class="elsevierStyleHsp" style=""></span>h in the reanimation unit were transferred to the hospital ward&#46; Postoperative analgesia consisted of an epidural catheter with bupivacaine and fentanyl in patients undergoing thoracotomy or a paravertebral catheter with the same medication in cases of VATS approach for 48<span class="elsevierStyleHsp" style=""></span>h and paracetamol and non-steroidal anti-inflammatory drugs thereafter&#46; Postoperative physiotherapy was initiated the day before surgery and continued after patient discharge&#46; During the first 2 years of the study&#44; patients were supervised by nursing staff during physiotherapy&#46; However&#44; in November 2002&#44; the current intensive physiotherapy protocol based on physical exercise on a static bike was implemented&#46; These sessions are supervised by an expert physiotherapist who also assists patients with breathing maneuvers using an incentive spirometer and helps them achieve effective coughing&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patient data were prospectively collected in an institutional database&#46; To improve the quality of the data included in the registry&#44; the completeness and accuracy of the data entries was monitored by a data manager at 2 different timepoints&#58; first&#44; upon discharge from the hospital&#44; and then at the time the last histological result was included in the final medical reports&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The outcome variable was FTR&#44; defined as mortality &#40;in-hospital or 30-day&#41; among patients who experienced a major postoperative complication&#46; In the event of death after hospital discharge&#44; patient records were re-evaluated to determine if the patient died as a result of an in-hospital complication&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Postoperative complication was defined as any adverse event that occurred during admission or within 30 days of surgery&#44; including&#58; respiratory failure &#40;need for mechanical ventilation for more than 24<span class="elsevierStyleHsp" style=""></span>h or need for re-intubation at any time&#41;&#44; acute respiratory distress syndrome&#44; atrial arrhythmia&#44; ventricular arrhythmia&#44; atelectasis requiring bronchoscopy&#44; pneumonia&#44; pulmonary embolism&#44; acute myocardial infarction&#44; renal failure&#44; cerebrovascular accident &#40;CVA&#41;&#44; prolonged air leak &#40;defined as persistent air leak through the pleural tube for more than 5 days after surgery&#41;&#44; hemothorax&#44; pneumothorax with or without air leak requiring drainage&#44; bronchial fistula&#44; wound dehiscence&#44; wound hematoma&#44; empyema&#44; chylothorax&#44; recurrent paralysis&#44; and phrenic nerve paralysis&#46; These complications were defined in advance according to the definition of variables published jointly by the American &#40;STS&#41; and European &#40;ESTS&#41; Societies of Thoracic Surgeons<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and subsequently reclassified retrospectively according to the standardized Clavien-Dindo classification of postoperative morbidity as major &#40;grade III&#58; complications requiring endoscopic or radiological reintervention with or without general anesthesia&#59; grade IV&#58; life-threatening complications requiring treatment in intensive or intermediate care&#59; grade V&#58; complications leading to patient death&#41; or minor &#40;grade I&#58; any deviation from the normal postoperative period that does not require reintervention&#44; while allowing the administration of electrolytes&#44; antiemetics&#44; antipyretics&#44; analgesics&#44; and physiotherapy&#59; grade II&#58; complications requiring pharmacological treatment with drugs other than those allowed for grade I complications&#44; including blood products and parenteral nutrition&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The variables considered as risk factors for postoperative morbidity and mortality&#44; mostly specified in the Eurolung 1 and 2 risk models<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#44; were used as independent predictors in multivariate binary logistic regression analysis&#58; age&#44; body mass index &#40;BMI&#41;&#44; cardiac&#44; renal&#44; cerebrovascular comorbidity &#40;CVA&#41;&#44; expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s predicted postoperatively &#40;ppoFEV1&#37;&#41;&#44; video-assisted thoracoscopy &#40;VATS&#41; approach&#44; extensive resection&#44; pneumonectomy&#44; and reintervention&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A logistic regression model was created for the occurrence of FTR&#46; A backward stepwise logistic regression test was used to select the variables&#46; Only variables with p value &#60;0&#46;05 remained in the final model&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">To estimate the predictive capacity of the model&#44; a non-parametric ROC curve was constructed and the area under the curve &#40;AUC&#41; and its 95&#37; confidence interval &#40;95&#37; CI&#41; were calculated&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Statistical analysis was carried out using the STATA&#47;IC 15&#46;1 statistical software package&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">During the study period&#44; 2569 cases underwent lung resection&#46; In total&#44; 53 patients &#40;2&#46;1&#37;&#41; were excluded due to incomplete data&#46; The demographic and clinical variables of the series are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Overall&#44; 223 &#40;8&#46;9&#37;&#41; had major complications and&#44; of these&#44; 49 &#40;22&#37;&#41; could not be rescued&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the stepwise logistic regression analysis &#40;dependent variable&#58; failure to rescue&#41;&#46; In the final model&#44; the variables associated with FTR were&#58; age&#44; history of stroke&#44; pneumonectomy&#44; and reintervention&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The ROC curve obtained&#44; that estimates the predictive capacity of the model&#44; can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The AUC was 0&#46;82 &#40;95&#37; CI&#58; 0&#46;77&#8211;0&#46;88&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Reproducible indicators that accurately reflect the quality of medical care are essential for health systems&#46; However&#44; traditional parameters&#44; such as complication rate&#44; appear to have a poor correlation with in-hospital mortality due&#44; mainly to differences in the characteristics and risk factors for death after complications among the different patient populations<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; Moreover&#44; the occurrence of postoperative complications is more strongly related to patient-related factors than to hospital characteristics and quality of care<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;18</span></a>&#46; These circumstances mean that the complication rate is a suboptimal indicator of quality of care&#46; A more precise parameter is the measure of the effectiveness of the response to a complication in preventing mortality&#46; Therefore&#44; the use of the FTR index as a measure of the quality of healthcare&#44; understood as the number of deaths among patients experiencing an adverse event such as a postoperative complication&#44; is increasing significantly&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">According to the latest report of the European Society of Thoracic Surgeons &#40;ESTS&#41;&#44; the rate of mortality and cardiorespiratory morbidity after anatomical lung resection is estimated to be 2&#46;3&#37; and 14&#46;9&#37;&#44; respectively<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; according to our results&#44; the prevalence of major complications after anatomical lung resection is 8&#46;9&#37;&#44; with the FTR index reaching 22&#37;&#46; This is similar to the data recorded by Ahmed et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> after cardiac surgery &#40;RTF&#58; 19&#46;8&#37;&#41;&#44; although greater than the 6&#37; published by Liou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> after esophagectomy&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In this study&#44; we identified several patient- and surgery-related factors that predict FTR after anatomical lung resection&#46; To date&#44; studies that have evaluated FTR have focused only on hospital characteristics such as size&#44; patient volume&#44; technological facilities&#44; educational level&#44; and nurse-patient ratios<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;22</span></a>&#46; In thoracic surgery literature&#44; FTR has been studied in lung and esophageal cancer&#44; and findings regarding hospital qualities have been similar<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;23&#44;24</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although modifying certain hospital characteristics may help improve outcomes&#44; our aim was to assess whether any specific patient- or surgery-related factors were associated with a higher probability of mortality after a major postoperative complication&#44; so that by identifying patients at high risk for FTR&#44; we could focus efforts on how to prevent complications in these patients or how to rescue them after a complication does occur&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our data show that age&#44; history of cerebrovascular disease&#44; pneumonectomy&#44; and need for reintervention increase the risk of failure to rescue after lung resection&#46; The logistic regression model based on these variables accurately predicts FTR &#40;AUC&#58; 0&#46;82&#41;&#46; All the variables listed by the risk models of cardiorespiratory morbidity and postoperative mortality &#40;Eurolung 1 and 2&#41; were included as independent variables in multivariate binary logistic regression analysis but&#44; of the patient-related factors&#44; only age and history of stroke emerged as predictors of FTR&#44; while for the surgical procedure&#44; pneumonectomy and the need for reintervention increased the risk of FTR&#46; The effect of the latter&#44; furthermore&#44; is very significant&#44; to the extent that a pneumonectomized patient with a major complication is 6&#46;6 times more likely to die than a patient with a smaller resection&#46; Similarly&#44; a patient who needs a reintervention is 12 times more likely to die than a patient who does not need a reintervention&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">These findings are consistent with previous studies&#46; Elderly patients have higher FTR rates after urgent surgical interventions than younger patients<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#46; Liou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and Varley et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> found that older age was a predictor of FTR after esophagectomy and duodenopancreatectomy&#44; respectively&#46; Our findings of a high risk after complex surgery such as pulmonary resection are therefore not unexpected&#44; as the patient is subjected to extreme physiological stress in all 4 situations&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Numerous studies have shown that pneumonectomy is associated with significant postoperative mortality that can be as high as 8&#46;4&#37; at 30 days and reach 18&#46;5&#37; within 6 months of the intervention<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; The factors that determine these results include patient age&#44; the laterality of the procedure&#44; and the occurrence of postoperative cardiorespiratory complications&#44; so it stands to reason that pneumonectomy is a predictor for FTR&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">However&#44; a recent British study comparing high-mortality hospitals versus low-mortality hospitals after esophagectomy showed that low-mortality hospitals performed more reinterventions for complications but had lower rates of FTR&#46; Our results contradict these findings&#44; and can be explained by the fact that reinterventions after lung resection are usually the consequence of a serious initial complication &#40;hemorrhagic or infectious&#41; from which additional complications arise &#40;prolonged intubation&#44; pneumonia&#44; etc&#46;&#41;&#46; It is&#44; therefore&#44; the accumulation of complications associated with the intervention that leads to FTR&#44; as occurs in other similar scenarios<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Our study has some limitations&#58; as in any retrospective analysis&#44; causality cannot be determined from the different variables analyzed&#59; mortality was only determined in-hospital and at 30 days after discharge&#59; deaths related to postoperative complications that occurred beyond 30 days were not included in the analysis&#59; finally&#44; in terms of the type of anatomical resection performed&#44; although the study included all patients undergoing standard segmentectomy&#44; lobectomy&#44; bilobectomy&#44; or pneumonectomy&#44; only procedures that were found in previous studies to constitute a potential risk of postoperative morbidity and mortality &#40;extended resection and pneumonectomy&#41; were taken into account and included in the multivariate analysis as independent risk variables&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results show that 22&#37; of patients with a major complication did not survive discharge&#46; Factors that predict mortality after major complications include age&#44; history of stroke&#44; pneumonectomy&#44; and reintervention&#46; Although failed rescue efforts may be the result of certain hospital deficiencies&#44; our results confirm the hypothesis that some patients are more likely to die after a major postoperative complication&#46; Further studies are needed to determine how complications could be detected earlier and treated more effectively in this group of high-risk patients&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Source of funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">This study has not received specific grants from public sector agencies&#44; the commercial sector&#44; or non-profit organizations&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Failure to rescue &#40;FTR&#41;&#44; defined as the mortality rate among patients suffering from postoperative complications&#44; is considered an indicator of the quality of surgical care&#46; The aim of this study was to investigate the risk factors associated with FTR after anatomical lung resections&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Patients undergoing anatomical lung resection at our center between 1994 and 2018 were included in the study&#46; Postoperative complications were classified as minor &#40;grade I and II&#41; and major &#40;grade IIIA to V&#41;&#44; according to the standardized classification of postoperative morbidity&#46; Patients who died after a major complication were considered FTR&#46; A stepwise logistic regression model was created to identify FTR predictors&#46; Independent variables included in the multivariate analysis were age&#44; body mass index&#44; cardiac&#44; renal&#44; and cerebrovascular comorbidity&#44; ppoFEV1&#37;&#44; VATS approach&#44; extended resection&#44; pneumonectomy&#44; and reintervention&#46; A non-parametric ROC curve was constructed to estimate the predictive capacity of the model&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A total of 2&#46;569 patients were included&#44; of which 223 &#40;8&#46;9&#37;&#41; had major complications and 49 &#40;22&#37;&#41; could not be rescued&#46; Variables associated with FTR were&#58; age &#40;OR&#58; 1&#46;07&#41;&#44; history of cerebrovascular accident &#40;OR&#58; 3&#46;53&#41;&#44; pneumonectomy &#40;OR&#58; 6&#46;67&#41;&#44; and reintervention &#40;OR&#58; 12&#46;26&#41;&#46; The area under the ROC curve was 0&#46;82 &#40;95&#37; CI&#58; 0&#46;77&#8211;0&#46;88&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Overall&#44; 22&#37; of patients with major complications following anatomical lung resection in this series did not survive until discharge&#46; Pneumonectomy and reintervention are the most significant risk factors for FTR&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El fallo en el rescate &#40;FTR&#41; definido como la tasa de fallecimientos entre los pacientes que sufren una complicaci&#243;n postoperatoria&#44; es considerado un indicador de la calidad de los cuidados quir&#250;rgicos&#46; El objetivo de este estudio es investigar los factores de riesgo asociados al FTR despu&#233;s de resecciones pulmonares anat&#243;micas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron en el estudio pacientes sometidos a resecci&#243;n pulmonar anat&#243;mica en nuestro centro entre 1994 y 2018&#46; Las complicaciones postoperatorias se clasificaron en menores &#40;grados I y II&#41; y mayores &#40;grados IIIa a V&#41; seg&#250;n la clasificaci&#243;n estandarizada de morbilidad postoperatoria&#46; Los casos que fallecieron tras una complicaci&#243;n mayor fueron considerados FTR&#46; Se cre&#243; un modelo de regresi&#243;n log&#237;stica por pasos para identificar los factores predictores de FTR&#46; Se consideraron variables independientes en el an&#225;lisis multivariante la edad&#44; &#237;ndice de masa corporal&#44; comorbilidad cardiaca&#44; renal&#44; cerebrovascular&#44; VEF1ppo&#37;&#44; abordaje VATS&#44; resecci&#243;n extendida&#44; neumonectom&#237;a y reintervenci&#243;n&#46; Se construy&#243; una curva ROC no param&#233;trica para estimar la capacidad predictiva del modelo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 2&#46;569 pacientes&#46; En total&#44; 223 casos &#40;8&#44;9&#37;&#41; tuvieron complicaciones mayores y 49 &#40;22&#37;&#41; no pudieron ser rescatados&#46; Las variables asociadas con FTR fueron&#58; edad &#40;OR&#58; 1&#44;07&#41;&#44; antecedente de ACV &#40;OR&#58; 3&#44;53&#41;&#44; neumonectom&#237;a &#40;OR&#58; 6&#44;67&#41; y reintervenci&#243;n &#40;OR&#58; 12&#44;26&#41;&#46; El &#225;rea bajo la curva de la curva ROC fue 0&#44;82 &#40;IC 95&#37;&#58; 0&#44;77&#8211;0&#44;88&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">22&#37; de los pacientes que presentan complicaciones mayores tras la resecci&#243;n pulmonar anat&#243;mica en esta serie no sobreviven al alta&#46; La neumonectom&#237;a y la reintervenci&#243;n son los factores de riesgo m&#225;s potentes para FTR&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "M&#233;todo"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez Hern&#225;ndez MT&#44; Novoa Valent&#237;n N&#44; Fuentes Gago M&#44; Aranda Alcaide JL&#44; Varela Sim&#243; G&#44; Jim&#233;nez L&#243;pez MF&#46; Variables predictivas de muerte en pacientes complicados tras resecci&#243;n pulmonar anat&#243;mica&#46; Arch Bronconeumol&#46; 2021&#59;57&#58;625&#8211;629&#46;</p>"
      ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">ROC curve for FTR according to the study model&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; ppoFEV1&#37;&#58; predicted postoperative forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s&#59; VATS&#58; video-assisted thoracoscopy&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex &#40;male&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2058 &#40;81&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;1&#46;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;2&#46;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coronary artery disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">380 &#40;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Approach &#40;VATS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">480 &#40;19&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extended resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">367 &#40;14&#46;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pneumonectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">307 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reintervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81 &#40;3&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">65&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ppoFEV1&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&#46;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;15&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p Value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;076&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;040&#8211;1&#46;113&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coronary artery disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;531&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;440&#8211;8&#46;662&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2021.07.003

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Year/Month	Html	Pdf	Total

2024 November	3	0	3
2024 October	32	19	51
2024 September	34	21	55
2024 August	54	27	81
2024 July	34	20	54
2024 June	50	26	76
2024 May	95	32	127
2024 April	33	25	58
2024 March	38	21	59
2024 February	25	31	56
2024 January	27	28	55
2023 December	21	25	46
2023 November	32	18	50
2023 October	32	35	67
2023 September	35	27	62
2023 August	41	30	71
2023 July	41	27	68
2023 June	34	18	52
2023 May	52	20	72
2023 April	39	19	58
2023 March	75	23	98
2023 February	36	28	64
2023 January	47	18	65
2022 December	67	23	90
2022 November	68	34	102
2022 October	60	37	97
2022 September	32	36	68
2022 August	57	41	98
2022 July	58	38	96
2022 June	77	36	113
2022 May	51	38	89
2022 April	60	31	91
2022 March	63	46	109
2022 February	33	14	47
2022 January	1	0	1
2021 October	2	0	2

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