Hospital volume and surgeon specialty are important determinants of outcome in lung cancer resections, but evidence-based minimal-volume standards are lacking. Evaluation of individual institutions in a national audit program might help elucidate the influence of individual quality-of-care parameters, including hospital volume, on outcome.

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A clinically relevant between-hospital variation in LOS after lung cancer surgery is observed in the Netherlands. Although residual confounding by comorbidity or socio-economic status cannot be excluded, this variation is deemed to be largely due to differences in perioperative care protocols. Evaluation of best practices can help to improve perioperative care for lung surgery patients and optimize LOS.

ObjectivesThis study aims to elucidate determinants for succesful implementation of the Enhanced Recovery After Thoracic Surgery (ERATS) protocol for perioperative care for surgical lung cancer patients in the Netherlands.SettingLung cancer operations are performed in both academic and regional hospitals, either by cardiothoracic or general thoracic surgeons. Limiting the impact of these operations by optimising and standardising perioperative care with the ERATS protocol is thought to enable reduction in length of stay, complications and costs.ParticipantsA broad spectrum of stakeholders in perioperative care for patients with lung resection participated in this study, ranging from patient representatives, healthcare professionals to an insurance company representative.InterventionsSemistructured interviews (N=14) were conducted with the stakeholders (N=18). The interviews were conducted one on one by telephone and two times, face to face, in small groups. Verbatim transcriptions of these interviews were coded for the purpose of thematic analysis.Outcome measuresDeterminants for successful implementation of the ERATS protocol in the Netherlands.ResultsSeveral determinants correspond with previous publications: having a multidisciplinary team, leadership from a senior clinician and support from an ERAS-coordinator as facilitators; lack of feedback on performance and absence of management support as barriers. Our study underscores the potential detrimental effect of inconsistent communication, the lack of support in the transition from hospital to home and the barrier posed by lack of accessible audit data.ConclusionsBased on a structured problem analysis among a wide selection of stakeholders, this study provides a solid basis for choosing adequate implementation strategies to introduce the ERATS protocol in the Netherlands. Emphasis on consistent and sufficient communication, support in the transition from hospital to home and adequate audit and feedback data, in addition to established implementation strategies for ERAS-type programmes, will enable a tailored approach to implementation of ERATS in the Dutch context.

BACKGROUND: Local treatment for pulmonary metastases is considered to be a reasonable treatment option in patients with oligometastatic disease. Percutaneous radio frequency ablation (RFA) has been reported as an alternative to surgery. Results of RFA for local control of pulmonary metastases were evaluated. METHODS: All consecutive patients treated with RFA for pulmonary metastases (2004)(2005)(2006)(2007)(2008)(2009) were included. RFA was performed percutaneously under computed tomographic guidance. Follow-up was scheduled at 1, 3, and 6 months after treatment and every 6 months thereafter. Major outcome parameters were local and any-site progression, complications, and survival. RESULTS: Ninety pulmonary metastases were treated, in 46 patients at 65 sessions. Many patients had recurrent metastases after previous surgery (n ¼ 36 of 46). Pneumothorax occurred in 34% (chest drain in 25%) and major complications in 6%. After median follow-up of 22 months (range, 2-65 months), 25 local progressions occurred after RFA; the 2-year local progression rate per lesion was 35%. Overall survival at 3 years was 69%. CONCLUSIONS: Notwithstanding its relatively low morbidity, follow-up after RFA for pulmonary metastases shows a considerable rate of local progression. The role of local ablation techniques for long-term disease control in oligometastatic disease is discussed.

OBJECTIVES Good perioperative care is aimed at rapid recovery, without complications or readmissions. Length of stay (LOS) is influenced not only by perioperative care routines but also by patient factors, tumour factors, treatment characteristics and complications. The present study examines variation in LOS between hospitals after minimally invasive lung resections for both complicated and uncomplicated patients to assess whether LOS is a hospital characteristic influenced by local perioperative routines or other factors. METHODS Dutch Lung Cancer Audit (surgery) data were used. Median LOS was calculated on hospital level, stratified by the severity of complications. Lowest quartile (short) LOS per hospital, corrected for case-mix factors by multivariable logistic regression, was presented in funnel plots. We correlated short LOS in complicated versus uncomplicated patients to assess whether short LOS clustered in the same hospitals regardless of complications. RESULTS Data from 6055 patients in 42 hospitals were included. Median LOS in uncomplicated patients varied from 3 to 8 days between hospitals and increased most markedly for patients with major complications. Considerable between-hospital variation persisted after case-mix correction, but more in uncomplicated than complicated patients. Short LOS in uncomplicated and complicated patients were significantly correlated (r = 0.53, P < 0.001). CONCLUSIONS LOS after minimally invasive anatomical lung resections varied between hospitals particularly in uncomplicated patients. The significant correlation between short LOS in uncomplicated and complicated patients suggests that LOS is a hospital characteristic potentially influenced by local processes. Standardizing and optimizing perioperative care could help limit practice variation with improved LOS and complication rates.

Background and purpose: This study aimed to investigate the embolic potential of carotid plaques, employing both the presence and the rate of micro-embolic signals (MESs), based on the presence and timing (current or past) of symptoms, degree of stenosis and ultrasonic characteristics of plaques.Methods: We used the transcranial Doppler (TCD) to monitor MES and the Doppler ultrasound to classify carotid plaques in newly symptomatic (acute stroke or transient ischaemic attack (TIA)), formerly symptomatic (relevant stroke or TIA per anamnesis) and asymptomatic patients with internal carotid artery (ICA) stenosis.Results: Stroke-related arteries evidenced a significantly greater presence of MES than the TIA-related and asymptomatic arteries (p ϭ 0.04), with no significant difference found between the latter two groups (stroke: 42/90, 46.7%; TIA: 15/49, 30.6%; asymptomatic: 40/130, 30.8%). Adjustment for anti-platelet treatment did not change this finding. The degree of stenosis, ultrasonic characteristics of texture and the density of plaques were not found to be associated with the presence or quantity of MES.Conclusion: MESs are present significantly more often in stenosed, stroke-related carotid arteries as compared with TIA-related or asymptomatic arteries. Neither the ultrasonic characteristics nor the degree of stenosis were found to influence the presence or rate of MES. Association between White Matter Ischaemia and Carotid Plaque Morphology as Defined by High-resolution In Vivo MRIPatterson A.

Objective To perform a qualitative evaluation of the Thyroid Network, with a quantitative analysis of second opinion referrals for patients in the southwestern part of the Netherlands who have thyroid nodules and cancer. Methods This prospective observational study registered all patients with thyroid nodules and cancer who were referred to the academic hospital from 2 years before and 4 years after the foundation of the Thyroid Network. We implemented biweekly regional multidisciplinary tumor boards using video conference and a regional patient care pathway for patients with thyroid nodules and cancer. For qualitative evaluation, interviews were conducted with a broad selection of stakeholders via maximum variation sampling. The primary outcome was the change in second opinions after the foundation of the Thyroid Network. Results Second opinions from Thyroid Network hospitals to the academic hospital decreased from 10 (30%) to 2 (7%) two years after the start of the Thyroid Network ( P = .001), while patient referrals remained stable (n = 108 to 106). Qualitative evaluation indicated that the uniform care pathway and the regional multidisciplinary tumor board were valued high. Discussion Establishing a regional network, including multidisciplinary tumor boards and a care pathway for patients with thyroid nodules and cancer, resulted in a decrease in second opinions of in-network hospitals and high satisfaction of participating specialists. Implications for Practice The concept of the Thyroid Network could spread to other regions as well as to other specialties in health care. Future steps would be to assess the effect of regional collaboration on quality of care and patient satisfaction.