BMJ  2004;329:1011-1012 (30 October), doi:10.1136/bmj.329.7473.1011

Paper

Variation in use of video assisted thoracic surgery in the United Kingdom

¹ Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, ² Cardiothoracic Unit, Guy's Hospital, London SE1 9RT

Introduction

Video assisted thoracic surgery (VATS) is a minimally invasive technique for the diagnosis and treatment of lung and pleural disease. Thoracotomy is replaced by up to three small incisions from 0.5 to 2.0 cm long and well lit video images are displayed on large screens, allowing the surgeon, assistants, and students a view.¹ Variation in the use of medical procedures cannot be fully explained by the prevalence of the disease in question or health characteristics of populations. The willingness of the surgeon to provide a procedure, rather than its appropriateness for the patient, may explain a substantial variation in practice.^{2 3 4}

In our companion paper in this issue we systematically reviewed the evidence for VATS for pneumothorax surgery, minor resections, and lobectomy.⁵ Here we determine variation in the use of this procedure in UK practice.

Participants, methods, and results

From the register of the Society of Cardiothoracic Surgeons of Great Britain and Ireland (2000-2002) we extracted for the counts of patients operated on for pneumothorax, lobectomy, and sublobar (usually wedge) resections. Multilevel logistic regression was used to take account of the clustering of patients within centres (MlwiN statistical package, release 1.10.0007). We transformed the proportions of VATS versus thoracotomy for each hospital on to log odds scales and used the variance among hospitals as a measure of the variation in VATS use. We estimated the correlation between VATS use for pneumothorax and minor resection with the multilevel approach.

Pneumothorax surgery—2606 procedures were performed in 40 centres. VATS was used in 1485 (57%) of these procedures. VATS use ranged from 0% to 100% (figure).

View larger version (32K): [in this window] [in a new window]   Variation between UK hospitals in use of VATS for pneumothorax. Centres are ranked by proportion of VATS use and vertical lines represent 95% confidence intervals

 

Minor resection—2691 procedures were performed in 39 centres. VATS was used in 1507 (56%), with less variation compared with pneumothorax surgery.

Lobectomy—3879 lobectomies were performed in 40 hospitals. VATS was used in only six hospitals, with two hospitals accounting for over 60% of the use. As only 3% (n = 123) of lobectomies were performed by VATS in just 15% of units, further statistical analysis was not considered useful.

Variation between hospitals in VATS use for pneumothorax surgery was substantially larger than that for minor resection (variance in use on log odds scale 5.0 and 1.1, respectively, P < 0.001). The correlation between use of VATS for pneumothorax surgery and minor resections was estimated to be 0.39 (P = 0.04). Variation was not related to the total number of procedures that the units had carried out.

What is already known on this topic Video assisted thoracic surgery is effective and is a less invasive treatment for pneumothorax than thoracotomy What this study adds In the United Kingdom adoption of video assisted thoracic surgery for pneumothorax ranges from none to 100%

Comment

There is wide variation in the adoption of VATS in UK thoracic surgery. We believe this variation is more likely to be related to preferences of individual surgeons rather than the facilities available because the correlation between use of VATS for pneumothorax and minor resections is not strong. Although some variation may be related to differences in patients' characteristics, differences in case mix are unlikely to explain this large variation in practice. Given the evidence for VATS use in pneumothorax and minor lung resections⁵ the large variation in the implementation of this technology deserves reflection. The transition from a policy of full thoracotomy to the new technology takes retraining and practice, but those who have adopted VATS find that rather than being a compromise procedure, undertaken to spare the patient a thoracotomy and to reduce pain and bed days, it is a technically better approach. The surgeon operates in a comfortable position with an enhanced and well lit view of the operative field, which is seen equally well by everyone in the operating room. This greatly facilitates training and supervision.

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Data were voluntarily provided by members of the Society of Cardiothoracic Surgeons of Great Britain and Ireland. Tom Treasure is responsible to the society for the collection and collation of these data and has a mandate from the society's annual general meeting of its members to disseminate information based on the data.

Contributors: AS, TT, and JvdM were responsible for study concept and design. TT and AS were responsible for acquisition of the data and administrative, technical, or material support. AS and JL analysed the data and provided statistical expertise. AS drafted and TT finalised the manuscript. All authors interpreted the results and critically revised the manuscript for important intellectual content. TT and AS are guarantors.

Funding: There was no specific funding for this study.

Competing interests: None declared.

Ethical approval: Not required.

References

1. Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW. One hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg 1992;54: 421-6.[Abstract]
2. Wennberg JE. Understanding geographic variations in health care delivery. N Engl J Med 1999;340: 52-3.[Free Full Text]
3. Detsky AS. Regional variation in medical care. N Engl J Med 1995;333: 589-90.[Free Full Text]
4. Laycock WS, Siewers AE, Birkmeyer CM, Wennberg DE, Birkmeyer JD. Variation in the use of laparoscopic cholecystectomy for elderly patients with acute cholecystitis. Arch Surg 2000;135: 457-62.[Abstract/Free Full Text]
5. Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials. BMJ 2004;329:.

(Accepted 30 September 2004)

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