# Evaluation of the Quality of Results of Lung Cancer Surgery in France Using the PMSI National Database

## TL;DR

This study uses French hospital data to show that lung cancer surgery outcomes vary widely, with higher complication rates in low-volume hospitals, suggesting the need for healthcare restructuring.

## Contribution

The study introduces a novel analysis of lung cancer surgery outcomes in France using national data to advocate for hospital reorganisation based on surgical volume.

## Key findings

- Severe complication rates vary up to three times between hospitals in France.
- Hospitals performing more than 100 procedures/year have significantly lower complication risks.
- Restructuring hospitals based on a 100-procedure/year threshold could prevent 477 severe complications.

## Abstract

Given the complexity of lung cancer surgery, it has become imperative to carry out an in-depth assessment of the current state of these surgical practices throughout France in order to improve the quality of care. This study aims to provide an overview of hospitals authorised to perform lung cancer surgery and to assess their performance based on key outcomes. This innovative work shows the variability of lung cancer surgery outcomes within French regions with complication rates (Clavien–Dindo > 2) up to three times higher between hospitals. A simulation of hospital reorganisation (threshold value = 100 procedures/year) made it possible to estimate that 477 severe complications or deaths could have been avoided over the study period (2019–2023). The clear link between surgical volume and patient outcomes calls for a serious re-evaluation of the current healthcare organisation for complex surgeries like lung cancer resection.

Background. Given the complexity of lung cancer surgery, this study aims to provide an overview of hospitals authorised to perform lung cancer surgery in France, and to assess their performance focusing on severe post-operative complications and 30-day in-hospital mortality based on the Clavien–Dindo classification (grade > 2). Methods. We included all patients (n = 64,304) who underwent pulmonary resection for lung cancer from the French hospital database (2019–2023). To quantify variations within regions, we used the ratio of the 90th to the 10th decile of the standardised outcome rate of the hospitals. We used a hierarchical logistic regression model to estimate the adjusted odds ratio (aOR) according to the number of annual procedures. We then used the results of this modelling to see how the standardised rate estimate might evolve after simulating a new organisation of hospitals authorised to perform this surgery. Results. A total of 18,151 patients (28%) had severe complications (Clavien–Dindo > 2). Compared to hospital performing less than 100 procedures/year, the risk of severe complications was significantly reduced for hospitals performing between 101 and 250 procedures/year (aOR = 0.83 [0.77–0.89]) and more than 250 procedures/year (aOR = 0.85 [0.77–0.93]). A simulation of hospital reorganisation, using 100 procedures/year as the threshold value, showed that 477 severe complications could have been prevented over the period. Conclusions. This study shows inequalities in performance indicators between hospitals in each French region. The influence of the volume of activity raises questions about the need to restructure the offer of care for complex surgeries, such as lung cancer surgery.