Measuring performance trajectories in lung cancer surgery: a longitudinal study using the French national hospital database from 2020 to 2024
Alain Bernard, Jonathan Cottenet, Pascale Tubert-Bitter, Catherine QuantinObjectives
Lung cancer surgery is associated with significant postoperative morbidity (15%–40%) and mortality (2%–5%), with considerable interhospital variability. This study conducts the first national longitudinal analysis of performance trajectories in lung cancer surgery using advanced trajectory modelling approaches to understand temporal dynamics of quality evolution across hospitals.
Methods
We included all adult patients (French national hospital database, n=56 299; 148 hospitals) who underwent lung resection for primary lung cancer in 2020–2024. The primary outcome was severe complications including major postoperative complications and 30-day mortality. Annual logistic regression models incorporating clinical and procedural variables calculated risk-adjusted rates (RAR) for each hospital. Hospitals were classified using funnel plots corrected for overdispersion. Hidden Markov Models estimated transition probabilities between performance categories, while group-based multitrajectory models identified subgroups of hospitals sharing similar evolution profiles, stratified by activity volume (low, <43; medium, 43-100; high, >100 procedures/year).
Results
Predictive models demonstrated excellent stable discrimination (mean area under the ROC curve=0.890). Markov models revealed strong performance inertia (persistence probabilities ≥78%). Trajectory analysis identified a complex non-linear relationship between volume and quality. Medium-volume hospitals showed optimal improvement trajectories (45.4–45.8% RAR reduction). Conversely, some low-volume centres experienced catastrophic deterioration (843% RAR increase), while paradoxically, a subgroup of high-volume hospitals also showed concerning performance degradation (151% increase).
Discussion
This study demonstrates heterogeneous performance trajectories in French lung cancer surgery, challenging the assumption that high-volume alone guarantees quality and suggesting organisational complexity challenges.
Conclusion
This study shows the value of implementing systematic outcome monitoring using existing administrative data to target quality improvement interventions and reduce inter-hospital performance variations.