Using Vizient database for benchmarking pulmonary resection outcomes
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Key findings
• The Vizient database is valid method of measuring pulmonary resection and provides benchmarking information compared to other institutions.
What is known and what is new?
• Currently, the Society of Thoracic Surgeons General Thoracic Surgical Database (GTSD) is used to benchmark thoracic surgery outcomes but it is costly and not all hospitals participate in the program.
• The Vizient database can provide outcome of lung resection and allows for benchmarking to similar hospital.
What is the implication, and what should change now?
• Hospital systems that do not have GTSD and use Vizient can modify the Vizient database to evaluate outcomes after lung resection. The database can provide benchmarking compared to other hospitals and would be more economical than purchasing the GTSD program.
Introduction
Pulmonary resection is performed by thoracic surgeons to treat diseases such as lung cancer, metastatic cancer of the lung, congenital abnormalities, or suspicious lung nodules. Several databases provide outcome and benchmark information for pulmonary resection, including the Vizient database (1), the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) (2,3), and the Society of Thoracic Surgeons General Thoracic Surgical Database (GTSD) (4). Both NSQIP and GTSD provide outcomes after lung resection; the data for NSQIP may not reflect the outcomes of the thoracic surgery program because it captures select cases instead of all of the cases of the surgery program (5). Thus, GTSD is the gold standard for determining outcomes after lung resection. The GTSD was established in 2002 and has more than 800,000 general thoracic surgery procedures, with 287 participating sites (4). The database is the gold standard for surgeons to understand outcomes and implement programs to improve outcomes in patients undergoing surgical resection (6,7). In 2021, the GTSD updated its database to abstract only patients with lung cancer. One downside of the GTSD program is that it is not universally adopted by all hospitals that perform pulmonary resection, and the data are limited to only lung cancer patients.
The Vizient database is a comprehensive collection of data and analytic services provided by Vizient Inc. The database was created to support hospitals in improving their performance and enhancing patient outcomes. The Vizient database was created using an administrative database that examined different aspects of patient care. Vizient is an administrative database that tracks the length of hospital stay (LOS), mortality, and readmission after a given procedure and provides an estimate of the observed to expected LOS and mortality. The advantage of this database is that it uses billing codes to determine patient outcomes and benchmarks them to other similar institutions to provide performance information for different groups. However, the standard Vizient database is not ideal for providing the surgical outcomes. The standard “Thoracic Surgery” outcome groups all cases coded by the hospital as a major thoracic procedure; thus, it captures all cases. The disadvantage of this database is that the outcomes may not reflect thoracic surgery performed by thoracic surgeons, since the coding error may place a procedure such as transbronchial lung biopsy performed by a pulmonologist as a major thoracic surgery. Thus, comparing the “Thoracic Surgery” outcomes among the hospitals does not help improve outcomes since the “Thoracic Surgery” bundle contains many procedures that are not performed by a thoracic surgeon. To provide useful outcome data for surgeons who perform lung resection, we modified the Vizient database to provide accurate data for lung resection at each institution. In this study, we aimed to validate the expected outcomes in the modified Vizient database, aligned with the expected risks after pulmonary resection. Moreover, we aimed to determine whether the outcomes could be compared with those of other hospitals. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-93/rc).
Methods
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of the Houston Methodist Hospital Research Institute (No. Pro00013680). Participants gave informed consent for participation in a registry for research. We performed a retrospective cohort study of pulmonary resection performed at Houston Methodist Hospital (HMH) from to 2019–2021 using the Vizient database and GTSD. We created a pulmonary resection Vizient dashboard by selecting pulmonary resection and excision procedures performed by surgeons in the Division of Thoracic Surgery from the Vizient database.
The dashboard was created by our Vizient analysts who were hired by the hospital. They created the dashboard by first sourcing the data directly from Vizient and matching it with our internal electronic medical record data. This combined data source allowed us to introduce Vizient risk-adjusted metrics for each encounter. They then limited their data to specific lobectomy procedures. Next, the analysts used Tableau as a visualization tool. They stratified the data based on the Houston Methodist facility, as well as the principal procedure physician and the specific procedure. They focused on high-level quality metrics including the case mix index (CMI), length of stay (LOS), mortality, and unplanned readmissions. They included Vizient risk-adjusted metrics for LOS and mortality, allowing them to compare our metrics with those of similar hospitals across the nation.
We validated the Vizient dashboard using the HMH GTSD. First, we examined whether all the cases captured by the GTSD were on the Vizient dashboard. Second, we validated the dashboard by examining the factors associated with the expected length of hospital stay and expected mortality, and analyzed the outcomes. Since there was a significant difference in LOS between patients who underwent wedge resection and those who underwent anatomical lung resection without differences in survival, we divided the lung resection between wedge resection and anatomic lung resection to understand how the Vizient database assesses these two types of procedures.
For the analysis of the factors associated with the expected LOS and mortality, we excluded diagnostic wedge resection and blebectomy that were captured in the modified Vizient database because the time of analysis our HMH GTSD collected all lung resections, except for these two case types. We used the GTSD and electronic health records to obtain the demographic information and patient comorbidities. We also performed pulmonary function tests for these patients, including the forced expiratory volume in 1 second (FEV1) and diffusion capacity for carbon monoxide (DLCO). Smoking status was recorded as ever or never smoking. Alcohol status was recorded as current drinking. We recorded whether preoperative chemotherapy or radiation was administered. Surgical approaches include robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open surgery. The extent of resection was determined as wedge resection, segmentectomy, or lobectomy. We noted whether the resection was anatomical or wedge resection. Final pathological data, including disease stage, were collected. Postoperative events and readmission rates were measured.
Statistical analysis
Generalized linear modeling was performed to determine the demographic characteristics, comorbidities, pulmonary function, social history, pathology, procedural factors associated with expected LOS, and expected mortality. We also examined the LOS index, mortality index, and 30-day readmission rates of similar institutions. The correlation between characteristics, expected LOS, and expected mortality was reported as beta coefficients (coef.) with 95% confidence intervals (CIs). The index values were reported as ratios. We then measured the LOS index, mortality index, and 30-day readmission rate in the Vizient database for similar institutions and compared the values measured in our Vizient dashboard. These parameters were reported as percentiles. The benchmark information was obtained from the GTSD.
Results
All patients in the GTSD were identified on the Vizient pulmonary resection dashboard. The Vizient pulmonary resection dashboard also included patients who underwent a diagnostic wedge as well as blebectomy for the treatment of spontaneous pneumothorax. Thus, the Vizient pulmonary resection dashboard was able to capture all pulmonary resections performed by thoracic surgeons that had occurred in the hospital.
A total of 184 patients underwent pulmonary resection for analysis of the expected LOS and expected mortality. The median age of the group was 70 years [interquartile range (IQR), 64–75 years], with the majority females (n=111, 60.3%) and white (n=131, 71.2%). Most patients had hypertension (n=113, 61.4%), and most patients were either former or current smokers (n=98, 53.3%). Most patients underwent RATS (n=182, 98.9%), with lobectomy (n=112, 60.9%) being the most common type of surgery. Most patients underwent pulmonary resection for primary lung cancer (n=140, 76.1%). Postoperative events occurred in 38 patients (20.7%) (Table 1). The Vizient database showed that most patients were coded as having pulmonary resection (n=105, 57.1%) and the majority were coded as MS-DRG 164, major chest procedures with complications or comorbidities (n=103, 56%). The expected median LOS for the cohort was 4.1 days (IQR, 3.5–4.9 days), and the average expected mortality was 0.5±0.6 (Table 2). The 30-day all cause readmission rate of the cohort was 7.1% and the surgery-related readmission rate was 2.2%.
Table 1
| Characteristics | Total (n=184) | Wedge resection (n=55) | Anatomic resection (n=129) | P value |
|---|---|---|---|---|
| Demographics | ||||
| Age (years) | 70.0 (64.0, 75.0) | 70.0 (60.0, 74.0) | 70.0 (64.0, 75.0) | 0.28 |
| Female | 111 (60.3) | 32 (58.2) | 79 (61.2) | 0.70 |
| Race/ethnicity | 0.51 | |||
| White | 131 (71.2) | 41 (74.5) | 90 (69.8) | |
| Black | 22 (12.0) | 8 (14.5) | 14 (10.9) | |
| Hispanic | 20 (10.9) | 5 (9.1) | 15 (11.6) | |
| Asian | 7 (3.8) | 1 (1.8) | 6 (4.7) | |
| Unknown | 4 (2.2) | 0 (0.0) | 4 (3.1) | |
| Clinical parameters | ||||
| Hypertension | 113 (61.4) | 39 (70.9) | 74 (57.4) | 0.08 |
| Congestive heart failure | 7 (3.8) | 3 (5.5) | 4 (3.1) | 0.44 |
| Coronary artery disease | 23 (12.5) | 5 (9.1) | 18 (14.0) | 0.36 |
| Myocardial infarction | 9 (4.9) | 2 (3.6) | 7 (5.4) | 0.61 |
| AFIB | 14 (7.6) | 3 (5.5) | 11 (8.5) | 0.47 |
| Pulmonary hypertension | 2 (1.1) | 0 (0.0) | 2 (1.6) | 0.35 |
| Major vascular disease | 4 (2.2) | 0 (0.0) | 4 (3.1) | 0.18 |
| DVT/PE | 9 (4.9) | 3 (5.5) | 6 (4.7) | 0.82 |
| Stroke | 10 (5.4) | 2 (3.6) | 8 (6.2) | 0.48 |
| Diabetes | 39 (21.2) | 11 (20.0) | 28 (21.7) | 0.80 |
| Dialysis | 3 (1.6) | 3 (5.5) | 0 (0.0) | 0.01 |
| Smoking | 98 (53.3) | 27 (49.1) | 71 (55.0) | 0.46 |
| Alcohol | 67 (36.4) | 19 (34.5) | 48 (37.2) | 0.73 |
| FEV1 (L) | 89.0 (76.5, 102.0) | 81.8 (67.5, 97.0) | 91.5 (78.5, 103.0) | 0.01 |
| DLCO (mL/min/mmHg) | 78.0 (67.8, 93.7) | 74.7 (64.8, 92.0) | 79.7 (68.7, 94.1) | 0.051 |
| Preop chemo | 8 (4.3) | 2 (3.6) | 6 (4.7) | 0.76 |
| Preop radiation | 1 (0.5) | 0 (0.0) | 1 (0.8) | 0.51 |
| Surgical parameters | ||||
| Approach | 0.25 | |||
| Robot-assisted | 182 (98.9) | 54 (98.2) | 128 (99.2) | |
| Video-assisted | 1 (0.5) | 1 (1.8) | 0 (0.0) | |
| Open | 1 (0.5) | 0 (0.0) | 1 (0.8) | |
| Conversion | 1 (0.5) | 0 (0.0) | 1 (0.8) | 0.51 |
| Extent of resection | <0.001 | |||
| Wedge | 55 (29.9) | 55 (100.0) | 0 (0.0) | |
| Segmentectomy | 13 (7.1) | 0 (0.0) | 13 (10.1) | |
| Lobectomy | 112 (60.9) | 0 (0.0) | 112 (86.8) | |
| Pneumonectomy | 4 (2.2) | 0 (0.0) | 4 (3.1) | |
| Pathology | <0.001 | |||
| Metastasis to lung | 18 (9.8) | 14 (25.5) | 4 (3.1) | |
| Lung cancer | 140 (76.1) | 21 (38.2) | 119 (92.2) | |
| Other | 26 (14.1) | 20 (36.4) | 6 (4.7) | |
| Surgical outcome | ||||
| Post-op event | 38 (20.7) | 2 (3.6) | 36 (27.9) | <0.001 |
Data are presented as median (IQR) or n (%). AFIB, atrial fibrillation; DLCO, diffusion capacity of the lungs for carbon monoxide; DVT/PE, deep vein thrombosis/pulmonary embolism; FEV1, forced expiratory volume in 1 second; GTSD, Society of Thoracic Surgeons General Thoracic Surgical Database; IQR, interquartile range; preop chemo, preoperative chemotherapy; post-op, postoperative.
Table 2
| Parameters | Total (n=184) | Wedge resection (n=55) | Anatomic resection (n=129) | P value |
|---|---|---|---|---|
| Case mix index | 2.5 (1.9, 2.6) | 2.5 (1.9, 2.6) | 2.5 (1.9, 2.6) | 0.75 |
| Procedure group | <0.001 | |||
| Excision | 79 (42.9) | 50 (90.9) | 29 (22.5) | |
| Resection | 105 (57.1) | 5 (9.1) | 100 (77.5) | |
| MS-DRG | 0.88 | |||
| DRG 163—major chest procedures with MCC | 16 (8.7) | 4 (7.3) | 12 (9.3) | |
| DRG 164—major chest procedures with CC | 103 (56.0) | 32 (58.2) | 71 (55.0) | |
| DRG 165—major chest procedures without CC/MCC | 65 (35.3) | 19 (34.5) | 46 (35.7) | |
| Vizient administrative data | ||||
| Expected LOS (days) | 4.1 (3.5, 4.9) | 3.4 (2.8, 3.9) | 4.4 (4.1, 5.3) | <0.001 |
| Expected mortality | 0.5±0.6 | 0.5±0.6 | 0.6±0.6 | 0.67 |
| Observed LOS (days) | 2.0 (1.0, 3.0) | 1.0 (1.0, 1.0) | 2.0 (2.0, 4.0) | <0.001 |
| LOS index without outliers | 0.5 (0.3, 0.7) | 0.3 (0.3, 0.4) | 0.6 (0.4, 0.9) | <0.001 |
| Mortality index | 0 (–) | 0 (–) | 0 (–) | – |
Data are presented as median (IQR), n (%), or mean ± SD. CC, comorbidity or complication; IQR, interquartile range; LOS, length of stay; MCC, major comorbidity or complication; MS-DRG, Medicare Severity Diagnosis Related Group; SD, standard deviation.
There were 55 patients who underwent wedge resection, and 129 patients underwent anatomical resection. We compared patients who underwent wedge resection with those who underwent anatomic resection. Patients in the wedge group had similar characteristics to those who underwent anatomical resection, except that patients who underwent wedge resection had more patients on dialysis (5.5% vs. 0, P=0.01) and had a lower FEV1 (81.8% vs. 91.5%, P=0.01). More patients who underwent wedge resection had metastasis to the lung (25.5% vs. 3.1%, P<0.001) and a lower stage of lung cancer (P<0.001). More patients in the wedge group were principally diagnosed with solitary pulmonary nodules (21.8% vs. 7%, P<0.001). Most of the patients in the wedge group were diagnosed with pulmonary excision (n=50, 90.9%), while most of the patients in the anatomical resection group were diagnosed with pulmonary resection (n=100, 77.5%). There was no difference in MS-DRG coding. More patients in the anatomical resection group experienced postoperative events (27.9% vs. 3.6%, P<0.001).
Generalized linear modeling showed that expected LOS was associated with congestive heart failure (beta coef. 0.88, 95% CI: 0.04–1.72, P=0.04) and pulmonary hypertension (beta coef. 3.22, 95% CI: 1.56–4.88, P<0.001), and anatomical resection (beta coef. 1.10, 95% CI: 0.73–1.48, P<0.001, Table 3). Expected mortality was associated with older age (beta coef. 0.01, 95% CI: 0.01–0.02, P<0.001), male (beta coef. 0.53, 95% CI: 0.37–0.70, P<0.001) and pulmonary hypertension (beta coef. 0.82, 95% CI: 0.01–1.63, P=0.047), lower FEV1 (beta coef. −0.01, 95% CI: −0.01 to 0, P=0.03, Table 4).
Table 3
| Characteristics | Multivariable (n/N=175/184) | |
|---|---|---|
| β coef. (95% CI) | P value | |
| Age (years) | 0.01 (−0.01, 0.03) | 0.28 |
| Congestive heart failure | 0.88 (0.04, 1.72) | 0.04 |
| Pulmonary hypertension | 3.22 (1.56, 4.88) | <0.001 |
| Case mix index | 0.42 (0.20, 0.63) | <0.001 |
| Extent of resection | ||
| Wedge | (Reference) | |
| Anatomic resection | 1.10 (0.73, 1.48) | <0.001 |
CI, confidence interval; coef., coefficient; GLM, generalized linear model; n, number of patients having complete data for the model’s variables; N, total number of patients in the cohort.
Table 4
| Characteristics | Multivariable (n/N=175/184) | |
|---|---|---|
| β coef. (95% CI) | P value | |
| Age (years) | 0.01 (0.01, 0.02) | <0.001 |
| Gender | ||
| Female | (Reference) | |
| Male | 0.53 (0.37, 0.70) | <0.001 |
| Pulmonary hypertension | 0.82 (0.01, 1.63) | 0.047 |
| FEV1 (L) | −0.01 (−0.01, 0.00) | 0.03 |
CI, confidence interval; coef., coefficient; FEV1, forced expiratory volume in 1 second; GLM, generalized linear model; n, number of patients having complete data for the model’s variables; N, total number of patients in the cohort.
The LOS index, which was calculated as the observed over expected LOS for the patient, was 0.63 (mean) and 0.5 (median), and the mortality index was 0 for the institution. The 30-day readmission rate for the surgery was 2.2%. Compared to other institutions, the LOS index, mortality index, and readmission rates were better than the 95 percentiles in similar institutions (Table 5). The GTSD benchmarked the hospital program as a two-star program (out of three stars), where 89% of the programs are two-star programs (8). Thus, the Vizient dashboard provides better benchmarking information than GTSD.
Table 5
| Percentile | Mortality index | LOS index | 30-day readmission (%) |
|---|---|---|---|
| 95 | 0.31 | 0.77 | 4.39 |
| 90 | 0.47 | 0.82 | 5.22 |
| 85 | 0.53 | 0.85 | 5.7 |
| 80 | 0.57 | 0.87 | 5.99 |
| 75 | 0.6 | 0.9 | 6.23 |
| 70 | 0.67 | 0.93 | 6.53 |
| 65 | 0.68 | 0.94 | 6.79 |
| 60 | 0.72 | 0.95 | 7.15 |
| 55 | 0.8 | 0.96 | 7.35 |
| 50 | 0.86 | 0.98 | 7.79 |
LOS, length of stay.
Discussion
The Vizient database can be modified to capture lung resection outcomes on a dashboard. The dashboard can provide information on the length of hospital stay, mortality, and readmission for all lung resections. The expected LOS and mortality correlate with expected factors that prolong the LOS and increase mortality risk. In addition, the outcomes can be compared to those of similar hospitals and provide ranking information. The cost of modifying the database to create a Vizient pulmonary resection dashboard is a couple of weeks of work by the analyst; however, once it is created, the data can be updated by analysts by spending a couple of hours per month.
Analysis of the GTSD over the years showed that many hospitals have not used the GTSD to track outcomes. In 2013, only 14% (169/1,187) of the hospitals that performed >5 lobectomies based on the Center for Medicare and Medicaid Services (CMS) participated in the GTSD program (9). In 2023, the number of participating institutions increased to 287 (4). Thus, many hospitals in the country that perform pulmonary resection do not participate in GTSD. Participation in the GTSD was significantly lower than that in the Society of Thoracic Surgeons (STS) Adult Cardiac Database, with a participation rate of 90% and a congenital heart surgery database of 95%. There are likely two main reasons for this lack of participation: the cost of participation in the program and institutional volumes. Most surgeons who perform pulmonary resection are cardiothoracic surgeons who perform cardiac surgery most of their time, with occasional pulmonary resection. There is a cost associated with participation in the GTSD, which includes hiring a full-time employee to enter the data into the database, and the cost of enrolling the surgeon and the institution in the program; most surgeons opt to participate only in the STS Adult Cardiac Database (10). In addition, most hospitals have a low volume of general thoracic surgery cases, which does not provide an incentive to participate in the GTSD. However, a large number of hospitals use the Vizient database to monitor outcomes.
GTSD provides granular information about morbidity associated with lung resection, which could explain the prolonged length of hospital stay. It tracks individual complications, such as pneumonia, atrial fibrillation, and persistent air leaks. On the other hand, the outcomes for the LOS and mortality in the Vizient database are reported as an index, which is the observed LOS over the expected LOS for the LOS index and the observed mortality over expected mortality for the mortality index. The average LOS index and mortality index were calculated to provide an aggregate number. This analysis is valid only if the expected LOS and mortality are related to known factors. Our study shows that the expected LOS calculated by the Vizient dashboard accurately adjusted for factors associated with a longer LOS. Pulmonary resection Vizient dashboard showed that the expected LOS was associated with two patient-related factors (congestive heart failure and pulmonary hypertension) and one procedural factor (anatomical resection) (11). Patients with congestive heart failure or pulmonary hypertension require a significant amount of time to recover after pulmonary resection. The Vizient database showed that expected mortality after pulmonary resection is associated with factors expected after lung resection. Studies have shown that older patients have a higher risk of death after pulmonary resection (12-14) after lung resection.
Using these index calculations, we compared the index outcomes (LOS and mortality) those with of other programs. We discovered that our program had better outcomes than 95% of the programs that participated in the Vizient program. This provided a better ranking assessment of our thoracic surgical program than the GTSD rating score. The Vizient database provides an excellent alternative for lower-volume programs to obtain granular and thorough data to understand areas of strength and areas needing improvement compared to similar institutions. More than a thousand institutes around the country utilize Vizient, and this body of work will show that they can use an already available administrative database to track at improve their outcomes.
A limitation of the Vizient database is that it is an administrative database. The database uses billing codes to determine the operation type. There could be errors in how the case was coded, which could have provided incorrect information. While all wedges should be coded as pulmonary excision and all anatomical resection should be coded as pulmonary resection, this was not the case in our analysis. However, our study showed that using these two codes for lung resection and limiting the data to individual surgeons, we were able to capture all lung resections performed at our institution. In addition, the expected LOS and mortality are based on the data entered in the chart; thus, if the information is not accurately documented, the expected data may not be accurate. However, our study showed that factors associated with poor outcomes increased the expected LOS and mortality. Finally, the database does not provide information on why the patient had a longer than expected LOS or why the patient was readmitted. However, individual patients could be identified from the dashboard and investigated to determine the cause of the poor outcomes.
Conclusions
The pulmonary resection Vizient dashboard is a valid method for measuring outcomes after lung resection. The database captures all pulmonary resections of the patient and provides risk adjustment based on the patient’s comorbidities. Although the database is not as robust as the GTSD, it provides monthly reports of pulmonary resection outcomes and quality data to develop quality improvement programs for institutions that do not have access to the GTSD but have access to the Vizient dashboard.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-93/rc
Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-93/dss
Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-93/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-93/coif). M.P.K. received royalty from Medtronic for teaching video and Honoria from Intuitive Surgical for teaching. The other authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of the Houston Methodist Hospital Research Institute (No. Pro00013680). Participants gave informed consent for participation in a registry for research.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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