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Ann Thorac Surg 2007;84:197-202
© 2007 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Influence of Preoperative Exercise Capacity on Length of Stay After Thoracic Cancer Surgery

Howard Weinstein, MDa,*, Andrew T. Bates, BSa, Barbara E. Spaltro, RN, MSa, Howard T. Thaler, PhDb, Richard M. Steingart, MDa

a Department of Medicine, Division of Cardiology, Memorial Sloan-Kettering Cancer Center, New York, New York
b Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York

Accepted for publication February 2, 2007.

* Address correspondence to Dr Weinstein, Department of Medicine, Division of Cardiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (Email: weinsteh{at}mskcc.org).

Presented at the Poster Session of the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Stress testing is frequently used to assess cardiac risk before thoracic surgery. However, the relationship between treadmill exercise capacity and length of stay (LOS) has not been investigated. We hypothesized that exercise capacity, a strong predictor of long-term prognosis, can also predict LOS after thoracic cancer surgery.

Methods: Accordingly, 191 consecutive patients who had exercise stress testing before major thoracic cancer surgery were retrospectively grouped by poor (<4 metabolic equivalents [METs], n = 31), fair (4 to 7 METs, n = 107), good (7 to 10 METs, n = 30), and excellent (>10 METs, n = 23) exercise capacity. The relationship between exercise capacity and LOS was then determined.

Results: Average LOS was inversely related to exercise capacity, with a nearly twofold increase in LOS between the excellent and poor exercise groups (4.8 versus 9.2 days). This relationship remained significant even after controlling for operation type, history of dyspnea, sex, and smoking history in analysis of covariance. Prolonged hospital stay (10 days or more) was strongly predicted by exercise capacity. Failure to exceed 4 METs was associated with a high risk of prolonged stay (9 of 31, 39%), whereas none of the 23 patients who exceeded 10 METs had a prolonged stay.

Conclusions: Treadmill exercise capacity has independent predictive value for LOS and risk of prolonged stay after thoracic cancer surgery. These findings have important implications for risk assessment and cost, suggesting that preoperative programs designed to improve exercise capacity may favorably influence LOS and associated costs.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Stress testing is commonly used to predict cardiac morbidity before noncardiac surgery [1–4]. In selected patients, exercise or pharmacologic stress testing provides incremental predictive value to clinical assessment [4]. For patients undergoing thoracic surgery, efforts to assess preoperative risk have focused on the pulmonary consequences of lung excision [5, 6]. To this end, several clinical markers have been evaluated as potential risk factors for thoracic surgery. Simple stair-climbing tests or more advanced forms of cardiopulmonary exercise testing have been advocated to identify patients at high risk for postoperative complications [7, 8] and to select the postoperative level of care [8]. Clinical risk scores have been developed to serve a similar purpose [9]. However, most patients with clinical or objective risk indicators will be free of postoperative complications, even in groups with the highest predicted risk [10, 11].

An important measure of postoperative outcome in cancer patients is the length of stay in hospital (LOS), yet predictors of LOS in these patients remain poorly defined. This outcome relates directly to morbidity and has important implications for cost effectiveness in an era of managed care and diagnosis-related fees. The influence of treadmill exercise capacity, a simple and accessible preoperative test of ischemia, on LOS has not been defined for patients undergoing thoracic cancer surgery.

Accordingly, we assessed the relationship between preoperative exercise capacity on LOS after thoracic cancer surgery in 191 consecutive patients who underwent major thoracic cancer surgery at our institution.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
The study design was retrospective. Outcomes were compiled on 191 consecutive ambulatory patients who underwent exercise stress echocardiography at Memorial Sloan-Kettering Cancer Center, New York, New York, between 1999 and 2002 to assess risk before major thoracic surgery. Exemption from Institutional Review Board approval was granted in accordance with institutional policy; a waiver to collect data without consent was approved on July 28, 2004, by the Institutional Review/Privacy Board. Surgery was performed a mean 20.6 days (range, 1 to 167) after stress testing. Exercise was performed at Memorial Hospital or at the Laurance Rockefeller Outpatient Pavilion, using similar stress testing equipment (Case 8000 Exercise Testing System and dedicated Marquette 2000 Treadmill; Marquette Diagnostic Systems, Milwaukee, Wisconsin; Philips Sonos; Philips Imaging Systems, Bothell, Washington; and Acuson Sequoia; Siemens Medical Systems, Malvern, Pennsylvania). Patients were referred for exercise stress echocardiography on clinical grounds by the referring surgeon, or by a consulting internist or cardiologist. The most common stress test indications listed were hypertension (in 65 patients), smoking history (51), coronary artery disease (9), prior myocardial infarction (19), peripheral vascular disease (18), chest pain (18), and abnormal electrocardiogram (ECG [18]). Stress tests were performed under the direct supervision of an attending cardiologist with standard (Bruce, Modified Bruce, or Naughton) exercise protocols. Exercise was symptom-limited.

Calculation of metabolic equivalents (METs) achieved on the treadmill was by the onboard computer of the treadmill monitoring unit. Patients were grouped by their treadmill exercise capacity into poor (≤4 METs), fair (4.1 to 7 METs), good (7.1 to 10 METs), and excellent exercise capacity (>10 METs).

Treadmill ECG results were categorized as ischemia, normal, or as nondiagnostic due to inadequate heart rate achieved or resting ECG abnormalities (left ventricular hypertrophy, left bundle branch block, digitalis effect, or resting ST depression). For echocardiographic interpretation, a normal test was defined as normal wall motion at rest with normal augmentation after exercise; ischemia as normal wall motion at rest with deterioration after exercise; infarct as hypokinesis, akinesis, or dyskinesis at rest with augmentation or persistence after exercise; and both ischemia and infarct as hypokinesis, akinesis, or dyskinesis at rest with deterioration after exercise.

Patients were not referred for preoperative fitness training and were prepared for surgery in accordance with the surgeons’ usual clinical practice. Results of exercise stress echocardiography were made available to the surgical team before surgery.

Length of stay was determined from the date of surgery up to and including the day of discharge. Postoperative complications were defined by chart review, including clinical notes, test results (eg, ECG evidence of atrial fibrillation or radiologic evidence of pneumonia or heart failure) and discharge summaries. Myocardial infarction was defined clinically, with confirmation by cardiac histochemical markers (creatine phosphokinase or troponin, or both).

Statistics
Comparisons between exercise groups were made by analysis of variance and covariance and by multiple comparison t tests. Log transforms of LOS were used in the analysis because of the skewed distribution of LOS toward high values and the tendency for standard deviation to increase with increasing group means. Proportions were compared by the Cochran-Armitage trend test and Fisher’s exact test. Statistics were calculated with SAS (SAS Institute, Cary, North Carolina).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
A total of 191 patients, 101 male and 90 female, underwent thoracic surgery for primary or metastatic lesions. The mean age was 68 years (range, 20 to 87). Forty-four patients (23%) underwent wedge resection, 104 (54%) lobectomy, 12 (6.2%) pneumonectomy, and 33 (17%) other thoracic procedures. Patient demographics are shown in Table 1.


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  		Table 1 Patient Demographics
 
Length of stay versus exercise capacity is shown for the complete data set in Figure 1. A complex, nonlinear relationship is evident, wherein diminishing exercise capacity results in wide LOS variability, more prolonged stays, and a higher average LOS. Treadmill exercise performance strongly predicted prolonged stay (defined arbitrarily as 10 or more days in hospital). None of the 23 patients with excellent exercise capacity (>10 METs) and only 2 of 30 patents (7%) with good exercise capacity (4.1 to 7 METs) had a prolonged stay. By contrast, 17 of 107 patients (16%) with fair exercise capacity (7.1 to 10 METs) and 9 of 31 patients (29%) with poor exercise capacity had a prolonged stay (Table 2). A discriminant threshold of 7 METs stratified patients into high (19%) and low (4%) risk of prolonged stay.


Figure 1
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  		Fig 1. Complete data set showing the influence of treadmill exercise capacity on length of stay (LOS). Several patients sharing X/Y values are represented by larger circles. (METS = metabolic equivalents.)

 

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  		Table 2 Prolonged Stay (≥ 10 Days) Versus Exercise Capacity
 
Average LOS was strongly and inversely related to exercise capacity (p < 0.003 for the trend), with a nearly twofold increase in LOS between the excellent and poor exercise groups (4.8 versus 9.2 days) and a progressive increase in LOS with decreasing exercise capacity. This relationship remained significant even after controlling for operation type, history of dyspnea, sex, and smoking history in analysis of covariance. In univariate analysis, LOS was increased by a history of heavy smoking (p = 0.005), male sex (p = 0.037), type of surgery (p < 0.0001), and prior dyspnea (p = 0.012), but not by the presence of ischemia detected by either ECG or echocardiographic criteria or by infarct detected by echocardiography.

There were no cardiac deaths and only 3 acute coronary syndromes (2 myocardial infarction, 1 unstable angina). Atrial fibrillation occurred in 22 patients (11.3%), incurring a mean LOS of 9.2 days (SD = 4.2), as compared with 6.5 days (5.2) in patients free of atrial fibrillation (p < 0.02). There was no relationship between exercise capacity and postoperative atrial fibrillation.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
We documented a strong inverse correlation between objective exercise capacity by treadmill testing and LOS after a wide range of thoracic procedures for lung cancer. This correlation remained significant even after controlling for sex, smoking history, preoperative dyspnea, and even the type of surgery. Analysis of the individual patient data showed that as exercise capacity diminished, both the variability in LOS and the risk of a prolonged hospital stay markedly increased. This effect was so strong that nearly all the prolonged stays (26 of 28) were among patients who failed to exceed 7 METs.

The exercise ECG response has proved valuable as a predictor of postoperative cardiac complications and as a long-term indicator of cardiac prognosis [12], but did not add to the prediction of LOS. If echocardiographic imaging is performed concurrently, as in this study, additional diagnostic power is added for the detection of ischemia [13], and potentially useful information is obtained on left ventricular and, of heightened importance in patients with lung disease, right ventricular function and pulmonary artery pressure; but LOS was not significantly related to stress-induced ischemia detected by either ECG or echocardiographic criteria nor to echocardiographic evidence of infarct.

Preoperative Evaluation of Patients Undergoing Thoracic Surgery: Divergent Approaches
From the cardiac or medical standpoint, clinical risk stratification of patients undergoing noncardiac surgery begins with an evaluation of their comorbidity and performance status, based on previously validated clinical risk indicators [14]. When performed by guidelines published jointly by the American Heart Association (AHA) and the American College of Cardiology (ACC) [4], patients with life-threatening conditions ("major clinical predictors") are excluded from elective surgery. Remaining patients are then assigned a patient-specific risk, based on minor and intermediate predictors [4]. The risk inherent in the surgical procedure is then considered. Thoracic surgery incurs intermediate or higher risk [4]. In a review of 3,368 patients with coronary artery disease from the Coronary Artery Surgery Study registry who were not revascularized and who underwent noncardiac surgery, thoracic surgery incurred among the highest rates of postoperative myocardial infarction and death [15]. Thus, for patients at intermediate risk of perioperative events, cardiac stress testing is then recommended before surgery [4].

From the pulmonary or surgical standpoint, the evaluation of patients before lung resection is predicated on the prediction of residual pulmonary function after resection, typically in the presence of preexisting lung disease [6]. This approach first measures preoperative pulmonary function (forced expiratory volume [FEV1], pulmonary diffusing capacity [DLCO], arterial blood gas). Below a critical threshold, a quantitative ventilation/perfusion scan is performed to predict postoperative parameters. Below a predicted postoperative threshold (eg, FEV1, DLCO <40%), cardiopulmonary stress testing is performed to assess for maximal oxygen uptake above a further threshold (eg, 15 mL · kg–1 · min–1). With this approach, testing for myocardial ischemia is either not pursued or is incidental to noninvasive pulmonary testing (Datta and Lahiri [6]). A similar approach is advocated by recent European guidelines on the selection of patients with lung cancer for surgery [5]. Their guidelines differ slightly from those of Datta by interjecting a shuttle walk test to determine the need for formal cardiopulmonary testing. From the cardiac standpoint, they defer to the ACC/AHA guidelines on the cardiac evaluation of patients undergoing noncardiac surgery.

Specific Clinical Risk Indicators for Thoracic Cancer Surgery
Contemporary mortality rates increase with age (4.0% > 70 years, 1.4% < 60 years) [16] and extent of surgery (5.7% for pneumonectomy versus 1.4% for lobectomy) [16], and these two factors remain significant in multivariate analyses of risk predictors [10, 11, 16–18]. Although the morbidity and mortality risk increases with age, an extensive literature supports surgical resection of lung cancers in the elderly [11, 18–21], with a recent decline in operative mortality in this age group [11, 20]. However, particularly poor outcomes after pneumonectomy [22–24] mandate careful patient selection.

Numerous other clinical and objective markers have been reported to increase perioperative morbidity and mortality in multivariate analysis: lung disease and low FEV1, comorbidity index, and preoperative chemotherapy [25]; vascular disease and insulin-dependent diabetes mellitus [17]; abnormal ECG, DLCO less than 70% [10]; FEV1 less than 70% [26]; weight loss exceeding 10% over 6 months, chronic obstructive pulmonary disease, low albumin, smoking, dyspnea [27], and coronary artery disease [28]; and for pneumonectomy, chronic obstructive pulmonary disease, elevated blood urea nitrogen [22], male sex [23], anemia [25], low predicted FEV1, and high low-density lipoprotein [24]. These predictors are most notable for their multiplicity and their poor reproducibility between studies.

Preoperative clinical risk indices have been proposed to predict morbidity after lung surgery, including the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) [29] and the Cardiopulmonary Risk Index (CPRI) [30]. However, these indices are cumbersome and do not strongly predict complications [9, 30]. These risk indices do not incorporate exercise capacity, determined either subjectively or objectively.

The evaluation of patients before thoracic surgery should incorporate the critical elements of both the cardiac and surgical approaches: assessment of performance status and comorbidity, and determination of cardiopulmonary reserve, in relation to the extent of the procedure. Optimally, such an assessment should accurately predict LOS, an objective and integrated outcome measure.

Prediction of LOS After Thoracic Surgery
Length of stay is an important measure after surgery; it encompasses the initial recovery time and integrates the impact of postoperative complications. Under extensive penetration of managed care and a strong impetus for cost containment, LOS after thoracic surgery must be anticipated and minimized. Yet the literature regarding this outcome measure for thoracic surgery is not robust.

For peripheral aortic surgery, only advanced age and obstructive lung disease among preoperative clinical markers predicted LOS [31]. After bypass surgery, LOS in an intensive care unit was influenced by multiple clinical markers, including lung disease, nonsinus rhythm, moderate or severe valve disease, urgent surgery, and on-pump technique [32]. But exercise data were not incorporated in this model.

After lung resection, LOS and hospital costs were increased by postoperative complications, in turn predicted by the diffusing capacity of carbon monoxide before surgery [33]. Maximum oxygen consumption with exercise, an expensive and labor-intensive test, did not predict pulmonary complications in this study.

Age has been extensively studied as a risk factor for complications after lung surgery, but data on the influence of age on LOS are sparse. Polancyk and colleagues [34], in a prospective cohort study of more than 4,000 patients undergoing a wide range of noncardiac surgery, found an increase in both postoperative complications and LOS as a function of age, independent of other predictors. Exercise data were not reported.

Cardiac arrhythmias increased median LOS after pneumonectomy from 8 to 11 days [27]. Arrhythmias were in turn predicted by age over 65 years, intrapericardial or extrapleural pneumonectomy, right-sided procedure, and any major complication.

Importance of Exercise Capacity Before Lung Resection or Other Major Procedures
The assessment of functional capacity before lung surgery has a firm basis in the literature. In 600 consecutive outpatients referred for preoperative evaluation before major noncardiac surgery, patients with poor functional reserve by self-reported exercise tolerance of less than 4 blocks and 2 flights of stairs had twice as many complications (20.4% versus 10.4%) as compared with patients with preserved exercise tolerance [35]. The likelihood of a complication was inversely proportional to self-reported exercise capacity, independent of all other patient characteristics [35]. The inability to perform preoperative bicycle ergometry incurred a twofold increase in complications after lung resection [36]. In a small-scale study of patients with high-risk pulmonary indices, the subset of patients able to reach a peak oxygen consumption of 15 mL · kg–1 · min–1 tolerated lung resection well [37].

Height achieved in a stair-climbing test was the only independent predictor of complications after lung resection [38] and one of only two independent predictors of cardiopulmonary complications after lobectomy in the elderly [39]. For high-risk thoracic, sternal, and upper abdominal procedures, stair-climbing capacity predicted complications [7]. These simple tests, however, do not assess for myocardial ischemia.

Mechanism of Effect of Exercise Capacity on LOS
Several factors could account for the inverse relationship observed between exercise capacity and LOS. The ability to perform high levels of treadmill exercise reflects high inherent or acquired fitness and motivation. Treadmill performance is an objective marker of the robustness needed to withstand the stresses of thoracic surgery, and to mobilize quickly after the procedure. The correlation between exercise capacity and LOS transcends the prediction of cardiac complications; cardiac events were relatively rare in this study, and LOS was independent of both ischemia and prior infarct detected on the preoperative stress echocardiogram. The effect of exercise capacity on LOS remained significant after controlling for sex, smoking history, type of lung surgery, and even preoperative dyspnea. Thus, these common indicators do not fully account for the relationship between exercise capacity and LOS. Although postoperative atrial fibrillation was associated with increased LOS, there was no relationship between exercise capacity and the incidence of postoperative atrial fibrillation. Thus, the influence of exercise capacity on LOS is independent of atrial fibrillation.

Study Limitations
The surgical team was aware of the stress-testing data, a potential confounding factor, if LOS was unduly influenced by the exercise testing results. Given the prevailing pressure to discharge patients expeditiously, this effect, if any, was likely minimal and was unavoidable in this study. The specific noncardiac complications that contributed to the LOS (such as respiratory failure, pneumonia, and air leak) were not assessed in this study, as the study was designed to measure the integrated endpoint of LOS and cardiac outcomes. Patients were referred for stress testing at the discretion of the surgeon or medical consultant, introducing a potential referral bias if patients at only higher perceived clinical risk were referred for stress testing. Offsetting this, however, is the lower risk inherent in patients who are able to exercise formally [36].

Implications
These findings may have important implications for risk assessment and for the prediction of outcomes and care utilization in patients and patient groups. Specifically, this study shows that patients at high risk for prolonged hospital stay can be identified preoperatively by exercise testing. Moreover, the influence of exercise capacity on LOS suggests the potential to reduce recovery times and LOS through preoperative exercise training. In a small-scale study of preoperative patients with lung disease, a home-based exercise program improved exercise capacity and well-being [40]. Further study is needed to establish the benefit of such programs on postoperative outcomes and LOS.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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Douglas E. Paull
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