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Version 2.41 The Society of Thoracic Surgeons General Thoracic Surgery Database Analyzed Procedure Data Collection Form Version 2.41 ©2018 The Society of Thoracic Surgeons Revised 5/31/2018 An Analyzed Procedure Data Collection Form (DCF) is required for all suspected or diagnosed Lung and Esophageal Cancer Resections and one should be initiated every time the patient enters the operating room. These cases are risk adjusted and are included in the Data Analysis Reports. Fields that appear underlined and in blue are required for analyzed procedure record inclusion. If any of these fields are missing data, the entire record will be excluded from analysis. Completion of the Thymus/Mediastinal Mass, Tracheal Resection and Hiatal Hernia/GERD sections is optional for analyzed procedures. Procedures highlighted below, if performed as isolated procedures or with only other highlighted procedures, are not collected unless the Surgeon Participant chooses to track them. If collected, use the Non-analyzed Procedure DCF. Highlighted procedures done in conjunction with analyzed (major) procedures should be included on this Analyzed Procedure DCF. A. Demographics Patient ID: ___________________PatID (80) Medical Record #:_________________ MedRecN (90) First Name:__________________ Middle Name:____________ Last Name:___________________ SSN#:______________ PatFName (100) PatMName(110) PatLName (120) SSN (130) Patient participating in STS-related clinical trial: ClinTrial (140) None Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 Trial 6 (If not “None” →) Clinical trial patient ID: _________________ ClinTrialPatID (150) Date of Birth:____/____/______ Age: ________ Patient Postal Code:_________ Gender: Male Female DOB (160) (mm/dd/yyyy) Age (170) PostalCode (180) Gender (190) Is the Patient's Race Documented? � Yes � No � Patient Declined to Disclose RaceDocumented (200) White/Caucasian Yes No Black/African American Yes No Race: If Yes select all that apply RaceCaucasian (210) RaceBlack (220) Asian Yes No American Indian/Alaskan Native Yes No RaceAsian (230) RaceNativeAm (240) Native Hawaiian/Pacific Islander Yes No Other Yes No RacNativePacific (250) RaceOther (260) Hispanic or Latino Ethnicity: Yes No Not Documented Ethnicity (270) B. Admission Admission Status: Inpatient Outpatient / Observation If Inpatient → Admission Date: ____/___/_____ AdmissionStat (280) AdmitDt (290) If Primary Payor is not None/Self→ Payor: Indicate the Primary payor: PayorPrim (300) Indicate the Secondary (supplemental) payor: PayorSecond (320) None/self None/self Medicare Medicare If Medicare → Fee For Service: Yes No PrimMCareFFS If Medicare → Fee For Service: Yes No (310) SecondMCareFFS (330) Medicaid Medicaid Military Health Military Health Indian Health Service Indian Health Service Correctional Facility Correctional Facility State Specific Plan State Specific Plan Other Government Insurance Other Government Insurance Commercial Health Insurance Commercial Health Insurance Health Maintenance Organization Health Maintenance Organization Non U.S. Plan Non U.S. Plan Surgeon Name:_________________________________ Surgeon’s National Provider ID: _______________________ Surgeon (340) SurgNPI (350) 1 Taxpayer ID#: __________________________________ Hospital Name:______________________________________ TIN (360) HospName (370) Hospital Postal Code:_________________ Hospital Region:________ Hospital’s National Provider ID:_______________________ HospZIP (380) HospStat (390) HospNPI (400) C. Pre-Operative Evaluation Height: ___________(cm) HeightCm (410) Weight: __________(kg) WeightKg (420) Unintentional Wt loss over past 3 months? (Enter “0” if none) - _____________(kg) WtLoss3Kg (430) CardioPulmonary History Congestive Heart Failure(CHF) If Yes→ EF ______% Hypertension Hypertn (440) Yes No Yes No CHF (450) EF (460) Coronary Artery Disease (CAD) Yes No Myocardial Infarction Yes No PreMI (480) CAD (470) Location – check all that apply: Afib per EKG within the last year; Valvular Heart AV Yes No PV Yes No Yes No with or without treatment AFIB Yes No Disease VHDLocAV (510) VHDLocPV (530) If Yes→ (490) VHD (500) MV Yes No TV Yes No VHDLocMV (520) VHDLocTV (540) Pulmonary Hypertension: Yes No Unknown PulmHypertn (550) Interstitial Fibrosis/ Interstitial Lung Disease InterstitialFib (560) Yes No Vascular History Major Vascular Disease Yes No MVD (580) DVT/PE Yes No DVTPE (590) Cerebral Vascular Disease History Cerebrovascular History: No CVD history Known disease, no events Transient Ischemic Attack (TIA) CerebroHx (610) If CVA→ Permanent Neurologic impairment Yes No Cerebrovascular Accident (CVA) PNI (620) Neuromuscular Disease Neurologic symptoms present Yes No NeuroSymptPres (630) Myasthenia Gravis Yes No MyasGravis (640) Endocrine / GI / Renal History Diabetes If Yes→ Type of therapy: None Diet Only Oral Insulin Yes No Diabetes (650) DiabCtrl (660) Other Subcutaneous Medication Other Unknown Liver Dysfunction Yes No LiverDys (670) On Dialysis Yes No Dialysis (680) Cancer History Coexisting Cancer Yes No CoexisCancer (690) Same disease, ≤ 6 months PreopChemoCurWhen (710) Preoperative Chemotherapy / Same disease,> 6 months Immunotherapy Yes No If Yes → Unrelated disease, ≤ 6 months PreopChemoCur (700) Unrelated disease, >6 months Same disease, ≤ 6 months PreopXRTDisWhen (730) Same disease,> 6 months Unrelated disease, ≤ 6 months Preop Thoracic Radiation Therapy Yes No If Yes → Unrelated disease, >6 months PreopXRT (720) If Same disease, ≤ 6 months → Completion Date ______________ PreopXRTCompDt (740) Prior Surgical History (check all that apply) Prior Cardiothoracic Surgery Yes No If Yes → Sternotomy Yes No PriorStern (760) PriorCTS (750) 2 VATS/Robotic Yes No (check all that apply) PriorVATS (770) If Yes → Right Left Bilateral PriorVATSLoc (780) Pulmonary resection Yes No PriorPulmRes (790) If Yes → Right Left Bilateral PriorPulmResLoc (800) Thoracotomy Yes No PriorThora (810) If Yes → Right Left Bilateral PriorThoraLoc (820) PreOp Medication History Chronic Immunosuppressive Therapy Yes No PreOpImmunoThx (830) Chronic anticoagulation Yes No (defined as any anticoagulation medication other than ASA) PreOpAnticoagThx (840) Home O2 PreOpHomeO2 (850) Yes No Pre-Operative Testing Creatinine level measured Yes No If Yes → Last creatinine level ________ CreatLst (880) CreatMeasured (870) Hemoglobin level measured Yes No If Yes → Last hemoglobin level _______ HemoglobinLst (900) HemoglobinMeasured (890) Pulmonary Function Tests performed? Yes No PFT (910) PFT Not Performed Reason Not a Major Lung Resection Never smoked, no lung disease If No → Pt. Unable to perform PFTNotPerReas(920) Tracheostomy or Ventilator Urgent or Emergent Status If Yes → FEV1 test performed? If Yes→ FEV1 % predicted: _________ Yes No Not Applicable FEV (930) FEVPred (940) DLCO test performed? If Yes→ DLCO % predicted: __________ Yes No Not Applicable DLCO (950) DLCOPred (960) Psychosocial History Cigarette smoking: Past smoker (stopped >1 month Never smoked Current smoker Unknown CigSmoking (970) prior to operation If ‘Past smoker’ or Pack Year Known or can be If Yes → Pack-Years _________ Yes No ‘Current Smoker’ → estimated PackYearKnown (980) PackYear (990) Narcotic dependency Yes No Alcohol Abuse Yes No NarcoticDepend (1000) AlcoholAbuse (1010) Dementia/neurocognitive dysfunction Yes No DemNeroDys (1020) Major Psychiatric Disorder Yes No PsychDisorder (1030) Living Status: Lives alone Lives with family or friend Assisted Living Nursing Home LiveStat (1040) Functional Status: Totally Independent Partially Dependent Unknown FuncStat (1050) Dependent 1 - Restricted in physically 2 - Ambulatory and capable of 0 - Fully active, able to carry strenuous activity but ambulatory all self-care but unable to carry on all pre-disease performance and able to carry out work of a out any work activities. Up and without restriction light or sedentary nature, e.g., about more ECOG Score: light house work, office work than 50% of waking hours ECOGScore (1070) 3 - Capable of only limited 4 - Completely disabled. self-care, confined to bed or Cannot carry on any self-care. 5 - Dead chair more than 50% of waking Totally confined to bed or chair hours D. Diagnosis (Category of Disease) Category of Disease: Check both Primary and Secondary Diagnosis (Category of Disease) (ICD-9, ICD-10). Indicate (circle) the Primary Diagnosis. CategoryPrim (1250) CategorySecond (1280) Note: Diagnosis is based on final pathology report. No Secondary Diagnosis (for Category of Disease - Secondary field only) Lung Cancer 3 Lung cancer, main bronchus, carina (162.2, C34.00) Lung cancer, lower lobe (162.5, C34.30) Lung cancer, upper lobe (162.3, C34.10) Lung cancer, location unspecified (162.9, C34.90) Lung cancer, middle lobe (162.4, C34.2) Lung tumor, metastatic (197.0, C78.00) Personal history of malignant neoplasm of bronchus and lung Malignant neoplasm other parts of bronchus or lung (162.8, C34.8) (V10.11, Z85.118) Neoplasm of uncertain behavior of trachea, bronchus and lung (235.7, DM38.1) Esophagus Cancer Esophageal cancer, esophagogastric junction (cardia) (151.0, C16.0) Malignant neo stomach unspecified (151.9, C16.9) Malignant neoplasm of the esophagus, unspecified (150.9, Esophageal cancer, upper third (150.3, C15.3) C15.9) Esophageal cancer, middle third (150.4, C15.4) Malignant other part esophagus, specified (150.8, C15.8) Esophageal cancer-lower
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