EPMA Journal

, Volume 10, Issue 2, pp 173–183 | Cite as

Development and validation of nomogram estimating post-surgery hospital stay of lung cancer patients: relevance for predictive, preventive, and personalized healthcare strategies

  • Xiang-Lin Hu
  • Song-Tao Xu
  • Xiao-Cen Wang
  • Jin-Long Luo
  • Dong-Ni Hou
  • Xiao-Min Zhang
  • Chen Bao
  • Dong YangEmail author
  • Yuan-Lin Song
  • Chun-Xue Bai



In the era of fast track surgery, early and accurately estimating whether postoperative length of stay (p-LOS) will be prolonged after lung cancer surgery is very important, both for patient’s discharge planning and hospital bed management. Pulmonary function tests (PFTs) are very valuable routine examinations which should not be underutilized before lung cancer surgery. Thus, this study aimed to establish an accurate but simple prediction tool, based on PFTs, for achieving a personalized prediction of prolonged p-LOS in patients following lung resection.


The medical information of 1257 patients undergoing lung cancer surgery were retrospectively reviewed and served as the training set. p-LOS exceeding the third quartile value was considered prolonged. Using logistic regression analyses, potential predictors of prolonged p-LOS were identified among various preoperative factors containing PFTs and intraoperative factors. A nomogram was constructed and subjected to internal and external validation.


Five independent risk factors for prolonged p-LOS were identified, including older age, being male, and ratio of residual volume to total lung capacity (RV/TLC) ≥ 45.0% which is the only modifiable risk factor, more invasive surgical approach, and surgical type. The nomogram comprised of these five predictors exhibited sufficient predictive accuracy, with the area under the receiver operating characteristic curve (AUC) of 0.76 [95% confidence interval (CI) 0.73–0.79] in the internal validation. Also its predictive performance remained fine in the external validation, with the AUC of 0.70 (95% CI 0.60–0.79). The calibration curves showed satisfactory agreements between the model predicted probability and the actually observed probability.


Preoperative amelioration of RV/TLC may prevent lung cancer patients from unnecessary prolonged p-LOS. The integrated nomogram we developed could provide personalized risk prediction of prolonged p-LOS. This prediction tool may help patients perceive expected hospital stays and enable clinicians to achieve better bed management after lung cancer surgery.


Length of stay Lung cancer Surgery Pulmonary function tests Prediction model Nomogram Advanced healthcare Individualized patient profile Hospitalization Economic burden Risk assessment Predictive preventive personalized medicine 



EPMA European Association for Predictive, Preventive and Personalised Medicine

PPPM predictive, preventive and personalized medicine

p-LOS postoperative length of stay

PFTs pulmonary function tests

IC inspiratory capacity

FEV1 forced expiratory volume in 1 s

DLCO diffusion capacity for carbon monoxide

FVC forced vital capacity

COPD chronic obstructive pulmonary disease

RV/TLC ratio of residual volume to total lung capacity

VATS video-assisted thoracic surgery

SD standard deviation

IQR interquartile range

ROC receiver operating characteristic

AUC area under the receiver operating characteristic curve

OR odds ratio

CI confidence interval

Authors’ contributions

Hu Xiang-Lin contributed to the study conception and design, data analysis, interpretation of the data, and drafting the manuscript. Yang Dong, Xu Song-Tao, Song Yuan-Lin, and Bai Chun-Xue contributed to the interpretation of the data and critical revision of the manuscript. Hu Xiang-Lin, Xu Song-Tao, Luo Jin-Long, Wang Xiao-Cen, Hou Dong-Ni, Zhang Xiao-Min, and Bao Chen contributed to the collection of the data. All authors read and approved the final manuscript.


This work was supported by State’s Key Project of Research and Development Plan in China (2017YFC1310602, 2017YFC1310600).

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethics approval and consent for participation

This study was approved by the Ethics Committee of Zhongshan Hospital, Fudan University, Shanghai, 200032, China. Informed consent for participation was obtained in this study. All procedures performed in the study involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Supplementary material

13167_2019_168_MOESM1_ESM.docx (15 kb)
ESM 1 (DOCX 15 kb)


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Copyright information

© European Association for Predictive, Preventive and Personalised Medicine (EPMA) 2019

Authors and Affiliations

  1. 1.Department of Pulmonary Medicine, Zhongshan HospitalFudan UniversityShanghaiChina
  2. 2.Department of Thoracic Surgery, Zhongshan HospitalFudan UniversityShanghaiChina
  3. 3.Department of Nursing, Zhongshan HospitalFudan UniversityShanghaiChina

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