Original article
General thoracic
Ninety-Day Costs of Video-Assisted Thoracic Surgery Versus Open Lobectomy for Lung Cancer

Presented at the Poster Session of the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.
https://doi.org/10.1016/j.athoracsur.2014.03.024Get rights and content

Background

Complications after pulmonary resection lead to higher costs of care. Video-assisted thoracoscopic surgery (VATS) for lobectomy is associated with fewer complications, but lower inpatient costs for VATS have not been uniformly demonstrated. Because some complications occur after discharge, we compared 90-day costs of VATS lobectomy versus open lobectomy and explored whether differential health care use after discharge might account for any observed differences in costs.

Methods

A cohort study (2007–2011) of patients with lung cancer who had undergone resection was conducted using MarketScan—a nationally representative sample of persons with employer-provided health insurance. Total costs reflect payments made for inpatient, outpatient, and pharmacy claims up to 90 days after discharge.

Results

Among 9,962 patients, 31% underwent VATS lobectomy. Compared with thoracotomy, VATS was associated with lower rates of prolonged length of stay (PLOS) (3.0% versus 7.2%; p < 0.001), 90-day emergency department (ED) use (22% versus 24%; p = 0.005), and 90-day readmission (10% versus 12%; p = 0.026). Risk-adjusted 90-day costs were $3,476 lower for VATS lobectomy (p = 0.001). Differential rates of PLOS appeared to explain this cost difference. After adjustment for PLOS, costs were $1,276 lower for VATS, but this difference was not significant (p = 0.125). In the fully adjusted model, PLOS was associated with the highest cost differential (+$50,820; p < 0.001).

Conclusions

VATS lobectomy is associated with lower 90-day costs—a relationship that appears to be mediated by lower rates of PLOS. Although VATS may lead to lower rates of PLOS among patients undergoing lobectomy, observational studies cannot verify this assertion. Strategies that reduce PLOS will likely result in cost-savings that can increase the value of thoracic surgical care.

Section snippets

Patients and Methods

The institutional review board approved this investigation. A retrospective cohort study was conducted of adult patients with lung cancer treated with lobectomy between January 1, 2008 and September 30, 2011. Data were obtained from the MarketScan database—an all-payer database with inpatient, outpatient, and pharmacy claims [15]. Inclusion criteria were patients with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for lung cancer, an

Results

Between 2008 and 2011, 9,962 eligible patients underwent lobectomy; 31% of these lobectomies were VATS approaches. Table 1 shows the differences in patient characteristics and health care use by approach to lobectomy. There were no age differences. Statistically significant differences in the distributions of sex, comorbidity index, and health plan type were not clinically significant. Just less than half of all patients received epidural anesthesia, with significantly lower use among patients

Comment

There is growing interest in assessing and improving the value of health care delivery. Defined as health benefits per dollar spent, value may be increased by improving outcomes or decreasing costs, or both. A VATS approach to lobectomy is an example of an increasingly common intervention in thoracic operations that may improve quality and decrease costs. The existing body of evidence suggests equivalent oncologic efficacy and lower postoperative morbidity and mortality 1, 2, 3, 4, 5, 6, 7, 8,

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