Farhood Farjah1, Leah M Backhus2, Thomas K Varghese2, Michael S Mulligan2, Aaron M Cheng2, Rafael Alfonso-Cristancho3, David R Flum3, Douglas E Wood2. 1. Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington; Surgical Outcomes Research Center, University of Washington, Seattle, Washington. Electronic address: ffarjah@uw.edu. 2. Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington. 3. Surgical Outcomes Research Center, University of Washington, Seattle, Washington.
Abstract
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.
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.
Authors: Rachel L Medbery; Theresa W Gillespie; Yuan Liu; Dana C Nickleach; Joseph Lipscomb; Manu S Sancheti; Allan Pickens; Seth D Force; Felix G Fernandez Journal: Ann Thorac Surg Date: 2016-07-29 Impact factor: 4.330