Incremental Cost Of Complications Of Lobectomy For Stage I NSCLC
Abraham D Geller, Douglas J Mathisen, Cameron D Wright, Michael Lanuti
Massachusetts General Hospital, Boston, MA
OBJECTIVES: Postoperative complications are widely understood to increase the cost of surgical care, but little has been done to quantify the cost impact of complications in thoracic surgery. The purpose of this study is to quantify the incremental cost of complications of lobectomy and identify specific targets for quality improvement and cost reduction.
METHODS: Patients treated with open or VATS lobectomy for stage I NSCLC between 2008 and 2014 were selected from an institutional patient database. A patient registry was queried for all adverse postoperative events (POE) recorded during a 90-day postoperative interval. POE was sub-classified as major or minor. Hospital billing data for each patient was obtained from a separate financial database and queried for all associated costs from the procedure until 90 days after surgery, and then concatenated with the clinical data by encounter. Linear regression analysis was used to assess the impact on cost of total vs. major POEs, and, in subsequent analysis, to estimate the mean incremental cost of each type of POE
RESULTS: 494 patients were identified as having undergone lobectomy for stage I NSCLC between 2008 and 2014, and had complete 90-day follow-up and cost data available. 35% of those patients experienced at least 1 POE and 18% experienced at least one major POE. The most common complications were atrial arrhythmia (13% of patients), prolonged air leak (8.3%), atelectasis (6.7%), and transfusion requirement (6.5%). Minor POEs increased the cost of lobectomy by an average of 26% per event (95CI 18-33%, P<0.001) compared to the cost of an uncomplicated lobectomy, and major POEs increased total cost by an average of 61% per event (95CI 54-67%, P<0.001). The greatest predictor of increased 90-day cost was new renal failure (defined as Cr>2 or Cr>2 x baseline), which increased cost by 272% (95CI 220-324%, P<0.001) compared to uncomplicated lobectomy. Prolonged air leak increased mean cost by 20% (95CI 4-37%, P=0.016), pneumonia by 79% (95CI 48-109%, P<0.001) and atrial arrhythmia by 27% (95CI 15-39%, P<0.001). Other significant predictors of increased cost were major pulmonary POEs (81% increase, 95CI 58-104%, P<0.001), major cardiovascular POEs (29% increase, 95CI 18-40%, P<0.001), minor pulmonary POEs (39% increase, 95CI 25-52%, P<0.001), major neurological POE (47%, 95CI 14-80%), and other major POEs (76%, 95CI 50-102, P<0.001).
CONCLUSIONS: Complications contribute significantly to total 90-day cost of lobectomy for stage I NSCLC. Analysis of 90-day postoperative outcomes more accurately captures costs associated with lobectomy not realized within a 30-day postoperative window. This study quantifies specific incremental costs associated with various types of complications. It also identifies actionable targets for cost reduction and surgical quality improvement. Further efforts to reduce cost while improving outcomes may identify strategies to predict and prevent the most common and costly complications identified here.
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