Ninety-day hospital costs associated with prolonged air leak following lung resection.

OBJECTIVES: Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization. METHODS: We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014-August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis. RESULTS: PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354€, standard deviation (SD) 7646 vs 5759€, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340€, SD 23 312 vs 13 102€, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022). CONCLUSIONS: PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.

Ninety-day hospital costs for anatomic lung resections†.

OBJECTIVES: The study aimed to assess the total cost (TC) and relative cost (RC) of 90-day postoperative care at the hospital after anatomic lung resection. METHODS: Six hundred and forty lung resections (April 2014-September 2016) were performed at a single centre (547 lobectomies, 55 pneumonectomies and 38 segmentectomies). TC was calculated up to 90 days from the date of surgery and included the postoperative cost of the index hospitalization and the costs of hospital or emergency department readmissions, clinic appointments, medications and radiology post-discharge up to 90 days from the operation. RC was calculated as the difference between the TC and the postoperative cost of the index hospitalization. Bivariate comparisons were performed by using the Mann-Whitney test. Multivariable regression analysis was used to identify the factors associated with TC. RESULTS: Median TC was €12 389.5 [interquartile range (IQR) 8455-23 043] for pneumonectomy, €9192.1 (IQR 6897-17 274) for open lobectomy, €7932.5 (IQR 5806-12 697) for video-assisted thoracoscopic surgery (VATS) lobectomy and €6609.9 (IQR 5215-13 907) for VATS segmentectomy. Median RCs were €4461.4 (IQR 1240-11 828) for pneumonectomy, €3326.8 (IQR 1626-8271) for open lobectomy, €2729.3 (IQR 1348-6312) for VATS lobectomy and €2771.5 (IQR 1229-9705) for segmentectomy. RC accounted for 36% of the TC for pneumonectomy, 36% for open lobectomy, 34% for VATS lobectomy and 42% for segmentectomy. Generalized linear models showed that age (P = 0.024), carbon monoxide lung diffusion capacity (P = 0.030) and body mass index (P = 0.015) were inversely associated with TC, whereas male gender (P = 0.054) was associated with increased cost. CONCLUSIONS: Cost-saving measures should be implemented to target not just the in-hospital but also the post-discharge period, particularly in patients with risk factors associated with increased cost.

Financial validation of the European Society of Thoracic Surgeons risk score predicting prolonged air leak after video-assisted thoracic surgery lobectomy.

OBJECTIVES: The objective of this study was to verify whether the European Society of Thoracic Surgeons prolonged air leak risk score for video-assisted thoracoscopic lobectomy was associated with incremental postoperative costs. METHODS: We retrospectively analyzed 353 patients subjected to video-assisted thoracoscopic lobectomy or segmentectomy (April 2014 to March 2016). Postoperative costs were obtained from the hospital Finance Department. Patients were grouped in different classes of risk according to their prolonged air leak risk score. To verify the independent association of the prolonged air leak risk score with postoperative costs, we performed a stepwise multivariable regression analysis in which the dependent variable was postoperative cost. RESULTS: Prolonged air leak developed in 56 patients (15.9%). Their length of stay was 3 days longer compared with those without prolonged air leak (8.3 vs 5.4, P < .0001). Their postoperative cost was higher than that of patients without prolonged air leak: $5939.8 versus $4381.7 (P = .001). After grouping the patients according to their prolonged air leak risk score, prolonged air leak incidence was 12.3% in class A, 13.7% in class B, 28.8% in class C, and 22.2% in class D (P = .020). The average postoperative cost was $4031.0 in class A, $4498.2 in class B, $6146.6 in class C, and $6809.3 in class D (analysis of variance test, P < .001). Multivariable regression analysis showed that being in classes C and D of PAL score (P = .001) and the presence of cardiopulmonary complications (P < .0001) were the only independent factors significantly associated with postoperative costs. CONCLUSIONS: We financially validated the European Society of Thoracic Surgeons prolonged air leak risk score for video-assisted thoracoscopic lobectomies, which appears useful in selecting those patients in whom the application of additional intraoperative interventions to avoid prolonged air leak may be more cost-effective.

The Severity of Complications Is Associated With Postoperative Costs After Lung Resection.

BACKGROUND: The objective of this study was to verify the association between the thoracic mortality and morbidity (TMM) classification system and hospital costs after lung resection. METHODS: Consecutive patients (n = 503) submitted to anatomic lung resections were analyzed (April 1, 2014, to March 31, 2016). TMM system was used to grade the severity of complications. Postoperative costs were retrieved from the financial department using an electronic patient-level information system. RESULTS: Two hundred seventy-two patients (54%) did not experience any complication. The distribution of postoperative complications in the remaining patients according to the TMM classification system was as follows: 57 (25%) grade I, 108 (47%) grade II, 29 (12%) grade III, 17 (7%) grade IV, and 20 (9%) grade V. The average postoperative cost of the uncomplicated patients was $3,560 (95% confidence interval [CI]: $3,440 to $3,680). The average postoperative costs of the patients with complications increased along with the grade of the TMM system; it was $4,548 (95% CI: $4,134 to $4,962) for grade I, $4,909 (95% CI: $4,537 to $5,281) for grade II, $6,392 (95% CI: $5,303 to $7,483) for grade III, and $14,547 (95% CI: $6,334 to $22,760) for grade IV. The average postoperative cost for the patients who eventually died was $17,695 (95% CI: $11,246 to $24,144). Linear regression analysis showed that a prolonged length of hospital stay (p < 0.0001) and an unplanned admission to the intensive care unit (p < 0.0001) were significantly associated with postoperative costs in patients with major complications. CONCLUSIONS: The severity of complications graded by the TMM system was associated with increasing postoperative costs. This instrument may be used to adjust lung resection reimbursement tariffs.

Factors associated with postoperative costs following anatomic lung resections without major complications.

OBJECTIVES: To detect factors associated with costs of anatomic lung resection without major complications. METHODS: Two hundred and fifty consecutive patients submitted to anatomic lung resection (185 by VATS) in 1 fiscal year (1 April 2014­31 March 2015) were included. Thoracic Morbidity and Mortality (TMM) system was used to grade the severity of complications. Two hundred and ten patients who did not develop major complications (TMM < 3) were analysed. Postoperative costs were retrieved from the Financial Department through a Patient Level Information and Costing System. Multivariable regression and bootstrap analyses were used to test the association of several baseline patient characteristics with costs and obtain an aggregate scoring system to estimate postoperative costs. RESULTS: Among the 210 patients, 117 (56%) did not develop any complication and 93 (44%) had minor complications. Their average postoperative cost was 4040€, significantly lower than the one observed in patients with major complications (13 156€, P < 0.0001). Multivariable regression revealed that open thoracotomy (P = 0.01), carbon monoxide lung diffusion capacity (DLCO) < 60% (P = 0.001) and coronary artery disease (CAD) (P = 0.009) were associated with postoperative costs. Open thoracotomy would increase the cost by 648€, DLCO < 60% by 935€ and CAD by 1043€. If all three factors were present, they would cause an increase of postoperative costs from 3592€ to 6219€. CONCLUSION: We were able to identify clinical factors associated with postoperative costs in patients without major complications. Recognizing groups of increased cost may lead to specific process analyses aimed at optimising their pathways of care and ultimately saving money. Moreover, these findings may help administrators to tailor future individualized lung resection reimbursement tariffs based on patient characteristics.