Quality and Cost in Thoracic Surgery

The financial impact and utilization of inpatient dermatology services: historical insights and future implications

Skin diseases affect millions of Americans, imposing a large financial burden on the U.S. healthcare system annually. Inpatient dermatology is a subspecialty focused on treating complicated skin diseases in hospitalized patients. Utilization of these services enhances diagnostic accuracy, shorten hospital stays, lower readmission rates, and improve patient outcomes. However, studies have indicated an overall decline in inpatient dermatology consultations and dermatology as primary admitting services. Currently, only two academic hospitals in the United States grant dermatologists admitting privileges, indicating decreased exposure to inpatient dermatology in residency despite the need for more hospital-based dermatologists. Therefore, this narrative review aims to characterize the financial impact and utilization of inpatient dermatology services. Historical and recent data consistently highlight the financial benefit of dermatologic hospitalizations and poor utilization of inpatient dermatology consultations. Teledermatology consultations also improve diagnostic accuracy and expedite interventions to improve patient outcomes. However, challenges like reduced reimbursement, lack of protocols, and limited resident training in inpatient dermatology have discouraged dermatologists from providing inpatient consultations. Policy changes are needed to promote these services that benefit patients as well as health systems.

Comprehensive value implications of surgeon volume for lung cancer surgery: Use of an analytic framework within a regional health system

Objective

We used a framework to assess the value implications of thoracic surgeon operative volume within an 8-hospital health system.

Methods

Surgical cases for non-small cell lung cancer were assessed from March 2015 to March 2021. High-volume (HV) surgeons performed >25 pulmonary resections annually. Metrics include length of stay, infection rates, 30-day readmission, in-hospital mortality, median 30-day charges and direct costs, and 3-year recurrence-free and overall survival. Multivariate regression-based propensity scores matched patients between groups. Metrics were graphed on radar charts to conceptualize total value.

Results

All 638 lung resections were performed by 12 surgeons across 6 hospitals. Two HV surgeons performed 51% (n = 324) of operations, and 10 low-volume surgeons performed 49% (n = 314). Median follow-up was 28.8 months (14.0-42.3 months). Lobectomy was performed in 71% (n = 450) of cases. HV surgeons performed more segmentectomies (33% [n = 107] vs 3% [n = 8]; P < .001). Patients of HV surgeons had a lower length of stay (3 [2-4] vs 5 [3-7]; P < .001) and infection rates (0.6% [n = 1] vs 4% [n = 7]; P = .03). Low-volume and HV surgeons had similar 30-day readmission rates (14% [n = 23] vs 7% [n = 12]; P = .12), in-hospital mortality (0% [n = 0] vs 0.6% [n = 1]; P = .33), and oncologic outcomes; 3-year recurrence-free survival was 95% versus 91%; P = .44, and 3-year overall survival was 94% versus 90%; P = 0. Charges were reduced by 28%, and direct costs were reduced by 23% (both P < .001) in the HV cohort.

Conclusions

HV surgeons provide comprehensive value across a health system. This multidomain framework can be used to help drive oncologic care decisions within a health system.

Textbook outcomes after oesophagectomy: a single-centre observational study

BACKGROUND

Textbook outcomes is a composite quality assurance tool assessing the ideal perioperative and postoperative course as a unified measure. Currently, its definition and application in the context of oesophagectomy in Australia is unknown. The aim of this study was to assess the textbook outcomes after oesophagectomy in a single referral centre of Australia and investigate the association between textbook outcomes and patient, tumour, and treatment characteristics.

METHODS

An observational study was retrospectively performed on patients undergoing open, laparoscopic, or hybrid oesophagectomy between January 2010 and December 2019 in a single cancer referral centre. A textbook outcome was defined as the fulfillment of 10 criteria: R0 resection, retrieval of at least 15 lymph nodes, no intraoperative complications, no postoperative complications greater than Clavien-Dindo grade III, no anastomotic leak, no readmission to the ICU, no hospital stay beyond 21 days, no mortality within 90 days, no readmission related to the surgical procedure within 30 days from admission and no reintervention related to the surgical procedure. The proportion of patients who met each criterion for textbook outcome was calculated and compared. Selected patient-related parameters (age, gender, BMI, ASA score, CCI score), tumour-related factors (tumour location, tumour histology, AJCC clinical T and N stage and treatment-related factor [neoadjuvant chemotherapy and surgical approach]) were assessed. Disease recurrence and one year survival were also evaluated.

RESULTS

110 patients who underwent oesophagectomy were included. The overall textbook outcome rate was 24%. The difference in rates across the years was not statistically significant. The most achieved textbook outcome parameters were 'no mortality in 90 days' (96%) and 'R0 resection' (89%). The least frequently met textbook outcome parameter was 'no severe postoperative complications' (58%), followed by 'no hospital stays over 21 days' (61%). No significant association was found between patient, tumour and treatment characteristics and the rate of textbook outcome. Tumour recurrence rate and overall long term survival was similar between textbook outcome and non-textbook outcome groups. Patients with R0 resection, no intraoperative complication and a hospital stay less than 21 days had reduced mortality rates.

CONCLUSIONS

Textbook outcome is a clinically relevant indicator and was achieved in 24% of patients. Severe complications and a prolonged hospital stay were the key criteria that limited the achievement of a textbook outcome. These findings provide meticulous evaluation of oesophagectomy perioperative care and provide a direction for the utilisation of this concept in identifying and improving surgical and oncological care across multiple healthcare levels.

Robotic-Assisted Minimally Invasive Esophagectomy: Postoperative Outcomes in a Nationwide Cohort

INTRODUCTION

Robotic-assisted minimally invasive esophagectomy (RAMIE) in clinical trials has demonstrated improved outcomes compared to open esophagectomy (OE). However, outcomes after national implementation remain unknown. The aim of this study was to evaluate postoperative outcomes after RAMIE.

METHODS

Patients who underwent elective esophagectomy between 2016 and 2020 were identified from the American College of Surgeons-- National Surgical Quality Improvement Program esophageal targeted participant user files and categorized by operative approach, with patients who underwent hybrid procedures excluded. Outcomes were compared between OE and minimally invasive esophagectomy (MIE)/RAMIE, with subset analyses by minimally invasive operative approach. Primary outcomes included pulmonary complications, anastomotic leak requiring reintervention, all-cause morbidity, and 30-d mortality.

RESULTS

In total 2786 patients were included, of which 58.3% underwent OE, 33.2% underwent MIE, and 8.4% underwent RAMIE. In the entire cohort, Ivor Lewis esophagectomy was the most common technique (64.6%), followed by transhiatal (22.0%), and a McKeown technique (13.4%). Comparing OE and MIE/RAMIE, pulmonary complications (21.5% versus 16.1%, P < 0.01) and all-cause morbidity (40.9% versus 32.3%, P < 0.01) were both reduced in the MIE/RAMIE group. When directly comparing MIE to RAMIE, there was no difference in the rate of pulmonary complications, anastomotic leak, all-cause morbidity, and mortality. However, RAMIE was associated with decreased all-cause morbidity compared to OE (40.9% versus 33.3%, P = 0.03).

CONCLUSIONS

RAMIE was associated with decreased morbidity compared to OE, with similar outcomes to MIE. The national adoption of RAMIE in this select cohort appears safe.

Development and validation of a nomogram to predict postoperative pulmonary complications following thoracoscopic surgery

Background

Postoperative pulmonary complications (PPCs) after thoracoscopic surgery are common. This retrospective study aimed to develop a nomogram to predict PPCs in thoracoscopic surgery.

Methods

A total of 905 patients who underwent thoracoscopy were randomly enrolled and divided into a training cohort and a validation cohort at 80%:20%. The training cohort was used to develop a nomogram model, and the validation cohort was used to validate the model. Univariate and multivariable logistic regression were applied to screen risk factors for PPCs, and the nomogram was incorporated in the training cohort. The discriminative ability and calibration of the nomogram for predicting PPCs were assessed using C-indices and calibration plots.

Results

Among the patients, 207 (22.87%) presented PPCs, including 166 cases in the training cohort and 41 cases in the validation cohort. Using backward stepwise selection of clinically important variables with the Akaike information criterion (AIC) in the training cohort, the following seven variables were incorporated for predicting PPCs: American Society of Anesthesiologists (ASA) grade III/IV, operation time longer than 180 min, one-lung ventilation time longer than 60 min, and history of stroke, heart disease, chronic obstructive pulmonary disease (COPD) and smoking. With incorporation of these factors, the nomogram achieved good C-indices of 0.894 (95% confidence interval (CI) [0.866–0.921]) and 0.868 (95% CI [0.811–0.925]) in the training and validation cohorts, respectively, with well-fitted calibration curves.

Conclusion

The nomogram offers good predictive performance for PPCs after thoracoscopic surgery. This model may help distinguish the risk of PPCs and make reasonable treatment choices.

Activity-Based Cost Analysis of Robotic Anatomic Lung Resection During Program Implementation

BACKGROUND

While robotic-assisted lung resection has seen a significant rise in adoption, concerns remain regarding initial programmatic outcomes and potential increased costs. We present our initial outcomes and cost analysis since initiation of a robotic lung resection program.

METHODS

Patients undergoing either video-assisted thoracoscopic lobectomy or segmentectomy (VATS) or robotic-assisted lobectomy or segmentectomy (RALS) between August of 2014 and January of 2017 underwent retrospective review. Patients underwent 1:1 propensity matching based on preoperative characteristics. Perioperative and 30-day outcomes were compared between groups. Detailed activity-based costing analysis was performed on individual patient encounters taking into effect direct and indirect controllable costs, including robotic operative supplies.

RESULTS

There were no differences in 30-day mortality between RALS (n = 74) and VATS (n = 74) groups (0% vs 1.4%; P = 1). RALS patients had a decreased median length of stay (4 days vs 7 days; P < .001) and decreased median chest tube duration (3 days vs 5 days, P < .001). Total direct costs, including direct supply costs, were not significantly different between RALS and VATS ($6621 vs $6483; P = .784). Median total operating costs and total unit support costs, which are closely correlated to length of stay, were lower in the RALS group. Overall median controllable costs were significantly different between RALS and VATS ($16,352 vs $21,154; P = .025).

CONCLUSIONS

A potentially cost-advantageous robotic-assisted pulmonary resection program can be initiated within the context of an existing minimally invasive thoracic surgery program while maintaining good clinical outcomes when compared with traditional VATS. Process-of-care changes associated with RALS may account for decreased costs in this setting.

Drivers of Cost Associated With Minimally Invasive Esophagectomy

BACKGROUND

In this era of value-based healthcare, costs must be measured alongside patient outcomes to prioritize quality improvement and inform performance-based reimbursement strategies. We sought to identify drivers of costs for patients undergoing minimally invasive esophagectomy for esophageal cancer.

METHODS

Patients who underwent minimally invasive esophagectomy for esophageal cancer from December 2008 to March 2020 were included. Our institutional Society of Thoracic Surgeons database was merged with financial data to determine inpatient direct accounting costs in 2020 US dollars for total, operative (surgery and anesthesia), and postoperative (intensive care, floor, radiology, laboratory, etc) services. A supervised machine learning quantitative method, the lasso estimator with 10-fold cross-validation, was applied to identify predictors of costs.

RESULTS

In the study cohort (n = 240) most had ≥cT2 pathology (82%), adenocarcinoma histology (90%), and received neoadjuvant therapy (78%). Mean length of stay was 8.00 days (SD, 4.13) with 45% inpatient morbidity rate and no deaths. The largest proportions of cost were from the operating room (30%), inpatient floor (30%), and postanesthesia care/intensive care units (20%). Preoperative predictors of operative costs were age (-5.18% per decade [95% confidence interval {CI}, -9.95 to -0.27], P = .039), body mass index ≥ 30 (+12.9% [95% CI, 0.00-27.5], P = .050), forced expiratory volume in 1 second (-3.24% per 10% forced expiratory volume in 1 second [95% CI, -5.80 to -0.61], P = .017), and year of surgery (+2.55% [95% CI, 0.97-4.15], P = .002). Predictors of postoperative costs were postoperative renal failure (+91.6% [95% CI, 9.93-233.8], P = .022), respiratory failure (+414.6% [95% CI, 158.7-923.6], P < .001), pneumonia (+136.1% [95% CI, 71.1-225.8], P < .001), and reoperation (+60.5% [95% CI, 21.5-111.9], P = .001).

CONCLUSIONS

Costs associated with minimally invasive esophagectomy are driven by preoperative risk factors and postoperative outcomes. These data enable surgeons and policymakers to reduce cost variation, improve quality through standardization, and ultimately provide greater value to patients.

Costs Associated With Lobectomy for Lung Cancer: An Analysis Merging STS and Medicare Data

BACKGROUND

Costs related to care of patients who undergo lobectomy for lung cancer may vary depending on patient, disease, and treating facility characteristics. We aimed to identify underlying case mix factors that contribute to variability of 90-day costs of lobectomy for early-stage lung cancer.

METHODS

The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for lobectomy for clinical stage I lung cancer (2008-2013). Demographics, clinical outcomes, and 90-day episode-of-care costs across all care settings were analyzed for patients successfully linked to Medicare data. Hospital costs were estimated from charges using cost-to-charge ratios. Comprehensive regression models were created to identify impact of preoperative patient factors and hospital characteristics on costs, and to delineate additive costs due to perioperative outcomes and complications.

RESULTS

The mean 90-day cost for lobectomy was $45,080 ± $38,239. Variables associated with significant additive costs were age greater than or equal to 75 years, American Society of Anesthesiologists classification III or IV, forced expiratory volume in 1 second less than 80% predicted, body mass index less than 18.5 or greater than 35, current or past smoker, cerebrovascular disease, chronic kidney disease, impaired functional status, open thoracotomy, prolonged operative time, government hospitals, metropolitan setting, and geographic location. Patients with 1 or more postoperative complication resulted in an overall mean added cost of $27,259. Added costs increased with the number of complications; isolated recurrent laryngeal nerve paresis ($3,911) and respiratory failure ($35,011) were associated with the least and most additive cost, respectively.

CONCLUSIONS

Lobectomy is associated with substantial variability of episode-of-care costs. Variability is driven by patient demographic and clinical factors, hospital characteristics, and the occurrence and severity of complications.