Cost and effectiveness of video-assisted thoracoscopic surgery for clinical stage I non-small cell lung cancer: a population-based analysis

Comparison of costs of hospitalization of patients with primary lung cancer after lobectomy with access through classic thoracotomy and VATS in the conditions of financing based on diagnosis-related groups

Background

One of serious problems in the management of health care units is rational management of financial resources allocated by the government for health care. This management is significantly influenced by the valuation tariff of health care services, including surgical procedures. The assessment of the cost-effectiveness of a particular service has a key role in the selection of procedures performed in a given health care unit. The aim of the study is to assess the costs of lobectomy via thoracotomy and video-assisted thoracoscopic surgery (VATS) in terms of the impact on the overall hospitalization cost and the answer to the question whether differences in hospitalization costs depending on the access are large enough to justify different valuation tariffs for surgery via traditional and minimally invasive access.

Methods

This is a retrospective analysis of data on the costs of treatment of patients who underwent lobectomy via traditional access or VATS due to non-small cell lung cancer. Data concerning valuation of the procedure and hospitalization were compared with general costs of hospital treatment of these patients.

Results

The study has proven that duration of the procedure (VATS: 145 min, thoracotomy: 143 min) and total value of hospitalization costs depending on the type of access (VATS: €2,235, thoracotomy: €1,500) were similar-the differences did not show statistical significance (P=0.96 and 0.05118). In contrast, the average time of patient stay in the hospital after surgery and the average cost of surgery were significantly different (3.69 for VATS vs. 5.71 days for thoracotomy with P=0.0000084 and €1,705 for VATS and €682 for thoracotomy with P=0.0114).

Conclusions

The total cost of patient hospitalization after lobectomy via VATS is similar to the cost of hospitalization after thoracotomy. Similar costs of both treatments with well-known benefits of VATS including shorter hospitalization and better quality of life of the patient speak in favor of a wider use of minimally invasive access with a good effect in the form of economical use of financial resources.

Is incentive spirometry beneficial for patients with lung cancer receiving video-assisted thoracic surgery?

Background

The effectiveness of Incentive spirometry (IS) in patients undergoing video-assisted thoracic surgery (VATS) remains lacking. We conducted a population-based study to investigate the effectiveness of IS on patients with lung cancers following VATS.

Methods

We identified patients newly diagnosed with lung cancer who underwent surgical resection by VATS or thoracotomy from the years 2000 to 2008 in the Longitudinal Health Insurance Database. Exposure variable was the use of IS during admission for surgical resection by VATS or thoracotomy. Primary outcomes included hospitalization cost, incidence of pneumonia, and length of hospital stay. Secondary outcomes included the frequency of emergency department (ED) visits and hospitalizations at 3-month, 6-month, and 12-month follow-ups after thoracic surgery.

Results

We analyzed 7549 patients with lung cancer undergoing surgical resection by VATS and thoracotomy. The proportion of patients who were subjected to IS was significantly higher in those who underwent thoracotomy than in those who underwent VATS (68.4% vs. 53.1%, P < 0.0001). After we controlled for potential covariates, the IS group significantly reduced hospitalization costs (− 524.5 USD, 95% confidence interval [CI] = − 982.6 USD – -66.4 USD) and the risk of pneumonia (odds ratio = 0.55, 95% CI = 0.32–0.95) compared to the non-IS group following VATS. No difference in ED visit frequency and hospitalization frequency at 3-month, 6-month, and 1-year follow-up was noted between the IS and the non-IS groups following VATS.

Conclusions

The use of IS in patients with lung cancers undergoing VATS may reduce hospitalization cost and the risk of pneumonia.

Comparative effectiveness of image-guided radiotherapy for non-operated localized esophageal squamous cell carcinoma patients receiving concurrent chemoradiotherapy: A population-based propensity score matched analysis

Background

Although concurrent chemoradiotherapy (CCRT) coupled with image-guided radiotherapy (IGRT) is associated with a theoretical benefit in non-operated localized esophageal squamous cell carcinoma (NOL-ESCC) patients, there is currently no clinical evidence to support this.

Results

The study population in the primary analysis comprised 866 patients who were well balanced in terms of their co-variables. The HR for mortality when group A was compared with group B was 0.82 (95% confidence interval, 0.7–0.95). SA revealed that the result was moderately sensitive.

Materials and Methods

Eligible patients diagnosed between 2008 and 2013 were identified in the Taiwan Cancer Registry. A propensity score-matched cohort was constructed [1:1 in groups A (with IGRT) and B (without IGRT)] to balance any observable potential confounders. The hazard ratio (HR) for mortality was compared between groups A and B during the follow-up period. Sensitivity analyses (SA) were performed to evaluate the robustness of the findings regarding the selection of confounders and a potential unobserved confounder.

Conclusions

The current results provide the first clinical evidence that CCRT coupled with IGRT is associated with better overall survival when compared with CCRT without IGRT in NOL-ESCC patients. However, this study should be interpreted with caution given its non-randomized nature and the moderate sensitivity of the data. Further studies are needed to clarify this finding.

Cost and effectiveness of lung lobectomy by video-assisted thoracic surgery for lung cancer

BACKGROUND

Video-assisted thoracic surgery (VATS) emerged as a minimally invasive surgery for diseases in the field of thoracic surgery. We herein reviewed our experience on thoracoscopic lobectomy for early lung cancer and evaluated Health System use.

METHODS

A cost-effectiveness study was performed comparing VATS vs. open thoracic surgery (OPEN) for lung cancer patients. Demographic data, tumor localization, dynamic pulmonary function tests [forced vital capacity (FVC), forced expiratory volume in one second (FEV1), diffusion capacity (DLCO) and maximal oxygen uptake (VO2max)], surgical approach, postoperative details, and complications were recorded and analyzed.

RESULTS

One hundred seventeen patients underwent lung resection by VATS (n=42, 36%; age: 63±9 years old, 57% males) or OPEN (n=75, 64%; age: 61±11 years old, 73% males). Pulmonary function tests decreased just after surgery with a parallel increasing tendency during first 12 months. VATS group tended to recover FEV1 and FVC quicker with significantly less clinical and post-surgical complications (31% vs. 53%, P=0.015). Costs including surgery and associated hospital stay, complications and costs in the 12 months after surgery were significantly lower for VATS (P<0.05).

CONCLUSIONS

The VATS approach surgery allowed earlier recovery at a lower cost than OPEN with a better cost-effectiveness profile.

Cost-effectiveness of neoadjuvant concurrent chemoradiotherapy versus esophagectomy for locally advanced esophageal squamous cell carcinoma: A population-based matched case-control study

Background

Neoadjuvant concurrent chemoradiotherapy (NCCRT) is often considered for locally‐advanced esophageal squamous cell carcinoma (LA‐ESCC) patients; however, no data regarding the cost‐effectiveness of this treatment is available. Our study aimed to evaluate the cost‐effectiveness of NCCRT versus esophagectomy for LA‐ESCC at population level.

Methods

We identified LA‐ESCC patients diagnosed within 2008–2009 and treated with either NCCRT or esophagectomy through the Taiwan Cancer Registry. We included potential confounding covariables (age, gender, residency, comorbidity, social‐economic status, disease stage, treating hospital level and surgeon's experience, and the use of endoscopic ultrasound before treatment) and used propensity score (PS) to construct a 1:1 population. The duration of interest was three years within the date of diagnosis. Effectiveness was measured as overall survival. We took the payer's perspective and converted the cost to 2014 United States dollars (USD). In sensitivity analysis, we evaluated the potential impact of an unmeasured confounder on the statistical significance of incremental net benefit at suggested willingness‐to‐pay.

Results

Our study population constituted 150 PS matched subjects. The mean cost (2014 USD) and survival (year) were higher for NCCRT compared with esophagectomy (US$91,460 vs. $75,836 for cost; 2.2 vs. 1.8 for survival) with an estimated incremental cost‐effectiveness ratio of US$39,060/life‐year.

Conclusions

When compared to esophagectomy, NCCRT is likely to improve survival and is probably more cost‐effective. Cost‐effectiveness results should be interpreted with caution given our results were sensitive to potential unmeasured confounder(s) in sensitivity analysis.

Video-assisted thoracoscopic surgery for non-small-cell lung cancer is beneficial to elderly patients

The aim of this study was to explore whether video-assisted thoracoscopic surgery (VATS) has short or long-term benefits in elderly patients with non-small-cell lung cancer compared with open surgery. Between June 2007 and December 2014, 579 patients older than 70 years underwent radical pulmonary resection for non-small-cell lung cancer, including 138 who received VATS and 441 who received open surgery. A retrospective pair-matched study was performed to compare 194 patients (97 pairs) who underwent either VATS or open resection. Patients were matched by age, sex, comorbidity, American Society of Anesthesiologists (ASA) score, tumor location, clinical TNM stage, and extent of pulmonary resection. Short and long-term outcomes were compared between the two groups. The overall incidence of postoperative 30-day complications was significantly lower in the VATS group than in the open surgery group. The major postoperative 30-day complication trended lower in the VATS group but was not significantly different. The length of postoperative hospital stay was significantly shorter. Kaplan-Meier analysis showed that 5-year disease-free survival and overall survival was similar between the two groups. In summary, in surgical management of elderly patients with non-small-cell lung cancer, VATS is associated with lower rates of morbidity as well as comparable disease-free survival and overall survival outcomes.