A Population-Based Cost Analysis of Thoracoscopic Versus Open Lobectomy in Primary Lung Cancer

Among the 5366 lung cancer patients who underwent lobectomy between 2004 and 2010, 3166 (59 %) underwent conventional open lobectomy and 2200 (41 %) had thoracoscopic lobectomy. Patient demographics and tumor characteristics are listed in Table 1. The average age in the open lobectomy group was 66.63 ± 11.11 years compared with 61.70 ± 11.02 years in thoracoscopic lobectomy group (p < 0.0001). There were more males in the open group than in the thoracoscopic (56.95 vs. 45.27 %). The mean Charlson score was higher in the open group compared with the thoracoscopic group (5.58 ± 3.22 vs. 4.87 ± 2.97; p < 0.0001). The most common tumor cell type was adenocarcinoma, which accounted for 66.23 % of tumors in the open group and 79.23 % in the thoracoscopic group. The patients in thoracoscopic group had earlier TNM staging compared with patients in open group.

Perioperative details and patient outcomes are listed in Table 2. The average anesthesia time was longer in the open group compared with the thoracoscopic group (5.55 ± 1.94 vs. 5.40 ± 1.79 h; p = 0.033). The average length of hospital stay was 17.49 ± 15.89 days in the open group and 13.00 ± 8.7 days in the thoracoscopic group. The average duration of chest tube placement after operation was longer in the open group compared with the thoracoscopic group (8.68 ± 5.10 vs. 6.44 ± 4.42 days, p < 0.001). The surgical mortality was greater in open group compared with the thoracoscopic group (1.04 vs. 0.41 %; p = 0.0096).

The detailed hospital costs are listed in Table 3. The total cost of the index hospitalization for lobectomy surgery was higher in the thoracoscopic group ($6,574.1 ± $3,605.9 vs. $6,329.9 ± $4434.3; p = 0.026). Regarding breakdown of total cost, only the operative costs and other cost were higher in the thoracoscopic group. The other cost included any instruments or equipment used other than operative costs, such as surgical stapling devices, energy-based vascular sealing and cutting devices, hemostat agents, and tissue adhesives. The 30-day after discharge costs involved any medical costs within 30 days after discharge and included any hospital emergency room visits, outpatient department visits, or any hospital or clinic visits other than the hospital where the patient underwent lobectomy. This cost was significantly higher in the open group compared with the thoracoscopic group ($831.90 ± $1759.90 vs. $612.80 ± $1401.00, p < 0.001).

Our study showed that the total hospital costs were higher in the thoracoscopic lobectomy group compared with the open lobectomy group, although the 30-day after discharge costs were significantly lower in the thoracoscopic group. Of the 41 % of patients who underwent thoracoscopic lobectomy for lung cancer treatment in our study, most were females and younger in age compared with the open group.

Lobectomy with radical lymph node dissection is still the mainstream treatment for resectable lung cancers worldwide. In a large study of lung cancer patients in Taiwan, the majority (64.1 %) underwent lobectomy.16 The thoracoscopic approach used in lobectomy has become more popular due to greater familiarity with this technique, comparable oncologic outcomes, and distinct advantages over open lobectomy, such as shorter duration of adjuvant chemotherapy, better patient tolerance, less pain, and shorter length of hospital stay.

A study of a general thoracic surgery registry database performed between 1999 and 2006 revealed that only 20 % of patients underwent thoracoscopic approach for primary lung cancer.17 Another recent national database analysis found that approximately 39 % of lung cancer patients underwent thoracoscopic lobectomy.18 In our study, adenocarcinoma was the predominant cell type in both open and thoracoscopic groups and tumor size tended to be smaller in the thoracoscopic group and the thoracoscopic group also had a lower T stage. The indication of thoracoscopic lobectomy in Taiwan included small peripheral lung cancer and that contributed to smaller tumor size in thoracoscopic group compared with open group.

The cost of thoracoscopic lobectomy compared with conventional open lobectomy has been analyzed in several studies ranging from small sample-sized studies performed at a single institution to large studies using a national database. Some studies have shown lower costs using thoracoscopic lobectomy. Park and colleagues compared robotic, video-assisted thoracoscopic surgery (VATS), and thoracotomy approaches to pulmonary lobectomy and found lower costs and shorter hospital stays in the VATS group.7 Casali and Walker reported that thoracoscopic lobectomy had higher surgical costs but lower total costs and this was felt to be related to the shorter hospital stays in the thoracoscopic lobectomy group.8 Burfeind and colleagues, in a retrospective analysis of primary lung cancer patients who received either thoracoscopic or open lobectomy, demonstrated less costs for thoracoscopic lobectomy in all phases of patient care.9 Swanson et al. also analyzed the cost differences between thoracoscopic and open lobectomy groups from a multi-institutional database and revealed that the VATS approach was less costly with fewer complications, shorter anesthesia times, and shorter hospital stays than open lobectomy.12 Fajah and colleagues studied patients who underwent lobectomy not just for lung cancer and further analyzed the 90-day cost after discharge.13 They found that the thoracoscopic group had significantly lower total 90-day index hospitalization costs and outpatient costs. In contrast, Gopaldas et al. examined the Nationwide Inpatient Sample database of the United States comparing VATS to open thoracotomy lobectomy and found that the cost of VATS lobectomy tended to be higher than open thoracotomy lobectomy, but the difference was not statistically significant.10 The VATS lobectomy group patients had similar hospital stays and more intraoperative complications compared with the open thoracotomy group. Recently, a study reported by Alpay et al. showed that VATS lobectomy costs were greater than costs from thoracotomy lobectomy.14 The authors concluded that these findings may have resulted from lower bed fees and higher disposable instrument costs. The total cost of thoracoscopic versus open lobectomy was variable in the above studies. These findings may be explained by different charge policies regarding surgical, anesthesia, and hospital fees, and variable professional and operative fees.

In Taiwan, the medical expenses are regulated by the government under the National Health Insurance Administration, Ministry of Health and Welfare. Although the fees for lobectomy and mediastinal lymph node dissection differ between thoracoscopic versus open approaches, the same procedure in different hospitals costs the same. We found that the operative cost was significant higher in the thoracoscopic group compared with the open group. The most important factor affecting anesthesia cost in our study was anesthesia time. Both anesthesia time and anesthesia cost were significantly higher in the open group compared with the thoracoscopic group. In our study, the length of hospital stay was significantly higher in the open group and that finding could have contributed to the higher cost of ordinary ward, ICU, nursing, and pharmacy costs. The other costs and operative costs were significantly higher in the thoracoscopic group, which made the total cost significantly higher in the thoracoscopic group. Similar to the study performed by Alpay et al., lower bed and manpower costs with higher disposable instrument costs may explain the higher total hospital costs in the thoracoscopic group in our study despite the shorter hospital stays and anesthesia times.14

Few studies have analyzed the cost of medical needs after discharge. One of the factors that may have influenced the after-discharge cost in our study was the postoperative complication rate, which may have resulted in more outpatient visits or readmissions. Farjah et al. analyzed the costs up to 90 days after discharge and also found a significantly lower cost in the thoracoscopic group.13 As they reported, outpatient use and readmissions accounted for near 16 % of the total 90-day costs after lobectomy. In our study, the 30-day after-discharge cost was significantly lower in the thoracoscopic group. This may be explained by less pain experienced by the patients and, thus, fewer required outpatient visits and analgesic agents along with fewer complications and less need for readmission.

The strength of our study was its large patient size, which included nearly 99 % of the resident population in Taiwan. This factor may have balanced the effects due to the differing economic status among patients and the different hospital volumes (i.e., between a medical center vs. a regional hospital). In addition, the 30-day after-discharge cost included all medical expenses incurred by the same patient at different hospitals.

Our study also had several limitations. The data were conducted on a retrospective cohort, based on diagnostic codes and prescription histories. Registry bias could not be fully excluded, but its influence may have been minimized by the review of the medical expenses conducted by government experts. In addition, although 13,846 (20.9 %) patients were excluded because of incomplete data, compared with other population databases, the percentage of patients with complete data was relatively high in our database.