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In The Annals of thoracic surgery ; h5-index 58.0

BACKGROUND : In the 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 (MIE) for esophageal cancer.

METHODS : Patients who underwent MIE for esophageal cancer were included (December 2008-March 2020). Our institutional Society of Thoracic Surgeons database was merged with financial data to determine inpatient direct accounting costs in 2020 United States dollar for total, operative (surgery/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), the majority had ≥cT2 pathology (82%), adenocarcinoma histology (90%), and received neoadjuvant therapy (78%). Mean length of stay was 8.00 days (standard deviation 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 post-anesthesia-care/intensive-care units (20%). Preoperative predictors of operative costs included: age (-5.18% per-decade [95% CI -9.95,-0.27], p=0.039), body mass index≥30 (+12.9% [0.00,27.5], p=0.050), FEV1 (-3.24% per-10%-FEV1 [-5.80,-0.61], p=0.017), and year of surgery (+2.55% [0.97,4.15], p=0.002). Predictors of postoperative costs included: postoperative renal failure (+91.6% [9.93,233.8], p=0.022), respiratory failure (+414.6% [158.7,923.6], p<0.001), pneumonia (+136.1% [71.1,225.8], p<0.001), and reoperation (+60.5% [21.5,111.9], p=0.001).

CONCLUSIONS : Costs associated with MIE are driven by preoperative risk factors and postoperative outcomes. These data enable surgeons and policy-makers to reduce cost variation, improve quality through standardization, and ultimately provide greater value to patients.

Panda Nikhil, Shagabayeva Larisa, Comrie Cameron E, Phan Nicole, Moonsamy Philicia, Jeffrey Yang Chi-Fu, Fernandez Felix G, Morse Christopher R