E. Eguia1, P. C. Kuo2, P. J. Sweigert1, M. H. Nelson1, G. V. Aranha1, G. Abood1, C. V. Godellas1, M. S. Baker1 1Loyola University Chicago Stritch School Of Medicine,General Surgery,Maywood, IL, USA 2University Of South Florida College Of Medicine,General Surgery,Tampa, FL, USA
Introduction:
Little is known regarding the impact of minimally invasive approaches to distal pancreatectomy (DP) on the aggregate costs of care for patients undergoing DP.
Methods:
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing laparoscopic (LDP) or open (ODP) distal pancreatectomy in FL, MD, MA, NY and WA between 2014 and 2016. Multivariable regression (MVR) was used to evaluate the association between surgical approach and rates of postoperative complication, overall lengths of stay (LOS) and aggregate costs of care including readmissions to 90 days following DP. Candidate variables were determined a priori using best variable subsets and included: age, gender, insurance, race/ethnicity, Charlson comorbidity index (CCI), pathology (benign vs. malignant), annual hospital DP volume broken into terciles (low: <6 DPs/year; moderate: 641 DPs/year) and overall LOS.
Results:
297 (11%) patients underwent LDP; 2,436 (89%) underwent ODP. On univariate analysis, patients undergoing LDP had higher rates of malignant pathology (53% vs. 39%, p<0.001), shorter overall LOS (6 days, IQR [5-10] vs. 7 days, IQR [5-13], p< 0.001) and lower aggregated costs of care ($22,734 vs. $26,910, p<0.001) than those undergoing ODP.
On MVR adjusted for age, gender, malignant pathology, CCI and hospital volume, LDP was associated with a decreased risk of prolonged LOS (OR 0.47; 95% CI [0.30, 0.74]) relative to ODP. Rates of perioperative morbidity and readmission for patients undergoing LDP were identical to those undergoing ODP.
On MVR adjusted for age, insurance, CCI and LOS, and volume, factors associated with being in the highest quartile for aggregate costs following DP included: male gender (OR 1.50; 95% CI [1.24,1.82]), CCI (OR 1.25; 95% CI [1.19, 1.31]), black race (OR1.40; 95% CI [1.02,1.91]), having Medicaid (OR 1.59 95% CI [1.12,1.25]), malignant pathology (OR 2.10; 95% CI [1.61, 2.74]) and readmissions (OR 5.29; 95% CI [4.35, 6.43]). Patients undergoing LDP had a lower risk of being in the highest quartile for costs (OR 0.52, 95% CI [0.37, 0.74]) than those undergoing ODP. The reduction in risk of being a high outlier for cost was independent of hospital volume but only high-volume centers realized an average lower aggregate cost of care (-$4,803; 95% CI: [-$8,341, -$1,265]) when utilizing LDP. In low (-$3,3010; 95% CI [-$8,008, $1,988]) to moderate (+$3,606; 95% CI [-$6,629, $13,841]) volume centers, the aggregate costs of care for LDP and ODP were statistically identical.
Conclusion:
Patients undergoing LDP have a lower risk of prolonged overall LOS relative to those undergoing ODP. This association is independent of hospital volume but translates into cost savings in high volume centers only. This finding suggests that high volume centers develop efficiencies of scale that allow them to realize aggregate cost savings when utilizing laparoscopic approaches to DP.