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 pancreaticoduodenectomy (PD) on the aggregate costs of care for patients undergoing PD.
Methods:
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing laparoscopic (LPD) or open (OPD) pancreaticoduodenectomy in FL, MD, 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 PD. 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), hospital PD volume broken to terciles (low: <17 PD/year; moderate to high: 17<PD/year <127; very high volume: >127 PD/year) and overall LOS.
Results:
513 (10.8%) patients underwent LPD; 4,746 (89.2%) underwent OPD. On univariate analysis, patients undergoing LPD had higher CCI (5 vs. 3, p<0.001) and higher rates of readmission (35% vs. 30%, p=0.04), malignant pathology (89% vs. 76%; p<0.001), and aggregate costs of care ($41,669 vs. $37,580, p<0.02) than those undergoing OPD.
On MVR adjusted for age, CCI, pathologic diagnosis, and hospital volume, LPD was associated with a lower risk of prolonged LOS (OR 0.77; 95% CI [0.61,0.97]) but greater risk of readmission (OR 1.24; 95% CI [1.02, 1.51). Rates of perioperative morbidity and overall LOS for patients undergoing LPD were identical to those for patients undergoing OPD.
On MVR adjusted for age, pathology, CCI, LOS, and volume, factors associated with being in the highest quartile for aggregate costs of care included: male gender (OR 1.19; 95% CI [1.04, 1.37]), CCI (OR 1.07; 95% CI [1.03, 1.11]), black race (OR1.41; 95% CI [1.12, 1.78]), Hispanic ethnicity (OR 1.90; 95% CI [1.50, 2.42]), Medicare insurance (OR 1.28 95% CI [1.05, 1.55]), readmission (OR 4:44; 95% CI [3.87, 5.09]) and low hospital volume (OR 2.46; 95% CI [1.97, 3.06]). Patients undergoing LPD in low (+$9,390; 95% CI [$2,948, $15,831]) and moderate to high (+$5,579; 95% CI [$1,783, $9,376]) volume centers had higher costs than those undergoing OPD in the same centers. In very high-volume centers, aggregate costs of care for patients undergoing LPD were identical to those undergoing OPD in the same centers (+$616; 95% CI [-$1,703, $2,936])).
Conclusion:
Rates of morbidity and overall LOS for patients undergoing LPD are statistically identical to those undergoing OPD. At low to moderate volume centers, the laparoscopic approach to PD is associated with higher aggregate costs of care relative to OPD whereas at very high-volume centers LPD is cost neutral. This finding suggests that high volume centers are able develop efficiencies of scale that act to mitigate costs inherent to adoption of the laparoscopic approach to PD.