Pretreatment patient comorbidity and tobacco use increase cost and risk of postoperative complications after esophagectomy at a high-volume cancer center.
OBJECTIVE
Understanding the mechanisms and drivers of cost is a key component of improving the value of cancer care at both the system and patient level. Previous research on the cost of esophagectomy has established important postoperative drivers of cost; however, no study has linked pretreatment patient characteristics with cost. We sought to identify pretreatment patient characteristics that increase inpatient cost, length of stay, and risk of anastomotic leak and major pulmonary event (MPE) after esophagectomy for locally advanced esophageal adenocarcinoma.


METHODS
We identified 191 patients with locally advanced esophageal adenocarcinoma treated with trimodality therapy at our institution between January 2002 and December 2008. All patients underwent espophagectomy 6 to 8 weeks after completion of neoadjuvant therapy. Multiple linear regression models were used to identify pretreatment predictors of total cost and length of stay. Multivariable logistic regression was used to identify pretreatment factors associated with leak and MPE.


RESULTS
Pretreatment comorbidity (β=0.1215, P=.039) and history of tobacco use (β=0.0022, P=.028) significantly increased cost of esophagectomy. A comorbid condition increased total cost by 12.9%. Comorbidity (β=0.2597, P=.001) and poor performance status (β=0.1514, P=.021) were also significantly associated with prolonged length of stay. Patients with a higher comorbidity score had an increased risk of anastomotic leak (odds ratio, 6.564; 95% CI, 1.676 to 25.716) and MPE (odds ratio, 2.732; 95% CI, 1.317 to 5.666).


CONCLUSIONS
Pretreatment patient comorbidity and tobacco use increases cost and risk of postoperative complications after esophagectomy. Other institutions must examine the relationship between their own costs and outcomes as cancer care delivery and payment systems become integrated at a national level.
The University of Texas MD Anderson Cancer Center; and The University of Texas School of Public Health, Houston, TX.
Caitlin C
CC
Murphy
James R
JR
Incalcaterra
Heidi W
HW
Albright
Arlene M
AM
Correa
Stephen G
SG
Swisher
Wayne L
WL
Hofstetter
D000230:Adenocarcinoma / Q000191:economics* / Q000453:epidemiology / Q000628:therapy; D000328:Adult; D000368:Aged; D057868:Anastomotic Leak / Q000191:economics* / Q000453:epidemiology / Q000209:etiology; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002173:Cancer Care Facilities / Q000191:economics; D002945:Cisplatin / Q000008:administration & dosage; D003131:Combined Modality Therapy; D015897:Comorbidity; D004938:Esophageal Neoplasms / Q000191:economics* / Q000453:epidemiology / Q000628:therapy; D016629:Esophagectomy / Q000009:adverse effects / Q000191:economics*; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009944:Organoplatinum Compounds / Q000008:administration & dosage; D000077150:Oxaliplatin; D011183:Postoperative Complications / Q000191:economics* / Q000453:epidemiology; D012306:Risk; D043823:Taxoids / Q000008:administration & dosage; D064424:Tobacco Use / Q000191:economics* / Q000453:epidemiology
D009944:Organoplatinum Compounds; D043823:Taxoids; D000077150:Oxaliplatin; D002945:Cisplatin; D005472:Fluorouracil