title: Video-assisted thoracic surgery lobectomy cost variability: implications for a bundled payment era.
abstract: BACKGROUND
  In 2013, the Centers for Medicare and Medicaid Services began its Bundled Payments for Care Improvement Initiative. If payments are to be bundled, surgeons must be able to predict which patients are at risk for more costly care. We aim to identify factors driving variability in hospital costs after video-assisted thoracic surgery (VATS) lobectomy for lung cancer.
  
  
  METHODS
  Our institutional Society of Thoracic Surgeons data were queried for patients undergoing VATS lobectomy for lung cancer during fiscal years 2010 to 2011. Clinical outcomes data were linked with hospital financial data to determine operative and postoperative costs. Linear regression models were created to identify the impact of preoperative risk factors and perioperative outcomes on cost.
  
  
  RESULTS
  One hundred forty-nine VATS lobectomies for lung cancer were reviewed. The majority of patients had clinical stage IA lung cancer (67.8%). Median length of stay was 4 days, with 30-day mortality and morbidity rates of 0.7% and 37.6%, respectively. Mean operative and postoperative costs per case were $8,492.31 (±$2,238.76) and $10,145.50 (±$7,004.71), respectively, resulting in an average overall hospital cost of $18,637.81 (±$8,244.12) per patient. Patients with chronic obstructive pulmonary disease and coronary artery disease, as well as postoperative urinary tract infections and blood transfusions, were associated with statistically significant variability in cost.
  
  
  CONCLUSIONS
  Variability in cost associated with VATS lobectomy is driven by assorted patient and clinical variables. Awareness of such factors can help surgeons implement quality improvement initiatives and focus resource utilization. Understanding risk-adjusted clinical-financial data is critical to designing payment arrangements that include financial and performance accountability, and thus ultimately increasing the value of health care.
authors.affiliation: Section of General Thoracic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Medbery
authors.affiliation: Department of Surgery Patient Safety and Data Management Program, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Sebastian D
authors.initials: SD
authors.lastname: Perez
authors.affiliation: Section of General Thoracic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Force
authors.affiliation: Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Theresa W
authors.initials: TW
authors.lastname: Gillespie
authors.affiliation: Section of General Thoracic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Allan
authors.initials: A
authors.lastname: Pickens
authors.affiliation: Section of General Thoracic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Miller
authors.affiliation: Section of General Thoracic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia. Electronic address: felix.fernandez@emoryhealthcare.org.
authors.forename: Felix G
authors.initials: FG
authors.lastname: Fernandez
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D005260:Female; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D008175:Lung Neoplasms / Q000191:economics* / Q000473:pathology / Q000601:surgery*; D008297:Male; D008484:Medicaid / Q000191:economics; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D011013:Pneumonectomy / Q000191:economics* / Q000379:methods; D011183:Postoperative Complications / Q000191:economics; D018570:Risk Assessment; D016019:Survival Analysis; D020775:Thoracic Surgery, Video-Assisted / Q000191:economics* / Q000379:methods; D013908:Thoracotomy / Q000191:economics / Q000379:methods; D016896:Treatment Outcome; D014481:United States