A cost-minimisation analysis of lobectomy: thoracoscopic versus posterolateral thoracotomy

Objective: Recent evidence suggests that lobectomy performed either through thoracoscopy (TL) or via a posterolateral thoracotomy (PLT) produces equivalent oncologic outcomes in appropriately selected patients. Advantages of thoracoscopic lobectomy include decreased postoperative pain, shorter length of stay, fewer postoperative complications and better compliance with adjuvant chemotherapy. This study evaluates the costs associated with lobectomy performed thoracoscopically or via thoracotomy. Methods: This is a retrospective analysis of actual costing and prospectively collected health-related quality of life (QOL) outcomes. Between 2002 and 2004, 113 patients underwent lobectomy (PLT: n = 37; TL: n = 76) and completed QOL assessments both preoperatively and 1-year postoperatively. Actual fixed and variable direct costs from the preoperative, hospitalisation and 30-day postoperative phases were captured using a T1 cost accounting system and were combined with actual professional collections. Cost utility analysis was performed by transforming a global QOL measurement to an estimate of utility and calculating a quality-adjusted life year (QALY) for each patient. Results: Baseline characteristics were similar in the two groups. Total costs ($US) were significantly greater for the strategy of PLT ($12,119) than for TL ($10,084; p = 0.0012). Even when only stage I and II lung cancers were included (n = 32 PLT, n = 69 TL), total costs for PLT were still higher than that for TL ($11,998 vs $10,120; p = 0.005). The mean QALY for the PLT group was 0.74 +/- 0.22 and for the TL group was 0.72 +/- 0.18 ( p = 0.68). Conclusions: In this retrospective analysis, TL was significantly less expensive than PLT from the preoperative evaluation through 30 days postoperatively, with overall savings of approximately $2000 per patient. In light of equivalent QALY outcomes, this cost utility analysis supports increased adoption of TL as a cost-minimisation strategy. The use of TL for the 50,000 lobectomies performed in the United States each year would represent a savings of approximately $100 million. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.