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Eur J Cardiothorac Surg 2005;27:329-333
© 2005 Elsevier Science NL

Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy

Gonzalo Varela*, Marcelo F. Jiménez, Nuria Novoa, José L. Aranda

Section of Thoracic Surgery, Salamanca University Hospital, 37007 Salamanca, Paseo de San Vicente 58, Spain

Received 20 August 2004; received in revised form 3 November 2004; accepted 8 November 2004.

* Corresponding author. Tel./fax: +34 923 291 383. (E-mail: gvs{at}usal.es).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Objective: Prolonged air leak (PAL) after pulmonary surgery is a frequent occurrence and is reported to cause increased length of stay (LOS) and hospital costs although the costs directly attributable to PAL have never been published. The present study aims to compare the prevalence of pulmonary complications (atelectasis, pneumonia and pleural empyema) in patients with or without PAL and to quantify economic costs directly incurred by PAL in a series of pulmonary lobectomies. Methods: A series of 238 patients scheduled for pulmonary lobectomy (January 2001–December 2003) have been reviewed. PAL was defined as air leakage which prevented hospital discharge for 5 postoperative days or over. Hospital costs (excluding operating room) for pulmonary lobectomies have been obtained and calculated as mean daily costs. Age, body mass index, diagnosis, Charlson co-morbidity index, ppoFEV1 and major post-operative cardio-pulmonary morbidity have been used to construct a Cox-regression model for hospital stay, considering deaths as censored cases. Individual risk function has been used as a new variable and expected LOS calculated for each case. This data has been used to estimate total excess hospital stay and costs incurred by cases with PAL. Results: Prevalence of PAL was 23 cases (9, 7%). Mean daily hospital cost for lobectomy was 632.49{euro}. For the whole series, mean hospital stay was 5 days (10 days for patients with PAL). PAL cases had more postoperative pulmonary morbidity (risk-ratio: 2.78). Variables showing independent influence on stay were: diagnosis of non-malignant disease (P=0.001); FEV1ppo (P=0.032) and cardio-respiratory morbidity (P<0.001). Calculated total excess stay for PAL patients was 62 days. A total expense of 39,437.39{euro} (38,724.96{euro} hospital and 712.43{euro} pharmacy charges) were estimated to result from postoperative air-leak. Conclusions: PAL patients are prone to developing major postoperative morbidity. PAL calculated costs are over 13000{euro} per year. This data is useful for designing technical cost-effective strategies to avoid post-lobectomy PAL.

Key Words: Lung resection • Adverse outcomes • Postoperative air-leak • Hospital costs


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Prolonged air-leak (PAL) after pulmonary resection is a frequent complication [1]. Several studies have been conducted in order to evaluate the effectiveness of adhesives or suture reinforcements for avoiding PAL but there is no evidence that such procedures are effective [2]. On the other hand, to the best of our knowledge, there has been no research into either cost evaluation of surgical strategies to avoid PAL or quantification of costs incurred by PAL. It can be hypothesised that patients suffering PAL have longer than average hospital stay (LOS) [3] and frequently associated postoperative morbidity (lobar collapse, nosocomial pneumonia and pleural empyema) due to prolonged LOS and pleural contamination. All these factors would be responsible for higher hospital costs.

The main objective of this investigation is to quantify economic costs directly attributable to PAL in a series of pulmonary lobectomies. Other specific objectives are: (1) to measure prevalence of PAL; (2) to compare the prevalence of pleural empyema and pneumonia in cases with or without postoperative PAL; and (3) to evaluate the influence of PAL and other clinical variables on LOS.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
2.1. Settings
A tertiary public university hospital receiving patient referrals from a geographic area of 56,470km2 in the west of Spain. There are no primary-care hospitals in the area specialising in long-stay surgical cases requiring only basic care and patients referred from outside the town are not usually discharged until they have no drains and are capable of self-help.

2.2. Patient population
A series of patients undergoing lobectomy in our Centre from January 2001 to December 2003 has been analysed. Clinical criteria for operation and hospital discharge have been published elsewhere [4]. In all cases, predicted postoperative FEV1 (ppoFEV1) was preoperatively calculated [5]. Most operations were performed through a muscle-sparing limited video-assisted thoracotomy. Adhesives, pleural tents or suture reinforcements were not routinely indicated. In presence of severe emphysema, synthetic-absorbable sealant [6] was discretionally available. One single water seal chest drain was left after resection under no wall suction. Postoperative pain was controlled by thoracic epidural analgesia and intensive physical therapy was begun the morning after surgery. Medical therapy was also pre and postoperatively standardised for chronic obstructive pulmonary disease, deep vein thrombosis prophylaxis, nosocomial pneumonia and postoperative atrial fibrillation.

2.3. Variables analysed
From the beginning of the Unit activities, all clinical variables were codified and prospectively recorded in a computerized database. A routine to control clinical information quality was instituted and all records reviewed by the same person before sending definitive data to the hospital central archive. Variables and outcomes were defined as follows:

1. Outcomes: PAL was defined as persistence of air-leak through the chest drain for 5 days or more.

LOS: Difference between hospital admission and discharge dates.

Pulmonary complication: pneumonia, pulmonary atelectasis and pleural empyema were considered. Nosocomial pneumonia was diagnosed by clinical criteria following Centers for Diseases Control [7] and The American Thoracic Society [8] recommendations.

Pulmonary lobar collapse was diagnosed by chest X-ray in all cases and treated by physical therapy. An aspirative bronchoscopy was indicated in cases unresponsive to physical measures.

Pleural empyema was diagnosed in the presence of purulent exudate through the chest drain and clinical signs of infection. Biochemical parameters were not considered for diagnosis.

2. Independent variables studied were: Age of the patient, diagnosis (malignant vs. inflammatory disease), body-mass index (BMI), ppoFEV1 value—as a percentage of the normal—, preoperative co-morbidity index [9] and major postoperative cardio-respiratory morbidity (binary variable; any of the following postoperative events were considered: pulmonary atelectasis or pneumonia, need of mechanical ventilation at any time after extubation in the operating room, pulmonary thromboembolism, arrhythmia, myocardial ischemia or infarct, clinical cardiac insufficiency, pleural empyema and bronchial fistula).

3. Economic data: Costs were obtained for each case from the hospital accounting department and from the hospital pharmacy department. Daily costs included hospital and pharmacy charges but operating room charges were considered homogeneous in all cases and excluded from the study.

2.4. Statistics
Descriptive statistics have been performed for independent variables and outcomes. Rates of nosocomial infection in PAL and non-PAL cases were arranged in 2x2 table and odds ratio (and its 95% confidence intervals) calculated. Probability of discharge was calculated by Cox regression analysis including the following variables in the model: age, diagnosis, BMI, ppoFEV1, co-morbidity index and postoperative cardio-respiratory morbidity. Log-rank test was used to evaluate differences in discharge probabilities between populations with and without PAL. Using clinical characteristics of each patient (age, diagnosis, BMI, ppoFEV1, co-morbidity index and postoperative cardio-respiratory morbidity) expected individual LOS was estimated by Cox-regression analysis. This value was plotted against individual true LOS. Difference between estimated and true LOS was found for each patient and the total LOS excess for PAL cases calculated. Cases with missing data were not entered in the model. Mean hospital charges were multiplied by the total days of excess stay. Mean daily pharmacy costs were obtained separately for patients with and without postoperative major cardio-respiratory morbidity and values used to calculate estimated excess of pharmacy expenses.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 Appendix A. Conference...
 References
 
3.1. Series description
Two hundred and thirty-eight cases have been studied. Most patients (87%) were operated on for lung cancer or other pulmonary malignancies. In Table 1, a descriptive study of all studied variables is presented. In 26 cases (2 PAL and 24 non-PAL cases) spirometric values were missing due to previous laryngeal surgery or patient's inability to perform the test correctly. Overall mortality (30 days) was 1.7% (four cases). Rate of postoperative pulmonary complications was 10.5% (25 cases; 17 nosocomial pneumonia, seven atelectasis without pneumonia, one pleural empyema). Three PAL cases were readmitted 1–3 weeks after hospital discharge due to pneumothorax (2 cases) and both pneumonia and pleural empyema (1 case). Re-admission LOS was 2 and 14 (pneumothorax cases), and 49 days (empyema patient).


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  		Table 1. Descriptive statistics from the series (238 cases)
 
3.2. Comparing pulmonary complications and LOS (PAL vs. non-PAL cases)
In Table 2, postoperative pulmonary complications are shown arranged as 2x2 distribution. PAL increased risk of pulmonary complications but results were not statistically significant (odds ratio 2.86; 95%IC: 0.96–8.58). Overall median LOS was 5 days (range: 3–34 days); PAL cases stayed longer (median 10, range 6–22) than non-PAL cases (median 5, range 3–34 days, P<0.001). Cox-regression analysis (Table 3) showed three variables independently related to prolonged stay: low ppoFEV1 (P=0.032), inflammatory disease (P=0.001) and major postoperative morbidity (P<0.001). Log-rank test showed that both PAL and non-PAL populations differed in LOS, independently of patient characteristics and postoperative events. (Fig. 1)


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  		Table 2. Risk of nosocomial respiratory infections and pulmonary atelectasis
 

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  		Table 3. Cox-regression model for hospital stay
 


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  		Fig. 1. Comparison of hospital stay probabilities. Patients with and without prolonged air-leak.

 
3.3. Estimating LOS
Using Cox-regression model, LOS was estimated for each case and plotted against recorded LOS. As can be seen in Fig. 2, most PAL cases (black dots) fall to the right side of the figure, meaning that, in such cases, recorded LOS was superior to that predicted. Differences between estimated and true LOS are presented in Table 4. A total of 62 days excess stay was calculated for the series.



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  		Fig. 2. Estimated vs. recorded LOS scatter plot in 238 cases.

 

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  		Table 4. Estimated excess hospital stay and cost calculation (21 PAL cases, 2 cases excluded due to missing spirometry values)
 
3.4. Cost calculation
Hospital and pharmacy costs are presented in Table 4. Daily hospital (623.49{euro}) and pharmacy charges (16.80{euro} in cases suffering major postoperative morbidity and 8.20{euro} in cases without postoperative adverse events) are multiplied by excess stay for each case, resulting in 38,724.96{euro} related to hospital and 712.43{euro} related to pharmacy charges. An estimated total expense of 39,437.39{euro} resulted from postoperative air-leak.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
Appendix A. Conference...
 References
 
Economic evaluation has become an important part of clinical medicine since health expenditure has increased enormously in the majority of countries [10]. As clinicians, we are focused on non-monetary benefits of medical interventions such as increased survival or improved quality of life, but we have to recognise that surgical practices are subject to undesirable harmful effects and associated costs. PAL has been cited as the most prevalent postoperative complication [11] and is reported in around 15–18% [12,13] of cases after lung resection. The prevalence of PAL reported here (10%) is slightly lower than that previously published though probably not statistically different. Several preoperative PAL risk factors have been identified: low preoperative pulmonary volumes [11,12], upper lobe resection [12,13], diabetes mellitus and low blood cholinesterase levels [13].

There is no standard definition of PAL in the literature. In several reports, PAL is considered after 7 [11,12] or 10 days [13]. In our report, we have defined PAL as air-leak for 5 or more days and we consider this to be more in concordance with the median hospital stay reported in our series (5 days).

According to our definition of PAL, it is reasonable to expect prolonged LOS in such complicated cases, as previously reported by others [3,11]. To avoid prolonged LOS and associated expenses, Cerfolio et al. [14] discharged home their PAL cases under Heimlich valve drainages. We consider this to be an excellent and secure practice for patients living in the hospital surroundings (which is not the case in most of our patients) but it is probably not free of expenses since, costs are shifted to primary or ambulatory care services.

In this report, we have implemented a mathematical LOS estimation from several clinical variables. Such a calculation is at its most accurate when dealing with large databases, which is not the case here and therefore our results should be interpreted with caution due to their variability. We have estimated a total of 62 excess days of hospital stay in PAL cases. Then, using direct medical (excluding operating room and drugs) and non-medical daily hospital costs we have calculated the total hospital expense attributable to PAL. We have supposed operating room costs homogeneous for all the series although in severe emphysema cases more suture machines and some sealants were probably used. Pharmacy charges have been independently considered since their value depends on the presence or absence of medical postoperative complications.

It is debatable whether all the excess stays were attributable to PAL, since, some of the patients also suffered cardio-respiratory post-operative morbidity. We have tried to demonstrate that PAL increases the risk of other postoperative morbidity. As we have shown, PAL patients have more than twice the probability of postoperative pulmonary complications than non-PAL cases. This is a clinically relevant finding although not statistically significant, probably due to the number of cases in the series.

As we have mentioned, three PAL patients were readmitted due to pneumothorax or infection that could have been related to PAL. We have not considered readmission expenses due to lack of evidence on the causes of the problem.

To avoid PAL, several surgical techniques have been published. Pleural tent seems to be an effective non-expensive practice in upper lobectomy cases [15,16]. Buttressed lung suture decreases hospital stay, according to Venuta et al. [17], but its results have not been reproduced by Miller et al. [18]. Using suture line sealants reduce air leak both in experimental [19,20] and clinical [6,21] settings and, despite reports that there is no scientific evidence supporting routine use of sealants [2], a prospective-randomised multi-centric study has been recently published [22] concluding that sealant use was associated with decreased LOS.

To the best of our knowledge, there are no published cost-effectiveness analyses of surgical strategies to avoid PAL. Economic evaluation of surgical practices depend on the quality of the underlying medical evidence [23]; cost-effectiveness analysis on PAL strategies then require well designed controlled clinical trials including a large enough number of cases to decrease the mathematical variability mentioned above. Such studies are difficult to conduct [24], especially in managed-care health systems [25].

To conclude PAL is a cause of prolonged LOS, accounting for more that 13,000{euro} a year in our centre; PAL patients are prone to developing major postoperative morbidity.


   Appendix A. Conference discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
References
 
Dr A. Turna (Istanbul, Turkey): I was wondering how many patients had COPD or emphysema, and did you make an analysis in the patients with emphysema or COPD, and did you especially assess the cost of bronchopleural fistula?

Dr Varela: To both questions, I'm afraid not. I can gather this information for the whole database, but it is not available at this moment. In our hospital, around 60% of operated cases for lung cancer have COPD, but I can't inform you at this time of the grade of emphysema.

Mr R. Berrisford (Exeter, UK): What is your policy on discharging patients with indwelling chest drains and flutter valves, because that would impact on your length of stay.

Dr Varela: I think this is a very important question. I think McKenna and maybe Cerfolio have published in the United States that they discharge patients having prolonged air leak with Heimlich valves. Unfortunately we are not in the situation to discharge most of our patients with such a valve because they live in rural areas away from the hospital, more than 100km or so. In such cases, maybe 90% of air leak patients have to stay in the hospital until they are reoperated in some cases or usually the air leak stops. To answer your question, only around 5–6% of air leak patients can be discharged with a Heimlich valve.

Dr S. Mattioli (Bologna, Italy): What is your policy in treating patients having prolonged air leaks?

Dr Varela: Do you mean what is our policy?

Dr Mattioli: Yes, do you switch the chest suction off?

Dr Varela: We almost never use suction in our cases since maybe 5 or 6 years ago. So the patient stays in the hospital, is treated by respiratory therapists, and the chest tube is connected to any kind of chest drainage unit, or even in some cases to a Heimlich valve.


   Footnotes
 
{star} Presented at the joint 18th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 12th Annual Meeting of the European Society of Thoracic Surgeons, Leipzig, Germany, September 12–15, 2004.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 

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