Drivers of Cost Associated with Minimally Invasive Esophagectomy.

BACKGROUND In the era of value-based healthcare, costs must be measured alongside patient outcomes to prioritize quality improvement and inform performance-based reimbursement strategies. We sought to identify drivers of costs for patients undergoing minimally invasive esophagectomy (MIE) for esophageal cancer. METHODS Patients who underwent MIE for esophageal cancer were included (December 2008-March 2020). Our institutional Society of Thoracic Surgeons database was merged with financial data to determine inpatient direct accounting costs in 2020 United States dollar for total, operative (surgery/anesthesia), and postoperative (intensive-care/floor/radiology/ laboratory/etc.) services. A supervised machine learning quantitative method-the lasso estimator with 10-fold cross-validation-was applied to identify predictors of costs. RESULTS In the study cohort (n=240), the majority had ≥cT2 pathology (82%), adenocarcinoma histology (90%), and received neoadjuvant therapy (78%). Mean length of stay was 8.00 days (standard deviation 4.13) with 45% inpatient morbidity rate and no deaths. The largest proportions of cost were from the operating room (30%), inpatient floor (30%), and post-anesthesia-care/intensive-care units (20%). Preoperative predictors of operative costs included: age (-5.18% per-decade [95% CI -9.95,-0.27], p=0.039), body mass index≥30 (+12.9% [0.00,27.5], p=0.050), FEV1 (-3.24% per-10%-FEV1 [-5.80,-0.61], p=0.017), and year of surgery (+2.55% [0.97,4.15], p=0.002). Predictors of postoperative costs included: postoperative renal failure (+91.6% [9.93,233.8], p=0.022), respiratory failure (+414.6% [158.7,923.6], p<0.001), pneumonia (+136.1% [71.1,225.8], p<0.001), and reoperation (+60.5% [21.5,111.9], p=0.001). CONCLUSIONS Costs associated with MIE are driven by preoperative risk factors and postoperative outcomes. These data enable surgeons and policy-makers to reduce cost variation, improve quality through standardization, and ultimately provide greater value to patients.