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Central Surgical Association

49th Annual Meeting

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Risk of Financial Toxicity Among Adults Undergoing Lung and Esophageal Resections for Cancer
Yas Sanaiha, Joseph Hadaya, Arjun Verma, *Jane Yanagawa, *Peyman Benharash
UCLA, Los Angeles, California, United States

Objective: Financial toxicity (FT), defined as the harmful financial burden experienced by patients undergoing cancer treatment, has been associated with adverse outcomes ranging from subjective distress to fiscal bankruptcy. Although recent studies have linked FT with higher mortality and treatment non-adherence, data in thoracic oncology is lacking. We characterized the risk of FT among patients undergoing surgical resection of lung and esophageal thoracic malignancies.
Methods: This was a cross-sectional study of adult hospitalizations in the 2008-2019 National Inpatient Sample(NIS) for pulmonary lobectomy or esophagectomy with a diagnosis of cancer. Income was estimated by applying a gamma distribution function and the World Bank Gini coefficient to income quartiles provided by the NIS. Risk of FT was defined as health expenditure (total hospitalization costs for the uninsured and maximum out-of-pocket costs for the insured) exceeding 40% of post-subsistence income. Mixed-effect regressions were used to identify patient and hospital factors associated with risk of FT. We also examined the association of FT with mortality, complications (cardiovascular, neurologic, infectious) and costs. We evaluated whether operations performed in high quality hospitals, defined as those in the lowest quartile of composite complications, would be associated lower costs and improved clinical outcomes among those at risk for FT.
Results: Of an estimated 350,364 patients (4.7% esophagectomy), 67.8% had public insurance, 28.7% private insurance and 1.2% were uninsured. Median hospitalization costs were $22,559 (95% CI 13,043-31,054) for lobectomy and $44,635 (95%CI 32,260-69,963) for esophagectomy. Among lobectomy candidates, 64.8% of uninsured and 15.2% of insured were at risk for FT. Esophagectomy patients were also at high risk for FT, regardless of insurance status (88.9% for uninsured and 15.7% for insured). The overall prevalence of FT remained steady throughout the study duration for lobectomy and esophagectomy patients (Figure 1A). After risk adjustment, Black and Hispanic race was associated with increased risk of FT (Figure 1B). Compared to private insurance both Medicare and Medicaid exhibited higher odds of FT (Figure 1B). Conversely, elective operative status (AOR 0.89, 95%CI 0.82-0.96) and thoracoscopic approach (AOR 0.95, 95% CI 0.91-0.99) were associated with reduced odds of FT. While FT did not alter the odds of acute mortality, complications, or costs, care at high quality hospitals was associated with reductions in all endpoints (Table).
Conclusions: Similar to prior work examining financial toxicity in abdominal oncologic surgery, thoracic surgery is not exempt from this phenomenon. Given improved quality and lower costs associated with high-quality hospitals, care subsidization to higher quality hospitals should be considered for thoracic oncologic care.

Figure 1. Annual Proportion of Risk of Financial Toxicity (FT) Stratified by Operation and Insurance Status (A) and Risk-adjusted Predictors of FT.

Table 1. Association of Risk-adjusted Mortality, Complications, and Costs with Financial Toxicity and Undergoing Resection at High Quality Hospitals. AOR-Adjusted Odds Ratio. 95% CI- Confidence Interval

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