Cost-effectiveness analysis of thoracoscopic versus open esophagectomy for esophageal cancer: A population-based study

The question as to whether the clinical benefits of video-assisted thoracoscopic esophagectomy (VATE) do outweigh its increased costs remains unanswered. Here, we analyzed the cost-effectiveness of VATE versus open esophagectomy (OE) in a real-world setting. Using 2008-2015 Taiwanese Health Insurance claim data, we identified 3271 patients with esophageal cancer who underwent transthoracic esophagectomy. By taking into account nine confounding variables, we constructed a 1:1 propensity score-matched sample of patients who underwent VATE or OE (n = 629 each). Direct costs incurred within three years after surgery and survival were analyzed. There were no significant intergroup differences in terms of R0 resection rates, length of stay, as well as 30- and 90-day mortality and unplanned readmission rates. However, the number of dissected nodes was higher in the VATE group (median: 24 vs. 18, P < 0.001). While VATE had higher index hospitalization costs (median, 12331 USD vs. 10730 USD, P < 0.001), cost differences were reduced over time. The average accumulated cost person-month of VATE declined below that of OE at 14 months after hospital discharge. Overall survival (OS) figures were more favorable for patients treated with VATE (3-year OS: 47% vs. 41%; life expectancy: 4.04 life-years [LY] vs. 3.30 LY). The cost-effectiveness plane showed that only 0.3% of all VATE procedures were more costly and less effective than OE. The probabilities for VATE to be cost-effective at the willingness-to-pay (WTP) thresholds of 10000 and 50000 USD/LY were 63.5% and 92.4%, respectively. Using commonly accepted WTP thresholds, VATE was more cost-effective than OE for patients with esophageal cancer.