The cost of end-of-life hospitalizations for lung disease is high but varies widely, averaging $29,981 per patient; this raises the question of whether lung transplantation could avert acute care costs for some patients. These were among study findings published in Chest.
Researchers sought to estimate and characterize costs associated with end-of-life lung disease hospitalizations, using data from the Healthcare Cost and Utilization Project’s (HCUP) National Inpatient Sample (NIS) from 2009 to 2019. The investigators’ ultimate goal was to determine whether lung transplantation could be a more cost-effective treatment option for some of these patients. As the study authors stated, “To investigate the cost-effectiveness of lung transplant as a treatment option in pulmonary disease, we must understand costs attributable to end-of-life hospitalizations for end-stage lung disease.”
The study sample included NIS patients 18 to 74 years of age hospitalized for pulmonary disease. Patients with history of lung transplant were excluded. Pulmonary disease admissions, procedures, interventions, and complications were identified with ICD codes. Notably, the NIS database includes a 20% stratified sample of US hospitals that includes 1000 hospitals across 37 states.
Among the 2,671,071 pulmonary disease admissions identified, 109,924 (4.1%) resulted in in-hospital death. The investigators divided patients into 4 main disease groups: (1) obstructive lung disease (eg, chronic obstructive pulmonary disease [COPD]); (2) pulmonary vascular disease (eg, idiopathic pulmonary arterial hypertension [IPAH]; (3) cystic fibrosis (CF) and immunodeficiency disorders; and (4) restrictive lung disease (eg, idiopathic pulmonary fibrosis [IPF]).
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Costs associated with lung transplantation are high, yet the procedure can potentially avert costly acute care delivered for individuals with end-stage lung disease.
Obstructive lung disease accounted for 94.1% of hospitalizations and 88.1% of in-hospital mortality; restrictive lung disease accounted for 4.7% of hospitalizations and 10.6% of in-hospital mortality.
Patients who died vs those discharged alive tended to be older (65 years vs 62 years), were more likely to be men (53.0% vs 45.2%), had a longer median length of stay (4.8 days vs 3.5 days) and were more likely to be admitted via hospital transfer (12.1% vs 3.8%).
The investigators estimated that the mean total inpatient cost of end-of-life lung disease hospitalizations was $1.42 billion per year, and that the mean inflation-adjusted hospitalization cost per patient was $29,981 (median: $18,043). The actual cost of hospitalizations varied widely by diagnosis and the procedures utilized. Younger patients receiving more procedures experienced the highest inpatient costs. Mechanical ventilation accounted for the greatest proportion of interventions among the most expensive admissions.
Nearly every year across the study period, mean inpatient cost increased for obstructive lung disease, and costs varied greatly for pulmonary vascular disease. The investigators found no significant trends in restrictive lung diseases or cystic fibrosis, although costs for CF were highly variable. Younger age, male sex, number of procedures and interventions, number of diagnoses at admission, and length of hospital stay were factors associated with increased cost.
Mortality rates for pulmonary vascular disease declined across the study period from 11.0% to 6.3%, although mortality rates for obstructive lung disease (3.8%), cystic fibrosis (1.6%), and restrictive lung disease (9.2%) remained stable over time.
Across the study period, significant increases were found in the use of dialysis, extracorporeal membrane oxygenation (ECMO), and mechanical ventilation. The investigators stated an increased rate of hospital transfers were associated with a proportionately greater increase in admissions resulting in in-hospital mortality.
Study limitations include unaccounted-for significant costs outside of hospitalization including rehabilitation, skilled nursing, and hospice, as well as in-hospital physician fees.
“Costs accrued during end-of-life hospitalizations vary across individuals but represent a significant healthcare cost,” said the investigators. “Costs associated with lung transplantation are high, yet the procedure can potentially avert costly acute care delivered for individuals with end-stage lung disease,” the study authors asserted, noting that lung transplant costs have yet to be included in cost-effectiveness studies.
