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Value Based Care of Patients with Achalasia: A Cost Comparison of Per Oral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy.
Elan R. Witkowski*, Ozanan R. Meireles, David W. Rattner
Surgery, Massachusetts General Hospital, Boston, MA
Background:
Value based healthcare is often distilled down to the proposition that Value= Quality/Cost. Both Laparoscopic Heller Myotomy (LHM) and Per Oral Endoscopic Myotomy (POEM) have been shown to be effective treatments to relieve dysphagia in patients with Achalasia. While the physiologic outcomes of these procedures appear to be comparable, the cost differences have not been as carefully examined. We hypothesized that the direct costs of POEM would be higher than LHM, and not directly offset by differences in short-term postoperative outcomes.
Methods:
Consecutive adult patients with confirmed achalasia (Chicago classification II and III) treated with POEM at a single academic medical center between 2012-2014 years were identified from the OR administrative database. A cohort of patients undergoing LHM by the same surgeons were similarly identified and matched by date of service. The direct OR costs (disposable instruments and supplies) were calculated, as were OR time, length of stay (LOS), and complications occurring within one year of intervention.
Results:
There were 16 patients who underwent POEM and a comparison group of 37 patients undergoing LHM identified during the study period. The median LOS was 1 day for both groups. There were no major postoperative complications in either group. No re-interventions were required within 30 days during the study period in any patient. One patient undergoing POEM required laparoscopic fundoplication for severe reflux 4 months post op.
Median direct costs were ,245 for POEM, and for LHM. Mean direct costs were ,322 for POEM, and for LHM. (p<0.05) Disposable supplies such as Endoscopic clips were a significant driver of these cost differences. Although OR time for POEM decreased slightly during the study period, OR direct costs did not decline as the surgeons gained greater experience with POEM.
Conclusions:
Both Heller myotomy and POEM are safe and effective, with similar short-term outcomes. The direct costs of POEM are higher, and do not appear to be offset by any decrease in length of stay or recovery captured by our current databases. The value proposition for POEM may be potentially altered by decreasing use of costly OR devices and supplies or by demonstrating significantly improved patient centered outcomes with validated QOL instruments. Absent these changes, LHM may offer the best value for treating patients with achalasia.
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