Endobronchial Valve Therapy vs Lung Volume Reduction Surgery in the United States.

Abstract

Lung volume reduction surgery (LVRS) and endobronchial valve (EBV) placement are therapeutic options in patients with advanced emphysema. This study sought to compare the 2 approaches by using a national data set. Using the US Centers for Medicare & Medicaid Services Inpatient Claims Database, the study evaluated beneficiaries with severe emphysema who were undergoing either LVRS or an EBV procedure in accordance with Medicare reimbursement criteria. Doubly robust risk adjustment was performed using inverse probability weighting and multilevel regression models and competing-risk time-to-event analysis. Lung volume reduction therapy was performed in 3219 patients: LVRS was performed in 2378 patients, and an EBV procedure was performed in 841. Before risk adjustment, patients undergoing an EBV procedure had lower Elixhauser comorbidity scores (3.37 vs 3.86; P < .001), shorter length of stay (4 days vs 7 days; P < .0001), and lower hospital charges ($124,540 vs $146,221; P < .0001) compared with patients who underwent LVRS. Most surgical procedures were minimally invasive (1897 video-assisted thoracoscopic surgery or robotic vs 481 open). After doubly-robust risk adjustment, the EBV procedure was associated with higher 30-day mortality (odds ratio [OR], 2.68, 95% CI, 1.88-3.87; P < .001), higher 30-day readmission rate (adjusted OR, 1.4; 95% CI, 1.21-1.63; P < .001), higher reintervention rate (adjusted OR, 17.2; 95% CI, 8.42-42.2; P < .001), and higher all-cause mortality at 1 year (adjusted OR, 1.75; 95% CI, 1.49-2.07; P < .001). Medicare beneficiaries who undergo EBV procedures have higher risk-adjusted mortality and procedure-related morbidity despite fewer comorbidities than patients undergoing LVRS. These results suggest the need to revisit multidisciplinary decision making regarding the role of surgery in the management of advanced emphysema.