PM6 - What Drives High Cytoreductive Surgery and HIPEC Costs: Patient, Provider or Tumor?

Introduction: Because cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for peritoneal malignancy is associated with significant cost, we sought to determine predictors of high cost care for patients undergoing CRS/HIPEC.

Methods: A merged fiscal and CRS/HIPEC database was queried for patients from 2014-2018. Hospital cost was defined as cost of the index procedure/hospitalization; high cost cases were > 75th percentile for costs. Bivariate analyses were performed, and significant (p<0.05) variables were entered in a multivariable linear regression, adjusting for patient and procedure specific factors. A separate linear regression was performed for length of stay (LOS).

Results: 59 patients underwent 61 procedures. Median cost was $30,552 (25,122-42,570) for high cost and $17,650 (15,228-20,042) and non-high cost cases. Median LOS was 8 (7-11.5) and ICU stay was 1 (1-1.5) day. LOS (p<0.01), ICU stay (p=0.049), EBL (p=0.04) and the comorbidity index Risk of Mortality (ROM) (p=0.03) were predictive of cost on multivariable analysis. Multivariable factors associated with LOS were OR time (p=0.04), ROM (p=0.04), Severity of Illness (SOI) (p<0.01), ASA class (p=0.01), ostomy creation (p=0.045) and discharge to SNF (p=0.03). Notably, complications by Clavien-Dindo grade, tumor-related factors, including PCI and CCR, and surgeon were predictive of neither cost nor LOS.

Discussion: Our results reveal that CRS/HIPEC cost is largely related to length/intensity of care, and high cost care is primarily influenced by comorbidities rather than complications, tumor biology or surgeon factors. As high resource care continues to be scrutinized, these data demonstrate that not all high cost CRS/HIPEC care is modifiable.