Economic impact of powered stapler in video-assisted thoracic surgery lobectomy for lung Cancer in a Chinese tertiary hospital: A cost-minimization analysis

Cao, Yang et al. Article Economic impact of powered stapler in video-assisted thoracic surgery lobectomy for lung Cancer in a Chinese tertiary hospital: A costminimization analysis Health Economics Review Provided in Cooperation with: Springer Nature Suggested Citation: Cao, Yang et al. (2022) : Economic impact of powered stapler in video-assisted thoracic surgery lobectomy for lung Cancer in a Chinese tertiary hospital: A cost-minimization analysis, Health Economics Review, ISSN 2191-1991, Springer, Heidelberg, Vol. 12, Iss. 1, pp. 1-13, https://doi.org/10.1186/s13561-022-00359-x This Version is available at: https://hdl.handle.net/10419/285249 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ RESEARCH Open Access Economic impact of powered stapler in video-assisted thoracic surgery lobectomy for lung Cancer in a Chinese tertiary hospital: a cost-minimization analysis Yang Cao 1 , Fang Xiong 1 , Xiaozhe Xia 1 , Pengjuan Gu 1 , Qinghong Wang 1 , Aiping Wu 1 , Huan Zhan 2 , Wendong Chen 3* and Zhaoxin Qian 1* Abstract Background: To assess the economic impact of powered stapler use in video-assisted thoracic surgery (VATS) lobectomy for lung cancer in a Chinese tertiary care hospital. Methods: This study identified 388 patients who received VATS lobectomy using the ECHELON powered stapler (n= 296) or the ECHELON manual stapler (n= 92) for lung cancer in a Chinese tertiary hospital. Multiple generalized linear regression analyses were conducted using data on hospital costs and patient characteristics to develop predictive equations for hospital costs in a cost-minimization analysis (CMA) model comparing hospital costs associated with the ECHELON powered stapler and the ECHELON manual stapler. CMA model was used to conduct scenario analysis to compare the ECHELON powered stapler with another manual stapler (Victor Medical). Results: The multiple generalized linear regression analyses identified that using the ECHELON powered stapler in VATS lobectomy for lung cancer was associated with significantly lower drug costs than using the ECHELON manual stapler (coefficient −0.256, 95% confidence interval: −0.375 to −0.139). The CMA model estimated that the ECHELON powered stapler could save hospital costs by ¥1653 when compared with the ECHELON manual stapler (¥65,531 vs. ¥67,184). The use of the ECHELON powered stapler also saved hospital costs by ¥4411 when compared with the Victor Medical manual stapler (¥65,531 vs. ¥69,942) in the scenario analysis. Conclusions: Compared to the two manual staplers used for VATS lobectomy for lung cancer in a Chinese tertiary hospital, the ECHELON powered stapler had 100% probability to save total hospital costs under present prices of the three staplers according to the CMA. Keywords: Powered stapler, VATS lobectomy, Lung cancer, Hospital costs, Cost-minimization analysis Introduction With its genesis as a “mechanical stitching device”in 1908, the stapler evolved from the “Fischer-Hul  tl stapler”, which weighed 5 kg and took 2 h to assemble, to the modern stapler with disposable staple cartridges and simplified hand-controlled, automatic firing mechanisms [1]. The utilization of stapler has been proven to reduce bleeding, postoperative air leak risk, tissue injury, and operative time in many surgery settings. Modern surgical staplers have been widely used for wound closure, organ resection, organ transection, and anastomoses [2]. One of the main applications of a mechanical stapler occurs © The Author(s). 2022 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. * Correspondence: [email protected];[email protected] 3 Normin Health Consulting Ltd, Toronto, Canada 1 Xiangya Hospital, Central South University, Changsha, China Full list of author information is available at the end of the article Cao et al. Health Economics Review (2022) 12:12 https://doi.org/10.1186/s13561-022-00359-x in pulmonary resection through video-assisted thoracic surgery (VATS), which lacks sufficient surgery space to perform endoscopic suturing [3]. The uneven force distribution inherent in manual stapler operation often causes instability of its distal tip and increases the risk of oozing or bleeding along the staple line. Therefore, a powered stapler was developed to address this limitation by using a motor to power both the staple firing and the cutting action of the blade. A powered stapler can reduce movement at the distal tip by 88% when compared to a manual stapler [4]. In addition, the use of a powered stapler can prevent the operating surgeon’s intraoperative hand tremors thereby minimizing tissue damage. However, there is dissonance among existing literature on the clinical and economic benefits associated with the use of a powered stapler in VATS lobectomy. For example, four real-world studies from the United States, South Korea, and Japan reported that the use of a powered stapler was associated with significantly lower risk of complications (i.e., bleeding and pleurodesis) and lower hospital costs than the use of a manual powered stapler in VATS lobectomy [4–7]. In contrast, three studies from the United States and Europe observed no significant differences in the incidences of complications (e.g., air leak, bleeding, post-surgery adverse events, and length of drainage therapy) between the two types of staplers [8–10]. We recently conducted a retrospective cohort study that observed comparable clinical outcomes associated with the two types of staplers but significantly shorter operation time and length of hospital stay associated with a powered stapler [11]. To further add meaningful evidence to the topic, this study employs the cost-minimization analysis (CMA) method to explore the potential economic benefits associated with using powered stapler in VATS lobectomy for lung cancer. Methods The superior clinical effects of powered staplers over manual staplers in VATS lobectomy for lung cancer have been widely presented [4–7]. To further compare the two types of staplers, this study uses CMA to assess the economic impact of utilizing a powered stapler in VATS lobectomy for lung cancer in a Chinese tertiary hospital. A retrospective cost analysis was conducted to support the development of the CMA model. The ethics approval of this study was obtained from the ethics review board of Xiangya Hospital, which provided deidentified data extracted from the hospital’s medical and billing records associated with patients who underwent VATS lobectomy for lung cancer. Retrospective cost analysis A retrospective cost analysis was conducted to develop predictive models for hospital costs associated with VATS lobectomy for lung cancer in a Chinese tertiary care hospital. The retrospective cost analysis was informed by data from the hospital information system of Xiangya Hospital, a teaching hospital affiliated with Central South University, Changsha, China. The hospital surgical records were screened to identify hospital episodes related to VATS lobectomy for lung cancer from January 1, 2016 to December 31, 2018. This study included patients with routine hospital discharge after VATS lobectomy for lung cancer to control the potential bias that may stem from incomplete information. Patients with extreme values for operation time (> 8 hours), length of hospital stay (> 21 days), excessive bleeding (> 600 ml), and/or excessive post-surgery drainage volume (> 2400 ml) were excluded to control the potential confounding effects from unusual clinical circumstances. Patients who died during the surgery were excluded as well. Since patients who used imported medical devices for surgery usually had a high socioeconomic status in China [12], the retrospective cost analysis included only patients who underwent VATS lobectomy using a powered stapler (ECHELON FLEX™ENDOPATH® Staplers) and a manual stapler (ECHELON FLEX™Articulating Endoscopic Linear Cutter) imported from the same manufacturer (Ethicon, NJ, USA) to minimize the confounding effects of a patient’s socioeconomic status. The electronic medical and billing records of the included hospital episodes were used to extract stapler utilization information (e.g., stapler types, numbers of utilized staplers and cartridges), patient baseline characteristics (i.e., demographics, social economic status, lung cancer histology, lung cancer tumor stage, bone marrow function, comorbidity, and operation site), and hospital costs (i.e., total hospital costs and classified hospital costs). This study divided the included patients into two groups according to the type of stapler used in their surgery (powered stapler group vs. manual stapler group) and compared their baseline characteristics, numbers of staplers and cartridges used during surgery, hospital costs in sub-categories, and total hospital costs. The statistical methods used for these comparisons included a Student’s t-test for continuous data, a Chi-square test for categorical data, and a Wilcoxon rank-sum test for the cost data. To develop predictive models for hospital costs in sub-categories in the CMA, we conducted simple and multiple generalized linear regression using patient characteristics and type of stapler as independent variables and hospital costs, which included disposable supplies costs, drug costs, surgery procedure-related costs, laboratory test costs, and other hospital costs, as dependent variables. Patient characteristics with a significant association with categorized hospital costs in the simple regression analyses were included in the multiple Cao et al. Health Economics Review (2022) 12:12 Page 2 of 13 generalized linear regression analyses on the categorized hospital costs. Cost-minimization analysis A decision-analytic model was constructed to simulate hospital costs for VATS lobectomy for lung cancer for two scenarios: utilizing the ECHELON powered stapler and utilizing the ECHELON manual stapler. In each scenario, the model simulated hospital costs associated with a stapler using the predictive models developed from the retrospective cost analysis. The baseline characteristics of the included patients in the retrospective cost analysis were applied to the model cohort in the constructed CMA model. The numbers of staplers and cartridges expended during surgery and their unit prices were used to calculate the acquisition costs of the staplers and cartridges in the two scenarios for the CMA. The constructed model for CMA was used to conduct the base case analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis (PSA) for the point estimations and uncertainty associated with the differences in simulated hospital costs between the ECHELON powered stapler and the ECHELON manual stapler. The baseline characteristics of the patient cohort from the retrospective cost analysis and the coefficients in the predictive models for the classified hospital costs were applied to run the base case analysis for the point estimations of the differences in total hospital costs and categorized hospital costs between the two scenarios. Oneway sensitivity analysis was conducted to assess the impact of uncertainty associated with each model variable on the differences in the estimated total hospital costs associated with the two scenarios. Monte Carlo simulation with 10,000 iterations based on the distributions of coefficients in the cost predictive equations in the CMA model was run to plot the distribution of the differences in the estimated total hospital costs associated with the two scenarios. To demonstrate the differences in total hospital costs between the ECHELON powered stapler and another approved manual stapler brand, this study applied the constructed model for CMA to conduct a scenario analysis comparing the ECHELON powered stapler against the Victor Medical manual stapler—another domestic surgical stapling device approved in Mainland China. Because the ECHELON and the Victor Medical manual staplers shared the same mechanics of operation, the scenario analysis assumed that the two manual staplers had the same hospital costs except for their acquisition costs, which were determined by their unit prices. Accordingly, the scenario analysis used the same predictive equations for the Victor Medical stapler and cartridge on categorized hospital costs in the CMA model to compare the simulated total hospital costs between the ECHELON powered stapler and the Victor Medical manual stapler. This study used the statistical software R to conduct a retrospective cost analysis. The statistical significance used in the retrospective cost analysis was a two-sided p-value less than 0.05. The CMA model was constructed in Microsoft Excel to run the base case analysis, one-way sensitivity analysis, and PSA. Results The initial search of the hospital surgery records identified 1022 patients who underwent VATS lobectomy for lung cancer during the defined study observation period. Based on the information on the utilization of staplers in VATS lobectomy, this study included 296 patients using the ECHELON powered stapler and 92 patients using the ECHELON manual stapler to conduct the retrospective cost analysis. The patient identification flowchart is illustrated in Fig. 1. The results of the retrospective cost analysis and the CMA comparing the use of a powered stapler with the use of a manual stapler for total hospital costs and categorized hospital costs are summarized in the subsequent sections. Retrospective cost analysis: baseline characteristics of the included patients The baseline characteristics of the included patients were summarized and compared between the two groups: patients whose procedure used the ECHELON powered stapler and those whose procedure used the ECHELON manual stapler. The two study groups had comparable baseline characteristics including age, gender distribution, BMI, and tumor stage distribution. The baseline characteristics with significant differences included area of residence (provincial capital city: 25.4% vs. 14.3%, p= 0.025; county: 7.5% vs. 19.8%, p= 0.001); urban resident insurance plan (22.0% vs. 7.7%, p= 0.019); abnormal erythrocyte counting (24.4% vs. 14.3%, p= 0.043); lobectomy site at bottom left lung (11.5% vs. 24.2%, p= 0.016); and the comorbidities that included bronchial disease (13.5% vs. 3.3%, p= 0.006), coronary heart disease (2.7% vs. 9.8%, p= 0.004), and sport system diseases (9.8% vs. 3.3%, p= 0.047). The baseline patient characteristics of the two study groups are summarized in Table 1. Retrospective cost analysis: number of used staplers and cartridges and categorized hospital costs The number of staplers used during surgery in the ECHELON powered stapler group and the ECHELON manual stapler group were highly comparable (1.2+/−0.6 vs. 1.2+/−0.5, p= 0.627). However, the powered stapler group used fewer cartridges than the manual stapler group (7.0+/−3.9 vs. 7.5+/−4.0, p= 0.076). Compared Cao et al. Health Economics Review (2022) 12:12 Page 3 of 13 with the ECHELON manual stapler group, the ECHELON powered stapler group had lower hospital costs for drugs (median: ¥10,161 vs. ¥13,592, p< 0.001) but higher operation-related hospital costs (median: ¥8257 vs. ¥7683, p < 0.001). The total hospital costs of the ECHELON powered stapler group were significantly lower than those incurred by the ECHELON manual stapler group (median: ¥64,322 vs. ¥67,298, p < 0.001) because the drug costs saved from the use of the powered stapler were higher than the sum of the powered stapler group’s increased operation-related hospital costs and stapler acquisition costs. The number of staplers used during surgery and categorized hospital costs for the two study groups are summarized in Table 2. Retrospective cost analysis: developing predictive equations for categorized hospital costs Our multiple generalized regression analysis identified that the categorized hospital costs for disposable supplies were significantly associated with BMI distribution (18.5 < =BMI < 24: coefficient −0.099, p= 0.007; 24 < = BMI < 28: coefficient −0.133, p= 0.001; 30 < =BMI < 40: coefficient −0.388, p= 0.002) and the following comorbidities: lung infection (coefficient −0.286, p= 0.004), tuberculosis (coefficient −0.205, p= 0.027), breast diseases (coefficient −0.524, p= 0.015). The categorized hospital costs for drugs were significantly associated with the use of a powered stapler (coefficient −0.256, p< 0.001), tumor stage I (coefficient −0.153, p < 0.001), BMI distribution for patients with 24 < =BMI < 28 (coefficient − 0.148, p= 0.005) and patients with 30 < =BMI < 40 (coefficient −0.330, p= 0.002), and the following comorbidities: urological diseases (coefficient 0.144, p = 0.005), endocrine diseases (coefficient −0.164, p= 0.019), and abnormal platelet counts (coefficient 0.233, p = 0.002). Additionally, the categorized hospital costs for operation were significantly associated with the following comorbidities: bronchial diseases (coefficient 0.108, p= 0.025), urological diseases (coefficient 0.074, p= 0.045), and immune system diseases (coefficient −0.393, p= 0.019). The categorized hospital costs for laboratory tests were significantly associated with BMI distribution for patients with 18.5 < =BMI < 24 (coefficient 0.100, p= 0.024), unspecified insurance plan (coefficient: 0.124, p=0.019), and the following comorbidities: diabetes (coefficient: 0.165, p=0.019), urological diseases (coefficient 0.133, p= 0.007), and immune system diseases (coefficient −0.521, p= 0.023). Lastly, the categorized hospital costs for other utilized resources were significantly associated with tumor stage I (coefficient −0.083, p= 0.033) and the following comorbidities: diabetes (coefficient 0.158, p= 0.020) and urological diseases (coefficient 0.176, p< 0.001). The results of the multiple generalized regression analyses for the categorized hospital costs are summarized in Table 3. Cost-minimization analysis: base case analysis The following values were used to conduct the base case analysis: (1) baseline characteristics of the included patients at an individual level in the retrospective cost Fig. 1 The flow chart of creating two study groups for the retrospective cost analysis comparing ECHELON powered stapler vs. ECHELON manual stapler Cao et al. Health Economics Review (2022) 12:12 Page 4 of 13 Table 1 Summary of patient characteristics of the created two stapler groups in the retrospective cost analysis Patient characteristics ECHELON powered stapler group (N= 296) ECHELON manual stapler group (N=92) P value %/Mean+/−SD %/Mean+/−SD Demographics Age (years) 57.9+/−8.9 58.5+/−9.0 0.823 Male gender 53.0% 63.0% 0.092 BMI (kg/m 2 ) 23.8+/−3.1 23.5+/−2.8 0.343 BMI < 18.5 3.8% 0.0% 0.609 18.5 < =BMI < 24 50.2% 62.4% 0.168 24 < =BMI < 28 36.9% 27.5% 0.280 28 < =BMI < 30 6.4% 7.6% 0.730 30 < =BMI < 40 2.7% 2.5% 1.000 Place of residence Provincial capital city 25.4% 14.3% 0.025 Prefecture-level city 59.3% 60.4% 0.910 County 7.5% 19.8% 0.001 Other cities 7.8% 5.5% 0.450 Public insurance plan Urban employee medical insurance 27.1% 19.2% 0.294 Urban resident medical insurance 22.0% 7.7% 0.019 New rural cooperative medical insurance 27.1% 36.5% 0.180 Others 23.7% 36.5% 0.080 Marital status Married 99.3% 100.0% 1.000 Single 0.7% 0.0% 1.000 Comorbidity Digestive system diseases 43.9% 38.0% 0.319 Urinary system diseases 23.0% 16.3% 0.173 Hypertension 20.3% 17.4% 0.543 Reproductive system diseases 17.2% 13.0% 0.342 Cerebrovascular/cerebrovascular diseases 15.9% 17.4% 0.731 Bronchial diseases 13.5% 3.3% 0.006 Endocrine system diseases 11.1% 7.6% 0.329 Sports system diseases 9.8% 3.3% 0.047 Diabetes 9.1% 8.7% 0.901 Heart disease 8.8% 12.0% 0.365 Emphysema 7.4% 7.6% 0.955 Bullae 5.1% 5.4% 0.889 Coronary heart disease 2.7% 9.8% 0.004 Tumor histology Squamous cell carcinoma 14.6% 14.8% 1.000 Adenocarcinoma 78.2% 81.5% 0.809 Other 7.1% 3.7% 0.792 Tumor stage Carcinoma in situ 1.0% 0.0% 0.332 Cao et al. Health Economics Review (2022) 12:12 Page 5 of 13 analysis; (2) the unit prices of the ECHELON powered stapler (PSE45A stapler: ¥6790, ECR45B cartridge: ¥2441) and the ECHELON manual stapler (EC45A stapler: ¥3970, ECR45B cartridge: ¥2441); and (3) the baseline coefficients of the predictive equations for the categorized hospital costs. As a result, the base case CMA estimated that the total hospital costs associated with the utilization of the ECHELON powered stapler and the ECHELON manual stapler were ¥65,531 and ¥67,184, respectively. The comparison of the distributions of hospital costs associated with the two types of staplers in the CMA suggested that the powered stapler Table 1 Summary of patient characteristics of the created two stapler groups in the retrospective cost analysis (Continued) Patient characteristics ECHELON powered stapler group (N= 296) ECHELON manual stapler group (N=92) P value %/Mean+/−SD %/Mean+/−SD I 56.5% 47.8% 0.148 II 11.8% 17.4% 0.167 III 29.7% 33.7% 0.471 IV 1.0% 1.1% 0.951 Bone marrow function Abnormal INR 3.9% 3.5% 1.000 Abnormal hemoglobin 15.9% 24.2% 0.085 Abnormal erythrocyte counts 24.4% 14.3% 0.043 Abnormal leukocyte counts 8.5% 9.9% 0.675 Abnormal platelet counts 7.5% 12.1% 0.197 Lobectomy site Upper right 38.1% 25.8% 0.082 Right middle 7.5% 3.0% 0.268 lower right 14.3% 24.2% 0.062 Upper middle right 0.8% 0.0% 1.000 Lower middle right 1.6% 1.5% 1.000 Left lung 0.4% 0.0% 1.000 Upper left 25.8% 21.2% 0.523 Bottom left 11.5% 24.2% 0.016 Table 2 Summary of the utilizations of staplers and classified hospital costs associated with VATS lobectomy for lung cancer in the created two stapler groups Study group ECHELON powered stapler ECHELON manual stapler P value Sample size 296 92 Outcomes Mean SD Median Q1-Q3 Mean SD Median Q1-Q3 Utilized number of staplers and cartridges Staplers 1.2 0.6 1.2 0.5 0.627 Cartridges 7.0 3.9 7.5 4.0 0.076 Classified hospital costs Staplers costs ¥24,645 ¥10,592 ¥21,437 (¥18,996–¥26,319) ¥23,255 ¥10,291 ¥21,058 (¥16,845–¥24,570) 0.656 Disposable supplies costs ¥9853 ¥3022 ¥9913 (¥7769–¥11,793) ¥10,518 ¥3638 ¥10,358 (¥8707–¥12,064) 0.080 Drug costs ¥10,079 ¥4504 ¥10,161 (¥7737–¥9212) ¥14,066 ¥5352 ¥13,592 (¥7298–¥8395) < 0.001 Operation related costs ¥7743 ¥2279 ¥8257 (¥1780–¥2731) ¥7523 ¥1731 ¥7683 (¥1834–¥2576) < 0.001 Laboratory tests costs ¥10,264 ¥4209 ¥10,323 (¥59,307–¥70,450) ¥11,215 ¥3723 ¥10,900 (¥63,141–¥74,624) 0.077 Other utilized hospital resources costs ¥2253 ¥892 ¥2269 (¥1780–¥2731) ¥2229 ¥743 ¥2179 (¥1834–¥2576) 0.524 Total hospital costs ¥64,836 ¥8928 ¥64,322 (¥59,307–¥70,450) ¥68,806 ¥10,616 ¥67,298 (¥63,141–¥74,624) < 0.001 Cao et al. Health Economics Review (2022) 12:12 Page 6 of 13 Table 3 The results of the multiple generalized linear regression analyses exploring the predictors for the classified hospital costs associated with VATS lobectomy for lung cancer in a Chinese tertiary care hospital A Hospital costs for disposable supplies Hospital cost classification Hospital costs for disposable supplies Variables Coefficient 95% CI P value Lower Upper Intercept 9.279 9.203 9.357 < 0.001 Powered stapler vs. Manual stapler −0.007 −0.084 0.069 0.854 Demographics Male vs. female 0.041 −0.048 0.129 0.361 BMI 18.5 < =BMI < 24 vs. Other BMI distribution ranges −0.099 −0.171 −0.028 0.007 24 < =BMI < 28 vs. Other BMI distribution ranges −0.133 −0.214 −0.052 0.001 30 < =BMI < 40 vs. Other BMI distribution ranges −0.388 −0.624 −0.134 0.002 Tumor histology Adenocarcinoma vs. Non-adenocarcinoma −0.041 −0.108 0.025 0.225 Tumor stage Stage I vs. Non-stage I 0.058 −0.005 0.120 0.072 Bone marrow function Abnormal INR vs. Normal INR 0.141 −0.022 0.311 0.099 Abnormal hemoglobin vs. Normal hemoglobin 0.076 −0.004 0.157 0.066 Lobectomy site Upper left vs. Non-upper left site −0.026 −0.100 0.050 0.500 Comorbidity Hypertension vs. Non-hypertension −0.051 −0.128 0.026 0.193 Immune system diseases vs. Non-immune system diseases 0.177 −0.193 0.583 0.355 Breast diseases vs. Non-breast diseases −0.524 −0.917 −0.075 0.015 B. Hospital for drugs Hospital cost classification Hospital costs for drugs Variables Coefficient 95% CI P value Lower Upper Intercept 9.492 9.337 9.649 < 0.001 Powered stapler vs. Manual stapler −0.256 −0.375 −0.139 < 0.001 Demographics Male vs. female 0.041 −0.048 0.129 0.361 BMI 24 < =BMI < 28 vs. Other BMI distribution ranges −0.148 −0.250 −0.044 0.005 28 < =BMI < 30 vs. Other BMI distribution ranges −0.330 −0.535 −0.112 0.002 Residence city County vs. Other cities 0.134 −0.002 0.273 0.058 Marital status Married vs. Other marital status −0.010 −0.129 0.106 0.864 Public health insurance plan Urban worker insurance plan vs. other insurance plan −0.049 −0.155 0.058 0.367 Tumor histology Adenocarcinoma vs. Non-adenocarcinoma 0.018 −0.074 0.109 0.702 Cao et al. Health Economics Review (2022) 12:12 Page 7 of 13 Table 3 The results of the multiple generalized linear regression analyses exploring the predictors for the classified hospital costs associated with VATS lobectomy for lung cancer in a Chinese tertiary care hospital (Continued) A Hospital costs for disposable supplies Tumor stage Stage I vs. Non-stage I −0.153 −0.240 −0.067 < 0.001 Bone marrow function Abnormal platelet counts vs. normal platelet counts 0.233 0.085 0.386 0.002 Lobectomy site Upper left vs. Non-upper left site 0.029 −0.071 0.131 0.576 Comorbidity Diabetes vs. Non-diabetes 0.124 −0.017 0.270 0.091 Cerebrovascular diseases vs. Non-cerebrovascular diseases 0.095 −0.018 0.210 0.103 Urological diseases vs. Non-urological diseases 0.144 0.045 0.246 0.005 Cardiovascular diseases vs. Non-cardiovascular diseases 0.073 −0.066 0.217 0.310 Endocrine diseases vs. Non-endocrine diseases −0.164 −0.297 −0.026 0.019 C. Hospital costs related to operation Hospital cost classification Hospital costs related to operation Variables Coefficient 95% CI P value Lower Upper Intercept 8.925 8.856 8.994 < 0.001 Powered stapler vs. Manual stapler 0.004 −0.065 0.072 0.909 Tumor stage Stage I vs. Non-stage I −0.052 −0.110 0.006 0.079 Lobectomy site Upper left vs. Non-upper left site 0.002 −0.070 0.075 0.954 Comorbidity Bronchial diseases vs. Non-bronchial diseases 0.108 0.015 0.203 0.025 Immune system diseases vs. Non-immune system diseases −0.393 −0.707 −0.047 0.019 Cerebrovascular diseases vs. Non-cerebrovascular diseases 0.040 −0.038 0.120 0.316 Urological diseases vs. Non-urological diseases 0.074 0.002 0.146 0.045 Cardiovascular diseases vs. Non-cardiovascular diseases 0.066 −0.032 0.167 0.196 Sport system diseases vs. Non-sport system diseases 0.071 −0.033 0.178 0.186 Vascular diseases vs. Non-vascular diseases 0.088 −0.142 0.334 0.472 D. Hospital costs for laboratory tests Hospital cost classification Hospital costs for laboratory tests Variables Coefficient 95% CI P value Lower Upper Intercept 9.133 8.851 9.417 < 0.001 Powered stapler vs. Manual stapler −0.094 −0.203 0.014 0.082 Demographics Age 0.002 −0.003 0.007 0.367 18.5 < =BMI < 24 vs. Other BMI distribution ranges 0.100 0.013 0.188 0.024 Public health insurance plan Urban worker insurance plan vs. Other insurance plans New rural cooperative medical insurance vs. Other insurance plans −0.029 −0.128 0.071 0.562 Tumor histology Cao et al. Health Economics Review (2022) 12:12 Page 8 of 13