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

A. Hayanga¹, X. Luo¹, S. Reddy², J. Mehaffey¹, D. Chauhan³, J. Lamb¹, N. Baker⁴, C. Mascio⁵, V. Badhwar¹, A. Seyfi. Toker^6
1West Virginia University, Morgantown, West Virginia ²WVU Heart and Vascular Institute, Morgantown, West Virginia ³WVU Medicine, Morgantown, West Virginia ⁴UPMC, Mount Clare, West Virginia ⁵WVU Medicine Children's Hospital, Morgantown, West Virginia ⁶West Virginia University, Department of Cardiovascular and Thoracic Surgery, Morgantown, West Virginia

Purpose: Lung volume reduction surgery (LVRS) and endobronchial valve placement (EBV) are therapeutic options in the management of advanced emphysema. Following FDA approval in 2018, the application of EBV has grown exponentially. We sought to compare lung volume reduction outcomes following LVRS and EBV among Medicare Beneficiaries.

Methods: Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries with severe emphysema undergoing either LVRS or EBV between January 1, 2019 and December 31, 2022. Medicare candidates for lung volume reduction therapy are non-smokers with severe symptomatic upper lobe-predominant emphysema, impaired quality of life despite optimal therapy, forced expiratory volume in first second (FEV1) < 45%, total lung capacity >100%, and residual volume >150% of predicted values, post-rehabilitation of ≥140 watts for men and ≥70 watts for women under 70 years. We utilized diagnosis-related group and International Classification of Diseases 10th revision procedure codes to define all variables and comorbidities including frailty by a validated metric. Doubly robust risk adjustment was performed using inverse probability weighting and multilevel regression models, as well as competing-risk time-to-event analysis for comparisons of LVRS and EBV.

Results: Lung volume reduction therapy was performed in 3,219 patients: LVRS in 2,378 and EBV in 841. Prior to risk adjustment, EBV patients had lower Elixhauser co-morbidity scores (3.37 vs 3.86, p < 0.001), shorter length of stay (4d vs 7d, p < 0.0001), and lower hospital charges ($124,540 vs $146,221, p < 0.0001) compared to those who underwent LVRS. Most LVRS procedures performed were minimally invasive (1,897 VATS/robotic vs 481 open). After doubly-robust risk adjustment, inclusive of frailty, compared to LVRS, EBV was associated with higher 30-day mortality (OR 2.68, 95% CI 1.88-3.87, p < 0.001), higher 30-day readmission rate (aOR 1.4, 95% CI 1.21-1.63, p < 0.001), higher reintervention rate (aOR 17.2, 95% CI8.42-42.2, p < 0.001), higher 30-day readmission with pneumothorax (aOR 2.09, 95% CI 1.58-2.79-42.2, p < 0.001), higher supplementary oxygen requirement (aOR 3.49, 95% CI 2.71- 4.55, p < 0.001), and higher all-cause mortality at 1-year (aOR 1.75, 95% CI 1.49-2.07, p< 0.001). (Figure)

Conclusion: Medicare beneficiaries who undergo EBV have higher risk-adjusted mortality and procedure-related morbidity despite presenting with fewer comorbidities than those undergoing LVRS. These concerning results suggest the need to revisit multidisciplinary decision-making regarding the role of surgery over bronchoscopic interventional therapy in the management of advanced emphysema.

Identify the source of the funding for this research project: NIH NHLBI 2UM1 HL088925 12 (VB, JHM, JWAH).