Long-term economic value analysis of reducing postoperative air leak following lung resection

Abstract

Background

Pulmonary air leak (PAL) is one of the most frequent complications following lung resection. While its short-term clinical and economic impacts are well documented, the long-term economic value of interventions that reduce PAL duration remains poorly quantified. This study developed a novel methodological framework to estimate the long-term economic value of PAL reduction and to provide a rapid, quantitative approach for assessing the cost-effectiveness of related clinical interventions.

Methods

We developed a hybrid decision-tree-Markov model simulating the natural history and health state transitions following pulmonary resection. Marginal analysis was applied to quantify the relationship between PAL duration (in days) and long-term costs (from both societal and healthcare system perspectives) as well as health outcomes measured in quality-adjusted life years (QALYs). Deterministic sensitivity analyses were performed on key model parameters to assess robustness.

Results

Each additional day of PAL was associated with an increase in long-term societal costs of USD 390.4, healthcare system costs of USD 348.1, and a loss of 0.0087 QALYs. Using a willingness-to-pay (WTP) threshold equivalent to one times China’s 2024 per capita GDP (USD 13,447.9), the monetized value of the QALY loss amounted to USD 117.6. Consequently, each 1-day reduction in PAL duration generated a total long-term economic benefit of USD 508.0 from a societal perspective and USD 465.7 from a healthcare system perspective. Sensitivity analyses confirmed the stability of these estimates across plausible parameter ranges.

Conclusions

This study provides the first quantitative estimation of the long-term economic value of reducing PAL duration after lung resection. The derived marginal values offer a practical, evidence-based tool for rapidly evaluating the economic rationale of PAL-targeted interventions and can inform clinical decision-making, health technology assessment, and policy development in thoracic surgery.

Highlight box.

Key findings

• Each additional day of pulmonary air leak (PAL) after lung resection is associated with USD 390.4 higher lifetime societal costs, USD 348.1 higher healthcare costs, and a loss of 0.0087 quality-adjusted life years (QALYs).

• Each 1-day reduction in PAL duration generated a total long-term economic value of USD 508.0 from a societal perspective and USD 465.7 from a healthcare system perspective.

What is known and what is new?

• It is known that prolonged PAL increases short-term complications, hospital length of stay and hospital costs.

• This study is the first to quantify the lifetime marginal impact of each additional PAL day on long-term costs, QALYs, and net economic value using a hybrid decision-tree-Markov model.

What is the implication, and what should change now?

• This approach offers a novel and pragmatic method to integrate long-term economic value into real-time, value-based clinical decision-making for PAL-reduction strategies.

• Thoracic surgeons, hospital administrators and payers should prioritize adoption of cost-effective PAL-reduction strategies by incorporating their long-term value on clinical and policy decisions.‘

Introduction

Pulmonary air leak (PAL) is one of the most common complications following pulmonary resection. It is defined as a pathological communication between the distal pulmonary parenchyma (alveoli) and the pleural space, typically resulting from surgical trauma and leading to accumulation of air in the pleural cavity, manifesting clinically as pneumothorax (1). Despite advances in surgical techniques and technology, PAL remains a significant challenge for thoracic surgeons. Reported PAL rates after pulmonary resection range from 20% to 33% (2), contributing to numerous adverse outcomes, including an increased incidence of postoperative complications such as extensive subcutaneous emphysema, pulmonary infections, surgical site infections, and empyema (3-5). Additionally, PAL significantly prolongs chest tube drainage time and hospital length of stay (LOS), thereby increasing overall patient costs and negatively impacting recovery and the efficient use of medical resources (5-7). This global health burden is rising, driving even greater morbidity and healthcare expenditures (8).

Previous studies on PAL have primarily focused on the short-term increases in medical costs due to prolonged drainage and hospitalization (6,7,9). However, limited attention has been given to the long-term economic implications and effectiveness of interventions aimed at reducing PAL duration. This study addresses this gap by developing a method to estimate the long-term economic value of reducing PAL duration using marginal analysis, a fundamental economic methodology that evaluates the incremental costs and benefits associated with unit changes in an economic activity. By applying marginal analysis, we quantify the relationship between incremental changes in PAL duration and corresponding marginal costs and health gains. This approach provides a novel framework to support clinical decision-making and health policy development regarding preventive and therapeutic strategies for PAL.

Methods

In this study, a hybrid Decision Tree-Markov analytic model was constructed for PAL after pulmonary resection to calculate the long-term cost and health outcome of patients with different duration of PAL, employing marginal analysis to assess quantitative relationships. Based on previous studies indicating that the median age of patients undergoing lung resection is approximately 60 years (5,6,10,11); thus, the model cohort was initialized at age 60 years.

Model structure and modeling framework

This study employed a hybrid modeling approach. First, a 1-month decision-tree model was constructed based on clinical outcomes related to PAL and perioperative management, as illustrated in Figure 1. Subsequently, a lifetime Markov model was developed based on long-term recurrence and complications post-surgery, as shown in Figure 2.

Figure 1.

Short-term decision tree model diagram for patients with PAL. PAL, pulmonary air leak.

Figure 2.

Long-term Markov model diagram for patients with PAL. PAL, pulmonary air leak.

In the short-term decision tree model, initial risk of developing PAL postoperatively was captured, with patients experiencing different PAL risk distributions. Based on expert clinical opinion, perioperative PAL and associated complications are generally resolved within this period, and all patients are assumed to achieve clinical stability before discharge, transitioning into the “stable” health state in the Markov model.

The Markov model incorporates four mutually exclusive health states—stable, PAL recurrence, chronic complications, and death. These states reflect the natural history of postoperative PAL, informed by comprehensive literature reviews and structured expert consultations. Each model cycle allows for transitions between these states according to defined transition probabilities. Patients in the stable state may develop chronic complications (primarily infectious sequelae such as pneumonia or empyema) with a certain probability; these complications are generally assumed to be treatable and resolved within the same cycle. PAL recurrence is modeled as a rare event occurring only during the first postoperative cycle and does not recur thereafter. When it occurs, it is generally curable but carries an elevated risk of triggering chronic complications in the same cycle. From any health state, patients may transition to Death. This is an absorbing state with no further transitions. The background mortality rate for patients in the stable state is derived from age-specific all-cause mortality rates reported in the China Health Statistical Yearbook (12), representing natural population-level mortality unrelated to surgery or PAL.

The model adopted a 30-year lifetime horizon, sufficient for the majority of the cohort to reach an absorbing state. The cycle length was set at 3 months, aligning with typical clinical follow-up intervals after pulmonary surgery. Consistent with the Chinese Guidelines for Pharmacoeconomic Evaluations (13), both costs and health outcomes occurring beyond one year were discounted at an annual rate of 5%.

Model input

Cost parameters

In this study, costs were calculated from both the societal and healthcare system perspectives. The societal perspective mainly encompasses direct medical costs and loss of production, whereas the healthcare system perspective is limited to direct medical costs only.

Short-term postoperative costs

Prolonged PAL following lung resection is associated with an elevated risk of postoperative complications, extended hospitalization, and consequently higher medical expenditures (14). The excess hospital costs resulted exclusively from the additional inpatient days and associated pharmacy charges incurred by the subjects with PAL until the leak resolved. Direct medical costs during the initial postoperative period were calculated as: short-term direct medical cost = daily hospitalization cost × postoperative length of stay (PLOS). Based on research by Wang et al. (15), and adjusted for the Medical Services Consumer Price Index (12), the daily hospitalization cost was estimated at USD 242.7 per day. According to structured expert consultation, PLOS was modeled as the duration of PAL (in days) plus two additional days to account for baseline postoperative observation unrelated to air leak.

From a societal standpoint, hospitalization imposes not only direct medical burdens but also significant indirect costs due to lost productivity, both for patients and their informal caregivers (typically family members). Moreover, even during stable recovery phases, routine outpatient follow-ups often require time away from work. Therefore, productivity losses were incorporated into the societal cost estimate. Specifically, indirect costs were calculated as: Indirect cost = PLOS× (national per capita daily wage) ×2 where the multiplier of 2 reflects lost earnings for both the patient and one accompanying caregiver. The national per capita daily wage was derived from official statistics (16) and denoted as USD 13.1/day.

Long-term Markov model state costs

In stable state, patients are clinically stable following recovery from surgery but require routine outpatient follow-up. Direct medical costs include fees for outpatient consultations and chest X-ray imaging, totaling USD 16.8 per cycle (17). Indirect costs reflect one day of lost productivity for both the patient and a caregiver (typically a family member), based on national average daily wage estimates.

Chronic Complications State represents episodes of infection-related sequelae such as pneumonia or empyema. Direct medical costs were derived from the China Health Statistical Yearbook (12), with an average treatment cost for pulmonary inflammation of USD 878.2. Productivity losses account for missed workdays during the acute phase, assuming an average hospital LOS of 7.7 days (12) and including time off for both the patient and one caregiver.

Although rare, PAL recurrence necessitates rehospitalization and intervention. Direct medical costs encompass thoracic drainage procedures, associated equipment and consumables (17,18), along with hospitalization fees (15). Based on expert clinical consultation, the average LOS for recurrence is 7 days, with daily hospitalization costs aligned with those used for the initial postoperative PAL period (USD 242.7/day) (15). Indirect costs again include lost wages for both the patient and a family member over the duration of hospitalization.

End-of-life costs were modeled as the total medical expenditures incurred during the last month of life, estimated at USD 2,600.7 (19). These costs are included only once, upon transition to the death state, and reflect terminal care utilization regardless of cause.

All costs are expressed in 2024 US dollars and, where derived from earlier sources, were inflated using China’s Medical Services Consumer Price Index. Consistent with Chinese pharmacoeconomic guidelines (13), future costs beyond the first year were discounted at an annual rate of 5%.

Utility parameters

In this study, the health output metric employs quality-adjusted life years (QALYs), calculated by multiplying the quality-of-life coefficient (utility value) for each health state by the total duration of survival in that state. Utility values were derived from published literature to reflect patient-reported health-related quality of life associated with each modeled state.

For the stable state, a utility weight of 0.85 was applied, reflecting the plateaued EQ-5D scores observed from post-operation in Bendixen et al. (20). For the PAL Recurrence state, a utility of 0.70 was assigned based on the same study of early recovery phase (20). The utility weight for the chronic complications state was set at 0.64, derived from the acute burden of severe postoperative respiratory complications in Zornić et al. (21). The death state was assigned a utility value of 0, consistent with standard practice in cost-utility analysis.

These utility weights are summarized in Table 1 and were applied uniformly across all model cycles. QALYs were discounted at an annual rate of 5%, in accordance with the Chinese Guidelines for Pharmacoeconomic Evaluations (13).

Table 1. Key model input parameters.

Parameter	Value	Source
Cost (USD)†
Postoperative daily hospitalization costs	242.7	(15)
2024 national per capita wage income	13.1	(16)
Outpatient service fees per visit	7.0	(17)
Chest X-ray imaging per time	9.8	(17)
Average treatment cost for pulmonary inflammation	878.2	(12)
Average LOS of pulmonary inflammation	7.7 days	(12)
Average cost for PAL treatment	1,805.2	(15,17,18)
Palliative care	2,600.7	(19)
Annual utility
Stable	0.85	(20)
PAL recurrence	0.70	(20)
Chronic complications	0.64	(21)
Incidence rates of chronic complications-pneumonia and empyema (3 months)	Prolonged air leak: 7.9%; non-prolonged air leak: 1.8%	(10)
Incidence rates of PAL recurrence-pneumothorax/subcutaneous emphysema (3 months)	Prolonged air leak: 4.2%; non-prolonged air leak: 0.95%	(10)
Annual age-specific natural mortality rate
60–64 years	0.70%	(22)
65–69 years	1.19%	(22)
70–74 years	1.86%	(22)
75–79 years	3.01%	(22)
80–84 years	5.16%	(22)
≥85 years	8.55%	(22)
Mortality of recurrent PAL (3 months)	Prolonged air leak: 2.4%; non-prolonged air leak: 1.0%	(23)
Annual mortality of chronic complications	10%	(24,25)
Annual recurrence of chronic complications	13.1%	(26)
Annual discount rates
Discount rate-costs	5%	(13)
Discount rate-QALYs	5%	(13)

^†, 1 USD = 7.196 CNY. LOS, length of stay; PAL, pulmonary air leak; QALYs, quality-adjusted life years.

Transition probability parameters

Prolonged duration of PAL has been associated with an increased risk of chronic complications, PAL recurrence, and mortality (3). All incidence rates were converted into cycle-specific transition probabilities using standard exponential conversion methods: $\text{r}=1-\left(\ln \left(1-{\text{P}}_1\right)\right)/{\text{t}}_1$ and ${\text{P}}_2=1-\exp \left(-{\text{rt}}_2\right)$ (where P denotes the probability of occurrence over time, and t represents the observation period) (27). Annual incidence or mortality rates (P annual) are further converted to 3-month transition probabilities (P3mo), calculated as: $\text{P3mo}=1-\exp \left[\text{ln}\left(1-\text{Pannual}\right)\times \left(3/12\right)\right]$.

The specific transition probabilities between health states were derived as follows: (I) the incidence rates of chronic complications (stable-state to chronic complications) and recurrent PAL (stable-state to recurrent PAL) in stable states were derived from the 90-day readmission rates of pneumothorax/subcutaneous emphysema, as well as pneumonia/empyema following lung resection, in the study by Brunelli et al. (10) (Table 1). To reflect the dependence of complication risk on PAL duration, linear interpolation was applied across PAL durations from 1 to 14 days. The resulting duration-specific quarterly transition probabilities are provided in Table S1. (II) The mortality probability in stable states (stable-state to death) was calculated using the age-specific natural mortality rate from the China Population and Employment Statistical Yearbook [2023] (22). After conversion to 3-month probabilities, the values were 0.17% (60–64 years), 0.30% (65–69 years), 0.47% (70–74 years), 0.76% (75–79 years), 1.31% (80–84 years), and 2.21% (≥85 years). (III) This self-transition probability of Stable was calculated as the residual: P_{Stable to Stable} =1−∑(all outgoing transitions from Stable). (IV) Given the clinical link between the duration of PAL and infectious sequelae, the transition probability from recurrent PAL to chronic complications was assumed equal to that from the stable state to chronic complications for the same PAL duration. (V) The mortality risk during PAL recurrence was derived from in-hospital mortality rates among PAL patients reported by Johnson et al. (23). Duration-dependent mortality rates for PAL lasting 1–14 days were obtained via linear interpolation and subsequently converted to 3-month probabilities (see Table S1). (VI) The probability of recurrent PAL transitioning to stable state was obtained by 1 subtracting the probabilities of recurrent PAL to death and recurrent PAL to chronic complications as: P_{recurrence to stable} =1 − (P_{recurrence to death} + P_{recurrence to chronic complications}). (VII) The mortality probability of chronic complications (chronic complications to death) was calculated using the case fatality rate of thoracic infections of 10% (24,25). Applying the same probability conversion formula yielded a 3-month mortality probability of 2.6%. (VIII) The recurrence probability of chronic complications (chronic complications-chronic complications) was derived from Ishifuji et al.’s (26) reporting a 13.1% recurrence rate of pneumonia, the corresponding 3-month transition probability was calculated as 3.4%. (IX) The transition probability of chronic complications to recovery (chronic complications to stable) was derived as the complement of other outgoing transitions: P_{chronic complications to stable} =1− (P_{chronic complications to chronic complications} +P_{chronic complications to death}), resulting in a 94% probability.

Quantifying the association between PAL duration and long-term costs and health outcomes

Using a modeling approach, this study quantified the association between the duration of PAL which is measured in days and its impact on long-term costs and the health outcomes, expressed as QALYs. Specifically, incremental changes in PAL duration were linked to corresponding changes in lifetime healthcare expenditures and QALYs accrued over a lifetime horizon.

Building on model simulations across a range of PAL durations (1–14 days), marginal analysis was conducted by regressing PAL duration (independent variable) against long-term costs and QALYs (dependent variables). The slope of the resulting regression curve represents the marginal effect: that is, the expected change in long-term cost or QALYs associated with a 1-day increase or decrease in PAL duration. This marginal estimate serves as a direct metric of the long-term economic value conferred by interventions that shorten PAL by 1 day.

The total long-term economic value of a 1-day reduction in PAL was calculated as the sum of: (I) avoided long-term costs (from both societal and healthcare system perspectives) and (II) the monetized health outcomes, derived by multiplying the QALY gain by a willingness-to-pay (WTP) threshold for a QALY.

Consistent with international and Chinese pharmacoeconomic guidelines, the WTP threshold for a QALY is commonly set at 1–3 times per capita gross domestic product (GDP). In this analysis, we adopted a threshold of one times China’s 2024 per capita GDP (USD 13,447.9) to monetize health benefits, thereby enabling integrated cost-benefit interpretation within a net monetary benefit framework.

Sensitivity analysis

To assess the robustness of the model’s conclusions, deterministic sensitivity analyses were performed on key input parameters, including health state utilities, cost estimates, discount rates, and event (transition) probabilities. Utility values, cost parameters, and event (transition) probabilities were varied ±20% around their base-case values; the discount rate was tested at 0% and 8%. These scenarios were evaluated to examine how parameter uncertainty influences the estimated long-term economic value of a 1-day reduction in PAL, from both societal and healthcare system perspectives.

Results

Long-term economic value of shorten PAL durations

Based on the analytic model, we estimated the impact of prolonged PAL duration on long-term costs and QALYs under a base-case treatment scenario.

As shown in Table S2, both societal and healthcare system costs increase with longer PAL duration. To quantify this relationship, marginal regression analysis was performed, treating PAL duration (in days) as the independent variable (x) and total long-term costs as the dependent variable. From the societal perspective, total cost (Y₁, in USD) was best described by a linear function: Y₁=390.4x +2,743.4, with a coefficient of determination of R²=0.9996 (Figure 3A). Similarly, from the healthcare system perspective, total cost (Y₂, in USD) followed the linear equation: Y₂=348.1x +2,151.5, with a coefficient of determination of R²=0.9996 (Figure 3B).

Figure 3.

Quantitative relationships of duration of PAL in association with cost changes from a societal perspective (A), cost changes from a healthcare system perspective (B), and changes in QALYs (C). PAL, pulmonary air leak; QALYs, quality-adjusted life years.

The slopes of these regression lines represent the marginal long-term cost per additional day of PAL: USD 390.4 from the societal perspective, and USD 348.1 from the healthcare system perspective. These results indicate that each additional day of PAL is associated with nearly USD 390 in incremental lifetime societal costs and approximately USD 348 in additional direct healthcare costs alone.

Consistent with the cost findings, QALYs accrued over the patient’s lifetime decline as PAL duration increases, as detailed in Table S3. This inverse relationship reflects the elevated risks of complications and recurrence associated with prolonged air leak, which collectively diminish long-term health-related quality of life. To quantify this association, a linear regression model was fitted with QALYs (Y) as the dependent variable and PAL duration in days (x) as the independent variable. The best-fit equation was: Y=−0.0087x +1.211, with a high coefficient of determination (R²=0.9947), indicating an excellent fit (Figure 3C). The slope of –0.0087 implies that each additional day of PAL is associated with a loss of 0.0087 QALYs. Using China’s 2024 per capita GDP of USD 13,447.9 that is a commonly accepted WTP threshold in Chinese pharmacoeconomic evaluations. The resulting monetary value of the health loss per additional PAL day is: 0.0087×13,447.9=USD 117.6. Thus, beyond cost increases, each extra day of PAL also entails an estimated USD 117.6 in forgone health benefits when valued at one times per capita GDP.

The long-term economic value of reducing PAL duration by 1 day was calculated as the sum of avoided long-term costs and monetized health gains. From the societal perspective, this comprises USD 390.4 in averted lifetime costs (including both direct medical and indirect productivity losses) plus USD 117.6 in preserved health benefits, yielding a total benefit of USD 508.0. From the healthcare system perspective, the benefit consists solely of direct cost savings (USD 348.1) plus the same monetized health gain (USD 117.6), resulting in a total of USD 465.7. The cumulative economic value increases linearly with greater reductions in PAL duration, calculated as: economic value of 1-day PAL reduction × total days of PAL reduction, reflecting the additive nature of per-day marginal benefits.

Sensitivity analysis

This study conducted a one-way sensitivity analysis on the model parameters, focusing on health utility values, costs, discount rates, and event incidence rates across different states. We examined how model parameters affect long-term economic value. The results demonstrated that the discount rate was the most influential factor, validating the robustness of the analysis, as shown in Figure 4A,4B.

Figure 4.

Tornado diagram for one-way sensitivity analyses. (A) The societal perspective. (B) The Chinese healthcare system perspective. PAL, pulmonary air leak; QALYs, quality-adjusted life years.

Discussion

PAL remains one of the most common complications following pulmonary resection. It is strongly associated with an elevated risk of postoperative complications, prolonged chest tube drainage, extended hospital LOS, increased healthcare expenditures, and diminished health-related quality of life (6,28,29). Although numerous domestic and international studies have confirmed the economic burden imposed by postoperative PAL on both patients and healthcare systems that primarily through increased inpatient costs, the long-term economic implications of PAL duration have received limited attention.

From a clinical and health systems perspective, effective PAL management is widely recognized as a key strategy for reducing secondary pulmonary complications and improving postoperative recovery. A range of medical and surgical interventions, including fibrin sealants, bovine pericardial patch, pleural tents, pleurodesis, digital chest drainage system, and endobronchial valves, have demonstrated efficacy in mitigating PAL (2). However, despite this therapeutic arsenal, there remains a critical evidence gap regarding the long-term economic value of interventions that reduce PAL duration. To address this gap, we developed a hybrid decision-tree-Markov model integrated with marginal analysis to quantify the relationship between PAL duration and both long-term costs and health outcomes (measured in QALYs). This approach enables the estimation of the total long-term economic value attributable to each incremental day of PAL reduction—a metric that combines direct cost savings with monetized health gains.

Our findings demonstrate that shortening PAL duration yields substantial long-term benefits from both societal and healthcare system perspectives. Specifically, each additional day of PAL is associated with incremental increases in long-term costs: USD 390.4 from a societal perspective and USD 348.1 from a healthcare system perspective. It means proactive measures to shorten PAL duration generates cost savings. Moreover, prolonged PAL leads to progressive health losses due to heightened risks of recurrence and chronic complications such as pneumonia and empyema. Each 1-day reduction in PAL duration averts a loss of 0.0087 QALYs, reflecting meaningful improvements in long-term health outcomes.

By integrating cost savings with monetized QALY gains, we estimate that each day of reduced PAL duration generates a total long-term economic value of USD 508.0 (societal) and USD 465.7 (healthcare system). These marginal estimates offer a practical, quantitative foundation for the rapid economic appraisal of PAL-targeted interventions, supporting timely, value-based decisions in thoracic surgical care.

In clinical practice, early identification of patients at high risk for PAL is essential to guide targeted preventive and therapeutic strategies. Prior studies have proposed risk stratification tools and predictive models to identify such high-risk individuals (30-34), with recent reports (35) reaffirming the centrality of these approaches in modern clinical workflows. Once identified, a comprehensive PAL management strategy combining prophylactic measures and timely intervention based on surgeon judgment can be effectively implemented. As the thoracic surgeon predicts the clinically meaningful changes, our model provides a complementary economic lens: by estimating the expected long-term monetary benefit of a given intervention (e.g., a 1-day reduction in PAL), clinicians can compare this benefit against the intervention’s total cost (unit price × quantity used). If the monetized benefit exceeds the cost, the intervention is deemed economically favorable under a net monetary benefit framework.

For example, if an intervention costing USD 400 is projected to reduce PAL duration by 1 day, it would yield a net societal benefit of USD 108.0 (USD 508.0–USD 400), supporting its adoption as a cost-effective strategy. Thus, our approach offers a novel, pragmatic method to integrate economic reasoning into real-time, value-based clinical decision-making.

The study also has certain limitations, mainly reflected in the following aspects: first, regarding data sources, there is still a lack of research in China on the incidence of PAL, the duration distribution of patients with PAL, and long-term prognosis such as adverse events and complication rates. This study used short-term postoperative data from abroad and clinical consultations to fit and extrapolate parameters, which may have certain deviations from the data of the China population and its long-term practices.

Second, concerning model structure and assumptions, we acknowledge two pragmatic simplifications. (I) We assumed a strict linear relationship between PAL duration and outcomes. While statistically robust within our observed cohort (1–14 days), this approach may not capture the non-linear escalation of risks (e.g., severe infections, readmissions) associated with extended PAL durations; thus, our estimates likely conservatively approximate the true impact for prolonged PAL. Future studies with larger cohorts are warranted to explore potential non-linear thresholds. (II) The model attributes PAL-related mortality solely to recurrence and chronic complications, omitting a direct “frailty-mediated” pathway. While prolonged PAL likely impacts long-term survival independently, specific data quantifying this effect distinct from complication-related deaths are unavailable. And we opted to omit this factor in the current model to mitigate the risk of double-counting. Therefore, our long-term QALY loss estimates are conservative, and the true mortality burden of PAL is likely underestimated.

Third, in terms of analytical methods, probabilistic sensitivity analysis (PSA) was not performed. As this study primarily aims to validate the structural feasibility of a novel methodological framework, we prioritized deterministic analyses to identify key drivers and verify model logic. Furthermore, deriving a probability distribution for our specific metric—net value saved per additional PAL day—entails a complex multi-step process (fitting daily incremental QALYs and daily incremental costs, and propagating their joint variability). The complexity could lead to obscure interpretability. Therefore, extensive one-way sensitivity analyses were conducted to confirm structural robustness. Current point estimates should be viewed as illustrative validations of the framework, paving the way for future studies with mature data to generate cost-effectiveness acceptability curves (CEACs) for definitive decision-making.

Finally, regarding the interpretation of results, it is crucial to emphasize that this study’s primary contribution is the methodological framework rather than the specific absolute monetary estimates, which are inherently context-dependent. Designed as a flexible tool, our model allows stakeholders to substitute local epidemiological and cost data to generate region-specific valuations. Thus, the framework offers a robust, adaptable approach for local decision-making beyond the specific figures reported here.

Future research should prioritize prospective, population-based studies in Chinese cohorts to characterize both short- and long-term PAL trajectories. With more robust, locally representative data, the validity of this framework can be further tested, thereby strengthening the evidence base for health policy and resource allocation decisions in thoracic surgery care.

Conclusions

This study presents an analytic model that quantifies the long-term economic value of reducing postoperative PAL duration. We estimate that each day of PAL reduction yields USD 508.0 in societal value and USD 465.7 in healthcare system value, combining both cost savings and monetized health gains. These findings provide a rapid, transparent, and actionable method to evaluate the long-term cost-effectiveness of PAL prevention and treatment strategies, thereby supporting evidence-informed clinical and policy decisions in thoracic surgery.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.