Exploratory cost-effectiveness model of electromagnetic navigation bronchoscopy (ENB) compared with CT-guided biopsy (TTNA) for diagnosis of malignant indeterminate peripheral pulmonary nodules.

INTRODUCTION: Lung cancer is accountable for 35 000 deaths annually, and prognosis is improved when the cancer is diagnosed early. CT-guided biopsy (transthoracic needle aspiration, TTNA) and electromagnetic navigation bronchoscopy (ENB) can be used to investigate indeterminate pulmonary nodules if the patient is unfit for surgery. However, there is a paucity of clinical and health economic evidence that directly compares ENB with TTNA in this population group. This cost-effectiveness study aimed to explore potential scenarios whereby ENB may be considered cost-effective when compared with TTNA. METHODS: A cohort decision analytic model was developed using a UK National Health Service perspective. ENB was assumed to have equal sensitivity to TTNA at 82%. Lifetime costs and quality-adjusted life-year (QALY) gain were calculated to estimate the net monetary benefit at a £20 000 per QALY threshold. Sensitivity analyses were used to explore scenarios where ENB could be considered a cost-effective intervention. RESULTS: Under the assumption that ENB has equal efficacy to TTNA, ENB was found to be dominant (less costly and more effective) when compared with TTNA, due to having a reduced risk and cost of adverse events. This conclusion was most sensitive to changes in the cost of intervention, estimates of effectiveness and adverse event rates. DISCUSSION: ENB is expected to be cost-effective when the likelihood of an accurate diagnosis is equal to (or better than) TTNA, which may occur in certain subgroups of patients in whom TTNA is unlikely to accurately diagnose malignancy or when an experienced practitioner achieves a high accuracy with ENB.

Incidental Pulmonary Nodules Are Common on CT Coronary Angiogram and Have a Significant Cost Impact.

BACKGROUND: Computed tomography (CT) coronary angiogram (CTCA) is commonly used for diagnostic evaluation of low-moderate risk patients due to its excellent performance and cost-effectiveness. However, previous cost analyses have not factored in the burden of management of pulmonary nodules, which are a common occurrence. We sought to describe the frequency and characteristics of lung nodules on CTCA in an Australian tertiary hospital, and to assess cost impacts. METHODS: Consecutive CTCAs performed in the calendar year 2012 were retrospectively identified from the imaging department database. Subjects were excluded if they were under the age of 35, had known malignancy or findings identified prior to CTCA. Patients were stratified on smoking history and nodule size. RESULTS: Of the 2479 CTCAs included, full-field imaging revealed nodules in 358 patients (13.9%). The nodules were generally small (73% <6mm), multiple (63%) and in the lower lobe (83.4%). There was no significant difference when stratified for smoking, with 60% of nodules detected in never-smokers. A minimum of 445 subsequent scans was required for nodule surveillance, resulting in an additional overall cost of $63.62 per CTCA. Limited-Field-of-View (L-FOV) would have identified only 22 nodules, with a cost of $6.14 for every CTCA performed, a cost saving of $57 per patient. CONCLUSIONS: Indeterminate pulmonary nodules are a common incidental finding on CTCA and prevalence appears to be independent of smoking status. There is a consequent significant cost burden that has not previously been recognised. Use of L-FOV reduces the number of nodules identified, with a significant cost benefit, but this has to be balanced against the ethical and medico-legal issues inherent in not reconstructing the irradiated lung.

Downstream Costs Associated with Incidental Pulmonary Nodules Detected on CT.

RATIONALE AND OBJECTIVES: To explore downstream costs associated with incidental pulmonary nodules detected on CT. MATERIALS AND METHODS: The cohort comprised 200 patients with an incidental pulmonary nodule on chest CT. Downstream events (chest CT, PET/CT, office visits, percutaneous biopsy, and wedge resection) were identified from the electronic medical record. The 2017 Fleischner Society Guidelines were used to classify radiologists' recommendations and ordering physician management for the nodules. Downstream costs for nodule management were estimated from national Medicare rates, and average costs were determined. RESULTS: Average downstream cost per nodule was $393. Costs were greater when ordering physicians over-managed relative to radiologist recommendations ($940) vs. when adherent ($637) or under-managing ($166) relative to radiologists recommendations. Costs were also greater when ordering physicians over-managed relative to Fleischner Society guidelines ($860) vs. when under-managing ($208) or adherent ($292) to guidelines. Costs did not vary significantly based on whether or not radiologists recommended follow-up imaging ($167-$397), nor whether radiologists were adherent or under- or over-recommended relative to Fleischner Society guidelines ($313-$444). Costs were also higher in older patients, patients with a smoking history, and larger nodules. Five nodules underwent wedge resection and diagnosed as malignancies. No patient demonstrated recurrence or metastasis. Average cost per diagnosed malignancy was $3090. CONCLUSION: Downstream costs for incidental pulmonary nodules are highly variable and particularly high when ordering physicians over-manage relative to radiologist recommendations and Fleischner Society guidelines. To reduce unnecessary utilization and cost from over-management, radiologists may need to assume a greater role in partnering with ordering physicians to ensure appropriate, guideline-adherent, and follow-up testing.

Management of pulmonary nodules according to the 2015 British Thoracic Society guidelines. Key messages for clinical practice.

The British Thoracic Society guideline on the investigation and management of pulmonary nodules is based on a comprehensive and systematic review of the literature on pulmonary nodules. Recent evidence has suggested that significant changes to existing guidelines are necessary. The use of 2 malignancy prediction calculators to better characterize the risk of malignancy was firmly supported by evidence, as were the recommendations for a higher nodule size threshold for follow­up (≥5 mm or ≥80 mm3) and a reduction of the follow­up period to 1 year for solid pulmonary nodules. Although caution is required where there is a history of cancer, both of these recommendations will reduce the number of follow­up computed tomographies, thereby improving cost­effectiveness and pressure on imaging services. Recent evidence has also confirmed the superiority of volumetry as the preferred measurement method and clarified the management of nodules with extended volume­doubling times. Acknowledging the good prognosis of subsolid nodules, there are recommendations for less aggressive options in their management. The guidelines recommend ordinal scale reporting for positron emission tomography-computed tomography to facilitate incorporation into risk models. There are recommendations on when biopsy is most helpful, the threshold for treatment without histological confirmation, and surgical and nonsurgical treatment. The guideline also provides evidence­based recommendations about the information that people need and that should be provided for them. The complexity of managing pulmonary nodules is made more accessible by 4 management algorithms. In the real world, it is surprising how easy these are to follow and how they seem to follow an intuitive approach.