Cost-Effectiveness of Alternative Management Strategies for Patients with Solitary Pulmonary Nodules

Michael K. Gould, Gillian D. Sanders, Paul G. Barnett, Chara Rydzak, Courtney C. Maclean, Mark B. McClellan, Douglas K. Owens

Research output: Contribution to journalArticle

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Abstract

Background: Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) is a potentially useful but expensive test to diagnose solitary pulmonary nodules. Objective: To evaluate the cost-effectiveness of strategies for pulmonary nodule diagnosis and to specifically compare strategies that did and did not include FDG-PET. Design: Decision model. Data Sources: Accuracy and complications of diagnostic tests were estimated by using meta-analysis and literature review. Modeled survival was based on data from a large tumor registry. Cost estimates were derived from Medicare reimbursement and other sources. Target Population: All adult patients with a new, noncalcified pulmonary nodule seen on chest radiograph. Time Horizon: Patient lifetime. Perspective: Societal. Intervention: 40 clinically plausible combinations of 5 diagnostic interventions, including computed tomography, FDG-PET, transthoracic needle biopsy, surgery, and watchful waiting. Outcome Measures: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: The cost-effectiveness of strategies depended critically on the pretest probability of malignancy. For patients with low pretest probability (26%), strategies that used FDG-PET selectively when computed tomography results were possibly malignant cost as little as $20 000 per QALY gained. For patients with high pretest probability (79%), strategies that used FDG-PET selectively when computed tomography results were benign cost as little as $16 000 per QALY gained. For patients with intermediate pretest probability (55%), FDG-PET strategies cost more than $220 000 per QALY gained because they were more costly but only marginally more effective than computed tomography-based strategies. Results of Sensitivity Analysis: The choice of strategy also depended on the risk for surgical complications, the probability of nondiagnostic needle biopsy, the sensitivity of computed tomography, and patient preferences for time spent in watchful waiting. In probabilistic sensitivity analysis, FDG-PET strategies were cost saving or cost less than $100 000 per QALY gained in 76.7%, 24.4%, and 99.9% of computer simulations for patients with low, intermediate, and high pretest probability, respectively. Conclusions: FDG-PET should be used selectively when pretest probability and computed tomography findings are discordant or in patients with intermediate pretest probability who are at high risk for surgical complications. In most other circumstances, computed tomography-based strategies result in similar quality-adjusted life-years and lower costs.

Original languageEnglish (US)
Pages (from-to)724-735
Number of pages12
JournalAnnals of internal medicine
Volume138
Issue number9
DOIs
StatePublished - May 6 2003
Externally publishedYes

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Solitary Pulmonary Nodule
Cost-Benefit Analysis
Quality-Adjusted Life Years
Positron-Emission Tomography
Costs and Cost Analysis
Tomography
Watchful Waiting
Needle Biopsy
Lung
Patient Preference
Health Services Needs and Demand
Information Storage and Retrieval
Medicare
Routine Diagnostic Tests
Computer Simulation
Registries
Meta-Analysis
Neoplasms
Thorax
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Cost-Effectiveness of Alternative Management Strategies for Patients with Solitary Pulmonary Nodules. / Gould, Michael K.; Sanders, Gillian D.; Barnett, Paul G.; Rydzak, Chara; Maclean, Courtney C.; McClellan, Mark B.; Owens, Douglas K.

In: Annals of internal medicine, Vol. 138, No. 9, 06.05.2003, p. 724-735.

Research output: Contribution to journalArticle

Gould, Michael K. ; Sanders, Gillian D. ; Barnett, Paul G. ; Rydzak, Chara ; Maclean, Courtney C. ; McClellan, Mark B. ; Owens, Douglas K. / Cost-Effectiveness of Alternative Management Strategies for Patients with Solitary Pulmonary Nodules. In: Annals of internal medicine. 2003 ; Vol. 138, No. 9. pp. 724-735.
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abstract = "Background: Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) is a potentially useful but expensive test to diagnose solitary pulmonary nodules. Objective: To evaluate the cost-effectiveness of strategies for pulmonary nodule diagnosis and to specifically compare strategies that did and did not include FDG-PET. Design: Decision model. Data Sources: Accuracy and complications of diagnostic tests were estimated by using meta-analysis and literature review. Modeled survival was based on data from a large tumor registry. Cost estimates were derived from Medicare reimbursement and other sources. Target Population: All adult patients with a new, noncalcified pulmonary nodule seen on chest radiograph. Time Horizon: Patient lifetime. Perspective: Societal. Intervention: 40 clinically plausible combinations of 5 diagnostic interventions, including computed tomography, FDG-PET, transthoracic needle biopsy, surgery, and watchful waiting. Outcome Measures: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: The cost-effectiveness of strategies depended critically on the pretest probability of malignancy. For patients with low pretest probability (26{\%}), strategies that used FDG-PET selectively when computed tomography results were possibly malignant cost as little as $20 000 per QALY gained. For patients with high pretest probability (79{\%}), strategies that used FDG-PET selectively when computed tomography results were benign cost as little as $16 000 per QALY gained. For patients with intermediate pretest probability (55{\%}), FDG-PET strategies cost more than $220 000 per QALY gained because they were more costly but only marginally more effective than computed tomography-based strategies. Results of Sensitivity Analysis: The choice of strategy also depended on the risk for surgical complications, the probability of nondiagnostic needle biopsy, the sensitivity of computed tomography, and patient preferences for time spent in watchful waiting. In probabilistic sensitivity analysis, FDG-PET strategies were cost saving or cost less than $100 000 per QALY gained in 76.7{\%}, 24.4{\%}, and 99.9{\%} of computer simulations for patients with low, intermediate, and high pretest probability, respectively. Conclusions: FDG-PET should be used selectively when pretest probability and computed tomography findings are discordant or in patients with intermediate pretest probability who are at high risk for surgical complications. In most other circumstances, computed tomography-based strategies result in similar quality-adjusted life-years and lower costs.",
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N2 - Background: Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) is a potentially useful but expensive test to diagnose solitary pulmonary nodules. Objective: To evaluate the cost-effectiveness of strategies for pulmonary nodule diagnosis and to specifically compare strategies that did and did not include FDG-PET. Design: Decision model. Data Sources: Accuracy and complications of diagnostic tests were estimated by using meta-analysis and literature review. Modeled survival was based on data from a large tumor registry. Cost estimates were derived from Medicare reimbursement and other sources. Target Population: All adult patients with a new, noncalcified pulmonary nodule seen on chest radiograph. Time Horizon: Patient lifetime. Perspective: Societal. Intervention: 40 clinically plausible combinations of 5 diagnostic interventions, including computed tomography, FDG-PET, transthoracic needle biopsy, surgery, and watchful waiting. Outcome Measures: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: The cost-effectiveness of strategies depended critically on the pretest probability of malignancy. For patients with low pretest probability (26%), strategies that used FDG-PET selectively when computed tomography results were possibly malignant cost as little as $20 000 per QALY gained. For patients with high pretest probability (79%), strategies that used FDG-PET selectively when computed tomography results were benign cost as little as $16 000 per QALY gained. For patients with intermediate pretest probability (55%), FDG-PET strategies cost more than $220 000 per QALY gained because they were more costly but only marginally more effective than computed tomography-based strategies. Results of Sensitivity Analysis: The choice of strategy also depended on the risk for surgical complications, the probability of nondiagnostic needle biopsy, the sensitivity of computed tomography, and patient preferences for time spent in watchful waiting. In probabilistic sensitivity analysis, FDG-PET strategies were cost saving or cost less than $100 000 per QALY gained in 76.7%, 24.4%, and 99.9% of computer simulations for patients with low, intermediate, and high pretest probability, respectively. Conclusions: FDG-PET should be used selectively when pretest probability and computed tomography findings are discordant or in patients with intermediate pretest probability who are at high risk for surgical complications. In most other circumstances, computed tomography-based strategies result in similar quality-adjusted life-years and lower costs.

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