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

Abstract

IntroductionLung 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.MethodsA 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.ResultsUnder 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.DiscussionENB 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.

Pilot study using virtual 4-D tracking electromagnetic navigation bronchoscopy in the diagnosis of pulmonary nodules: a single center prospective study

“…As has been mentioned in reviews (12), a combination of factors is essential for bronchoscopic diagnosis of pulmonary nodules: (I) selecting the correct airway to reach the target (navigation), (II) approaching the target as close as possible (peripheral access), (III) confirming the location of the target before sampling (confirmation), and (IV) sampling the same place as confirmed prior (realtime feedback). As a navigational modality, robust evidence on ENB has accumulated regarding its safety (15,24), diagnostic performance (15,19), and cost-effectiveness (28).…”

Cone beam CT-guided navigation bronchoscopy: a cost-effective alternative to CT-guided transthoracic biopsy for diagnosis of peripheral pulmonary nodules

“…Our decision analytical model shows that CBCT-NB can be a cost-effective diagnostic modality in the workup of intermediate risk PNs both when directly compared with CT-guided transthoracic biopsy, and when compared with direct treatment (without pathology proven malignancy) in TTNB ineligible patients. A cost-effectiveness study on electromagnetic navigation bronchoscopy (EMN) by Rickets et al 26 showed that EMN was expected to be cost-effective if EMN could obtain the same diagnostic accuracy as TTNB. Our study confirms these findings.…”

“…In case of no malignancy at baseline, health utilities of a Dutch healthy 65 years old were used 18. Utility loss due to TTNB or CBCT-NB were based on complications and associated utility loss 26. Following VATS or SABR, an initial utility loss representing the direct impact of treatment was followed by a yearly less pronounced utility loss reflecting long-term consequences 27 28.…”

Advances in Diagnostic Bronchoscopy

“…It is worth mentioning that a cohort study revealed that ENB is more cost-effective when the likelihood of an accurate diagnosis is equal to that of TTNA. This can happen in certain subgroups in whom TTNA is unlikely to achieve an accurate diagnosis, or is performed by experienced operators to reach a high accuracy with ENB [85].…”