New Lung Biopsy Approach Could Save $2000 per Patient

Laird Harrison

October 25, 2011

October 25, 2011 (Honolulu, Hawaii) — Endobronchial ultrasound-guided biopsy transbronchial needle aspiration (EBUS) could cost about $2000 less per patient than mediastinoscopy in detecting mediastinal lymphadenopathy, researchers reported here at CHEST 2011: American College of Chest Physicians Annual Meeting.

The technique is highly effective in diagnosing malignant disease, said Ching-Fei Chang, MD, director of bronchoscopy at the University of Southern California (USC) in Los Angeles. "Our diagnostic yield even shocked me."

Recent reviews have reported that EBUS has a sensitivity of 88% to 93% and a specificity of 100%, which is comparable to the gold standard of surgical mediastinoscopy, Dr. Chang said.

Although EBUS has gotten increasing attention for its accuracy, Dr. Chang and her colleagues wanted to know if it could also save money. "Very few studies have looked at its cost effectiveness. In this era of run-away healthcare costs, I think this question is becoming more and more important to study," she said.

Cost saving is especially important in government-run institutions and others where the payer and healthcare provider are the same entity, said Dr. Chang. She noted that the Los Angeles County Hospital (which is run by the USC) sees 800,000 indigent and underserved patients each year and often loses money.

The accuracy of EBUS is important in establishing its cost effectiveness. Because it produces so few false positives, a positive diagnosis with EBUS does not require further investigation with mediastinoscopy, Dr. Chang said. Negative findings with EBUS, however, must be confirmed with mediastinoscopy.

To explore the diagnostic yield and cost effectiveness, Dr. Chang and colleagues looked retrospectively at a series of 50 patients who underwent EBUS to make a diagnosis of mediastinal lymphadenopathy from January 2010 to April 2011.

Dr. Chang, who performed all the EBUS procedures after 2 days of training, correctly diagnosed 39 patients, missing 5 diagnoses that were later made by other means, for an overall diagnostic yield of 78%. Six patients were lost to follow-up.

Of the 44 patients with confirmed diagnoses, 31 had a malignant cause of adenopathy and 13 had a benign cause. EBUS only missed 1 confirmed diagnosis, in a patient who had Hodgkin's lymphoma. So among the malignant cases, EBUS had a diagnostic yield of 97%.

Dr. Chang cautioned that this rate could be particularly high because she cherry-picked cases that looked like good candidates for EBUS on the basis of computed tomography scans. She also noted that county hospitals have a large population of smokers, who are likely to have more advanced cancer.

For the 13 benign cases, the diagnostic yield was 69%. The 4 benign diagnoses missed by EBUS were made in the same procedure by a transbronchial biopsy. Because of the limited sample size, Dr. Chang cautioned against drawing conclusions about the power of EBUS to diagnose benign conditions.

Dr. Chang and colleagues proceeded to analyze the procedure's cost effectiveness using Medicare reimbursement figures.

For surgical mediastinoscopy, they estimated a faculty fee of $2400, a proceduralist fee of $416, an anesthesiologist fee of $262, and a pathologist fee of $94, for a total of $3172.

For EBUS, they estimated a faculty fee of $723, a proceduralist fee of $271, an anesthesiologist fee of $0, and a pathologist fee of $94, for a total of $1068.

The cost savings of EBUS over surgical mediastinoscopy were $2084, Dr. Chang announced.

She acknowledged that Medicare reimbursement gives only a rough approximation of actual costs, which could be very complicated to estimate and would likely vary a lot from one hospital to another.

Although few hospitals have purchased EBUS equipment, Dr. Chang estimated that they could recoup their investment with fewer than 80 cases.

Session moderator Ashutosh Sachdeva, MD, assistant clinical professor at Virginia Commonwealth University in Richmond, told Medscape Medical News that EBUS looks particularly promising for public hospitals. "If you are a private hospital, you will do more mediastinoscopy to get more money," he said. "If you are a county hospital, you will focus on reducing costs."

But Dr. Sachdeva, who was not involved in the study, wondered if conventional transbronchial needle aspiration could be even more cost effective. "I would like to see EBUS compared to the usual transbronchial needle aspiration," he said.

Dr. Chang and Dr. Sachdeva have disclosed no relevant financial relationships.

CHEST 2011: American College of Chest Physicians Annual Meeting: Abstract 935A. Presented October 24, 2011.