Michael K. Gould, MD, MS; Gillian D. Sanders, PhD; Paul G. Barnett, PhD; Chara E. Rydzak, BA; Courtney C. Maclean, BA; Mark B. McClellan, MD, PhD; Douglas K. Owens, MD, MS
Gould MK, Sanders GD, Barnett PG, Rydzak CE, Maclean CC, McClellan MB, et al. Cost-Effectiveness of Alternative Management Strategies for Patients with Solitary Pulmonary Nodules. Ann Intern Med. 2003;138:724-735. doi: 10.7326/0003-4819-138-9-200305060-00009
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Published: Ann Intern Med. 2003;138(9):724-735.
Positron emission tomography (PET) with 18-fluorodeoxyglucose (FDG) is a potentially useful but expensive test to diagnose solitary pulmonary nodules.
To evaluate the cost-effectiveness of strategies for pulmonary nodule diagnosis and to specifically compare strategies that did and did not include FDG-PET.
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.
All adult patients with a new, noncalcified pulmonary nodule seen on chest radiograph.
40 clinically plausible combinations of 5 diagnostic interventions, including computed tomography, FDG-PET, transthoracic needle biopsy, surgery, and watchful waiting.
Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.
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.
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.
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.
The recommended sequence of tests when CT results are possibly malignant ( ) and when CT results are benign ( ) is shown. Subsequent test selection is shown to be a function of pretest probability and the corresponding post-test probability once the results of CT are known. Note that surgery is preferred when positron emission tomography (PET) results are positive, biopsy is preferred when PET results are negative, and watchful waiting is preferred when biopsy results are nondiagnostic. Recommendations are based on the assumption that society is willing to pay $100 000 per quality-adjusted life-year gained. Results were very similar when willingness to pay was assumed to be $25 000 or $50 000 per quality-adjusted life-year gained. FDG-PET = positron emission tomography with 18-fluorodeoxyglucose.
The algorithm pertains to patients with low (10% to 50%), intermediate (51% to 76%), and high (77% to 90%) pretest probability of malignancy. Note that in patients with very low pretest probability (<10%), biopsy is preferred when computed tomography ( ) results are possibly malignant and watchful waiting is preferred when CT results suggest a benign diagnosis. In patients with very high pretest probability (>90%), surgery without diagnostic testing is the preferred strategy. FDG-PET = positron emission tomography with 18-fluorodeoxyglucose.
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Selective use of FDG-PET imaging for pulmonary nodule diagnosis represents a good value for the health care dollar relative to other commonly accepted medical and public health interventions.
Dissemination of FDG-PET imaging for diagnosis of pulmonary nodules is worthwhile based on efficiency criteria.
Current policies that deny reimbursement for needle biopsy after FDG-PET should be reconsidered. When FDG-PET results are negative, it is usually more effective to perform needle biopsy rather than watchful waiting, except when pretest probability is very low.
Computed tomography with dynamic contrast enhancement seems to be a promising alternative to FDG-PET that warrants further study. It seems to be most cost-effective when used selectively in patients with low to intermediate pretest probability who have possibly malignant results on noncontrast CT.
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