COST ANALYSIS OF INTRA PROCEDURAL RAPID ON SITE EVALUATION OF CYTOPATHOLOGY WITH ENDOBRONCHIAL ULTRASOUND

Budget impact models for lung cancer interventions: A systematic literature review

BACKGROUND

Budget impact models (BIMs) forecast the financial implications of adopting new technologies and the potential need for budget reallocation, thus playing a crucial role in reimbursement decisions. Despite the importance of accurate forecasts, studies indicate large discrepancies between estimates and reality. We are developing an artificial intelligence-based clinical decision tool to identify patients with non-small cell lung cancer who are most likely to benefit from immunotherapy.

OBJECTIVE

To evaluate the budgetary implications and describe a systematic literature review of published lung cancer BIMs.

METHODS

We searched PubMed and EMBASE for studies published between 2010 and 2023 that include BIMs that describe lung cancer interventions. Forward and backward reference searches were performed for all qualifying studies. We extracted author and publication year, country, interventions, disease stages, time horizon, analytical perspective, modeling methods used, types of costs included, sensitivity analyses conducted, and data sources used. We then evaluated adherence to the Professional Society for Health Economics and Pharmacoeconomics Research best-practice guidelines.

RESULTS

A total of 25 BIMs were identified, spanning 14 different countries. Model structure could not be ascertained definitively for nearly half of the models. The cost calculator approach was most common among the others. Time horizons ranged from 1 to 5 years, in line with recommendations. Most models compared drugs, 4 compared nondrug interventions, and 7 compared diagnostic technologies. Assumptions about market uptake were poorly documented and poorly motivated. Inclusion of cancer-related costs was rare. Adherence to best practices was variable and did not appear to improve over time.

CONCLUSIONS

The number of published BIMs for lung cancer exceeded expectations. There were modest trends toward publication frequency and model quality over time. Our analysis revealed variability across the models, as well as their adherence to best practices, indicating substantial room for improvement. Although none of the models were individually suitable for the purpose of evaluating an artificial intelligence-based treatment selection tool, some models provided valuable insights.

Optimizing Diagnostic and Staging Pathways for Suspected Lung Cancer: A Decision Analysis

BACKGROUND

The optimal diagnostic and staging strategy for patients with suspected lung cancer is not known.

RESEARCH QUESTION

What diagnostic and staging strategies are most cost-effective for lung cancer?

STUDY DESIGN AND METHODS

A decision model was developed by using a hypothetical patient with a high probability of lung cancer. Sixteen unique permutations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound, electromagnetic navigation, convex endobronchial ultrasound with or without rapid-onsite evaluation (ROSE), CT-guided biopsy (CTBx), and surgery were evaluated. Outcomes included cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio, and willingness-to-pay thresholds. Sensitivity analyses were performed on primary outcomes.

RESULTS

For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy costs $1,694 more than the best CTBx strategy but resulted in fewer complications (risk difference, 14%). The additional cost of bronchoscopy to avoid one complication from a CTBx strategy was $12,037. The cost and cumulative complications of bronchoscopy strategies increased compared with CTBx strategies for small lesions. The cost and cumulative complications of bronchoscopy strategies decreased compared with CTBx strategies when a bronchus sign was present, but bronchoscopy remained more costly overall. For a central lesion and/or radiographic N1-3 disease, convex endobronchial ultrasound with ROSE followed by lung biopsy with incremental cost-effectiveness ratio, if required, was more cost-effective than any CTBx strategy across all outcomes. Strategies with ROSE were always more cost-effective than those without, irrespective of scenario. Trade-offs also exist between different bronchoscopy strategies, and optimal choices depend on the value placed on individual outcomes and willingness-to-pay.

INTERPRETATION

The most cost-effective strategies depend on nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of ROSE. For most clinical scenarios, many strategies can be eliminated, and trade-offs between the remaining competitive strategies can be quantified.

Rapid onsite evaluation uses a very small proportion of total material aspirated at endobronchial or endoscopic ultrasound in the investigation of suspected thoracic malignancy

INTRODUCTION

The objectives were: to measure the proportion of aspirated material used to make direct slides for rapid onsite evaluation (ROSE) at endobronchial (EBUS) and endoscopic ultrasound (EUS) in suspected thoracic malignancy; and to correlate pass weights with ROSE category and needle size.

METHOD

All EBUS and EUS cases for possible thoracic malignancy October 2018-May 2019 were included. All material from each pass was expelled into a Petri dish. One drop of material was placed on each of two slides; one used for ROSE, the other fixed and remaining material processed to cell block. Dish and slides were weighed before and after this procedure on a sensitive balance and weight of aspirate and slide material calculated. When ROSE identified malignancy, slide production ceased but target sampling for ancillary studies continued.

RESULTS

ROSE accuracy was 96.8%. Mean percentage by target of aspirated material used to make direct slides for ROSE was 1.9% in malignant cases and 3.6% in non-malignant cases (P = .027 for difference). Mean percentage by pass was 5.9%. Mean weight of a single aspirate was 128.8 mg. Mean weight of aspirates insufficient on ROSE (175.7 mg) was significantly higher than the mean weight of benign or malignant aspirates (117.1 and 114.0 mg, respectively). Mean weight of aspirates using 22G needles (132.6 mg) was significantly higher than that for 25G needles (87.1 mg).

CONCLUSION

Material made into direct slides at EBUS and EUS and used in part for ROSE uses a tiny proportion of aspirated material with over 98% processed to cell block and available for ancillary testing in malignant cases.

Diagnostic value of rapid on-site evaluation during transbronchial biopsy for peripheral lung cancer

BACKGROUND

An increasing number of pulmonary lesions-particularly, peripheral lung lesions-are identified with current technological advancements. Notably, the yield of traditional bronchoscopy for the diagnosis of peripheral lung lesions is low. This study evaluated the diagnostic value of rapid on-site evaluation (ROSE) during transbronchial biopsy for peripheral lung cancer.

METHODS

This study included 641 patients who underwent transbronchial biopsy for suspected lung cancer at the Respiratory Department of Tianjin Medical University General Hospital between January 2012 and December 2016. Based on whether ROSE was used, patients were assigned to the ROSE group (353 patients) or non-ROSE group (288 patients). In the ROSE group, several air-dried smears were processed with Diff-Quik staining; the remaining samples were placed in 10% formalin. Diagnostic yields for central and peripheral lung cancer were compared between the two groups. In addition, ROSE results were compared with final diagnoses.

RESULTS

Diagnostic yield for peripheral lung cancer, stratified by pathology, was significantly higher in the ROSE group than in the non-ROSE group (42.9% vs. 30.7%, P < 0.05). The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of ROSE for peripheral pulmonary lesions were 90.0%, 89.5%, 94.0%, 82.8% and 89.8%, respectively. Conformance was high between ROSE and final pathologic evaluations during transbronchial biopsy (Kappa = 0.780, P = 0.035). There were no procedure-related deaths.

CONCLUSIONS

ROSE during conventional transbronchial biopsy improves diagnostic yield, stratified by pathology, for patients with peripheral lung cancer via live feedback. Moreover, ROSE diagnosis correlates with final cytopathological diagnosis.

Small lung lesions invisible under fluoroscopy are located accurately by three-dimensional localization technique on chest wall surface and performed bronchoscopy procedures to increase diagnostic yields

Background

Nowadays, small peripheral pulmonary lesions (PPLs) are frequently detected and the prognosis of lung cancer depends on the early diagnosis. Because of the high fee and requiring specialized training, many advanced techniques are not available in many developing countries and rural districts.

Methods

Three sets of opaque soft copper wires visible under the fluoroscopy (Flu) in the Flu-flexible bronchoscopy (FB) group (n = 24), which determined the three planes of the lesion, were respectively placed firmly on the surface of the chest wall with adhesive tape on the chest wall. The FB tip was advanced into the bronchus toward the crosspoint of the three perpendicular planes under Flu with careful rotation of a C-arm unit. Then the specimen were harvested focusing around the crosspoint for pathologic diagnosis. The rapid on-site evaluation (ROSE) procedure was also performed. The average Flu time during FB procedures were recorded and diagnostic accuracy rates in the Flu-FB group were compared with the other group guided by radial endobronchial ultrasound (R-EBUS) (n = 23).

Results

The location of the core point of the lesion, whether it was visible or not under the fluoroscopy could be recognized by three-dimensional localization technique. The accuracy rates of diagnostic yields were 62.5% in the Flu-FB group, and was similar as 65.2% in the R-EBUS group (P > 0.05). However, in the Flu-FB group, there was a decreasing tendency on accurate diagnosis rates of lower lobe (LL) lesions when comparing with non-LL lesions (3/8 = 37.5% vs 12/16 = 75%, P = 0.091) while in the R-EBUS group it was similar (9/12 = 75% vs 6/11 = 54.6%, P = 0.278). In the Flu-FB group, fluoroscopy time was negatively correlated with the lesion length (r = −0.613, P = 0.001), however, there was no significant difference between the lesions invisible or not (5.83 ± 1.45 min vs 7.67 ± 2.02 min, P = 0.116) under the fluoroscopy, as well as no significant difference among SPN, mGGO and GGO (6.12 ± 2.05 min, 7.25 ± 1.33 min and 7.80 ± 2.02 min, P > 0.05).

Conclusions

Small PPL whether it is visible or not under fluoroscopy can be located accurately by our three-dimensional localization technique on chest wall surface and performed bronchoscopy procedures to increase diagnostic yields. It is more convenient, economical and reliable with the similar diagnostic yields than R-EBUS guided method.

Trial registration

Current Controlled Trials ChiCTR-DDD-16009715. The date of registration: 3rd Nov, 2016. Retrospectively registered.