Departments: Interventional Pulmonology in Other Journals
Cost Effectiveness of Lung-Volume-Reduction (LVRS) for Patients with Severe Emphysema
N Engl J Med. 2003;348:2092–2102. National Emphysema Treatment Trial Research Group, Fred Hutchinson Cancer Research Center, Seattle; University of California, San Diego, La Jolla; and University of Washington, Seattle, WA.
This report, as part of the National Emphysema Treatment Trial (NETT) studies, evaluated the data from the NETT study described previously to prospectively assess the cost effectiveness of LVRS. As noted previously, a total of 1218 patients with severe emphysema were evaluated at the 17 medical centers in the United States. After a period of pulmonary rehabilitation, they were randomly assigned to undergo lung-volume-reduction-LVRS (LVRS; n = 608) or to receive continued MT (MT; n = 610). Costs of medical care, medications, transportation, and time spent receiving therapy were obtained from Medicare claims and data from the trial. Cost effectiveness was calculated as the ratio of the difference in costs between the LVRS group and the MT group divided by the difference in quality-adjusted life-years gained between the 2 groups. Cost-effectiveness ratios were computed for the trial period (3 y of follow up) and then projected for 5 and 10 years after randomization. Cost effectiveness was calculated with the use of modeling based on observed trends in survival, cost, and quality of life. When the subgroup of 140 patients with excess mortality and little chance of improved functional status after LVRS were excluded from analysis, the cost-effectiveness ratio for LVRS as compared with MT was $190,000 per quality-adjusted life-year gained at 3 years and $53,000 per quality-adjusted life-year gained at 10 years. The mean total costs per person at 3 years were $98,952 in the LVRS group and $62,560 in the MT group (P < 0.001). Per-person costs for direct medical care alone were $80,818 in the LVRS group and $43,689 in the MT group over the 3-year period (P < 0.001). Nonmedical costs did not differ significantly between the 2 groups (P = 0.57). Patients who underwent LVRS for upper-lobe emphysema with low exercise capacity and had lower mortality and better functional status than patients who received MT exhibited a cost-effectiveness ratio of $98,000 per quality-adjusted life-year gained at 3 years and $21,000 at 10 years. Based on these estimations, the authors concluded that over a 3-year follow up, LVRS is costly relative to MT. They also infer that although the predictions are subject to substantial uncertainty, the procedure could be cost effective if benefits can be maintained over time. When and if LVRS becomes the accepted standard of treatment for optimally selected group of patients with severe emphysema, a substantial number of patients could qualify for the surgical therapy. The cost–benefit aspect of the procedure will come to the forefront in the discussions on the procedure. As noted by the authors of this analysis, the effect of LVRS on the national health care budget is uncertain, but it could be substantial. They estimate that if 1% of the estimated 2 million persons with emphysema in the United States were potentially eligible for LVRS, national health expenditures for this procedure (excluding those for initial screening and the costs of pulmonary rehabilitation) might range from $100 million to $300 million per year.