title: Navigational bronchoscopy with biopsy versus computed tomography-guided biopsy for the diagnosis of a solitary pulmonary nodule: a cost-consequences analysis.
abstract: BACKGROUND
  Solitary pulmonary nodules (SPNs) are frequent and can be malignant. Both computed tomography-guided biopsy and electromagnetic navigational bronchoscopy (ENB) with biopsy can be used to diagnose a SPN. A nondiagnostic computed tomography (CT)-guided or ENB biopsy is often followed by video-assisted thoracoscopic surgery (VATS) biopsy. The relative costs and consequences of these strategies are not known.
  
  
  METHODS
  A decision tree was created with values from the literature to evaluate the clinical consequences and societal costs of a CT-guided biopsy strategy versus an ENB biopsy strategy for the diagnosis of a SPN. The serial use of ENB after nondiagnostic CT-guided biopsy and CT-guided biopsy after nondiagnostic ENB biopsy were tested as alternate strategies.
  
  
  RESULTS
  In a hypothetical cohort of 100 patients, use of the ENB biopsy strategy on average results in 13.4 fewer pneumothoraces, 5.9 fewer chest tubes, 0.9 fewer significant hemorrhage episodes, and 0.6 fewer respiratory failure episodes compared with a CT-guided biopsy strategy. ENB biopsy increases average costs by $3719 per case and increases VATS rates by an absolute 20%. The sequential diagnostic strategy that combines CT-guided biopsy after nondiagnostic ENB biopsy and vice versa decreases the rate of VATS procedures to 3%. A sequential approach starting with ENB decreases average per case cost relative to CT-guided biopsy followed by VATS, if needed, by $507; and a sequential approach starting with CT-guided biopsy decreases the cost relative to CT-guided biopsy followed by VATS, if needed, by $979.
  
  
  CONCLUSIONS
  An ENB with biopsy strategy is associated with decreased pneumothorax rate but increased costs and increased use of VATS. Combining CT-guided biopsy and ENB with biopsy serially can decrease costs and complications.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA. dalecr@uw.edu
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Dale
authors.forename: David K
authors.initials: DK
authors.lastname: Madtes
authors.forename: Vincent S
authors.initials: VS
authors.lastname: Fan
authors.forename: Jed A
authors.initials: JA
authors.lastname: Gorden
authors.forename: David L
authors.initials: DL
authors.lastname: Veenstra
mesh_terms: D001706:Biopsy / Q000191:economics; D001999:Bronchoscopy / Q000191:economics*; D003365:Costs and Cost Analysis; D003663:Decision Trees; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis* / Q000191:economics; D015641:Radiography, Interventional / Q000191:economics; D012680:Sensitivity and Specificity; D003074:Solitary Pulmonary Nodule / Q000175:diagnosis* / Q000191:economics; D020775:Thoracic Surgery, Video-Assisted / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000191:economics*