title: Cost-effectiveness of initial diagnostic strategies for pulmonary nodules presenting to thoracic surgeons.
abstract: BACKGROUND
  Patients presenting to thoracic surgeons with pulmonary nodules suggestive of lung cancer have varied diagnostic options including navigation bronchoscopy (NB), computed tomography-guided fine-needle aspiration (CT-FNA), (18)F-fluoro-deoxyglucose positron emission tomography (FDG-PET) and video-assisted thoracoscopic surgery (VATS). We studied the relative cost-effective initial diagnostic strategy for a 1.5- to 2-cm nodule suggestive of cancer.
  
  
  METHODS
  A decision analysis model was developed to assess the costs and outcomes of four initial diagnostic strategies for diagnosis of a 1.5- to 2-cm nodule with either a 50% or 65% pretest probability of cancer. Medicare reimbursement rates were used for costs. Quality-adjusted life years were estimated using patient survival based on pathologic staging and utilities derived from the literature.
  
  
  RESULTS
  When cancer prevalence was 65%, tissue acquisition strategies of NB and CT-FNA had higher quality-adjusted life years compared with either FDG-PET or VATS, and VATS was the most costly strategy. In sensitivity analyses, NB and CT-FNA were more cost-effective than FDG-PET when FDG-PET specificity was less than 72%. When cancer prevalence was 50%, NB, CT-FNA, and FDG-PET had similar cost-effectiveness.
  
  
  CONCLUSIONS
  Both NB and CT-FNA diagnostic strategies are more cost-effective than either VATS biopsy or FDG-PET scan to diagnose lung cancer in moderate- to high-risk nodules and resulted in fewer nontherapeutic operations when FDG-PET specificity was less than 72%. An FDG-PET scan for diagnosis of lung cancer may not be cost-effective in regions of the country where specificity is low.
authors.affiliation: Tennessee Valley Health System Veterans Affairs, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Deppen
authors.affiliation: Tennessee Valley Health System Veterans Affairs, Nashville, Tennessee.
authors.forename: William T
authors.initials: WT
authors.lastname: Davis
authors.affiliation: Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Green
authors.affiliation: Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Otis
authors.initials: O
authors.lastname: Rickman
authors.affiliation: Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Melinda C
authors.initials: MC
authors.lastname: Aldrich
authors.affiliation: Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Sarah
authors.initials: S
authors.lastname: Fletcher
authors.affiliation: Tennessee Valley Health System Veterans Affairs, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Joseph B
authors.initials: JB
authors.lastname: Putnam
authors.affiliation: Tennessee Valley Health System Veterans Affairs, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee. Electronic address: eric.grogan@vanderbilt.edu.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Grogan
mesh_terms: D044963:Biopsy, Fine-Needle; D001999:Bronchoscopy; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis* / Q000191:economics; D008297:Male; D008875:Middle Aged; D049268:Positron-Emission Tomography; D019057:Quality-Adjusted Life Years; D003074:Solitary Pulmonary Nodule / Q000175:diagnosis* / Q000191:economics; D066231:Surgeons; D020775:Thoracic Surgery, Video-Assisted; D014057:Tomography, X-Ray Computed
chemical_list: D019788:Fluorodeoxyglucose F18
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