Surgical disinvestment: endobronchial ultrasound for lung cancer diagnosis and staging

A/Professor Richard KingChair, Victorian Policy Advisory Committee on TechnologyDepartment of Health, Victoria, Australia

26 June 2012

Clinical problem

• Detect problems of lungs and mediastinum (e.g. sarcoidosis)

• Diagnose lung cancer or lymphoma

• Check lymph nodes before considering lung removal surgery to treat lung cancer

• Diagnose certain types of infection, especially those that can affect the lungs (e.g. tuberculosis)

• Recommend appropriate treatment (e.g. surgery, radiation, chemotherapy) for lung cancer

Standard clinical practice

Mediastinoscopy:

• A surgical procedure to examine the inside of the upper chest between and in front of the lungs (mediastinum)

• Used to biopsy lymph nodes in mediastinum to stage and diagnose lung cancer and other conditions

• Requires a general anaesthetic and ~2 day hospital stay

• Low, but significant, complications (e.g. hospital-acquired infection, collapsed lung, heart and great vessel damage)

• Biopsy: Sn 40-80%, Sp %50-100

New health technology

Endobronchial ultrasound-guided FNA:

• Same day procedure

• Can be performed in outpatient setting, not operating theatre (i.e. no surgery required)

• Eliminates complications (almost)

• Rapid and accurate diagnosis (often same day vs. weeks)

• Immediate commencement of treatment

• Accurate results reduces need for some lung surgeries

EBUS in practice

EBUS costs

Capital medical equipment:

• Ultrasound tower/workstation ($55,000)

• EBUS-capable bronchoscope (@ $80,000)

Training

• Surgeons, physicians, nurses (@ $15,000)

Activity

• Cost per case (procedure, consumables) @ $2,300

EBUS Results

• Sensitivity 91%, Specificity 100%

• No significant procedure-related complications

• Operating theatre time freed up by providing EBUS in outpatient setting

• Immediate pathology results: quicker & targeted treatment

• Reduced referrals for lung resection surgery

• Significant learning curve

• Additional costs re maintaining & repairing fragile endoscopes

EBUS-driven disinvestment

EBUS has significantly reduced need for mediastinoscopy:

• >50% after 12 months (some hospitals report >90%)

• 80% after 24 months

• 95% after 36 months

EBUS has significantly reduced need for lung resections:

• Frees up operating theatre time and associated hospital costs

Return on investment for EBUS

Surgical mediastinoscopy ~ $7,300 per procedure

Health department capital investment in EBUS = $400,000

90% substitution of surgical mediastinoscopy:

• ‘Released savings’ from non-admitted setting per patient ~ $3,000

• ‘Released savings’ from non-use of OR per patient ~ $2,100

• Total ‘released savings’ per EBUS procedure ~ $5,100

• Literature reports per patient cost saving of EBUS cf. surgical mediastinoscopy @ >$5,000

‘Released value’ to hospital:

• Year 1 > $800,000/year per site; Year 2, @ n=4 sites, > $3.2M/year

Health system impact

• EBUS is a safe, minimally invasive, cost effective procedure with high sensitivity and specificity for Dx and staging of lung cancer

• EBUS procedure costs are adequately funded through casemix

• EBUS has had a major impact on clinical practice with almost 100% disinvestment of mediastinoscopy/surgical procedure

• Estimated released value of $3.2M per year across four hospitals

• Public hospital system investment also driving private patient revenue generation for public hospitals

Acknowledgements

Department of Health

• Dr Paul Fennessy

• Ms Suzanne Byers

Monash Medical Centre

• Dr Michael Farmer, Professor Bill Sievert

Austin Hospital

• Professor Simon Knight, Ms Leanne Turner