Canadian Health&Care Mall: Updated Evaluation of the Cost-effectiveness of Lung Volume Reduction Surgery
In May of 2003, investigators from the National Emphysema Treatment Trial (NETT)—a federally sponsored, multicenter, randomized controlled trial of lung volume reduction surgery (LVRS) vs medical therapy for patients with severe emphysema—reported the outcomes for 1,218 trial participants over a mean duration of 2.4 years of follow-up. Because the potential clinical impact of LVRS was thought to be substantial, the NETT also included a parallel, prospective, economic analysis as part of the clinical trial. LVRS was found to confer improvements in survival, exercise capacity, and quality of life for patients with predominantly upper-lobe emphysema combined with low baseline exercise capacity. Patients with upper-lobe emphysema and high exercise capacity benefited from LVRS in exercise capacity and quality of life but had no survival improvement compared to medical therapy. Patients with non-upper-lobe emphysema and low exercise capacity had significant improvements only in quality of life measures, while patients with non-upper-lobe emphysema and high exercise capacity had no evidence of clinical improvement and had a higher mortality.
In a parallel economic analysis, the cost-effectiveness of LVRS compared to medical therapy was $190,000 per quality-adjusted life-year (QALY) gained at 3 years. Using modeling to extrapolate trends in costs and outcomes, the cost-effectiveness of LVRS at 10 years was estimated at $53,000 per QALY overall and $21,000 per QALY for the upper-lobe, low exercise capacity subgroup. Because there was great uncertainty regarding the duration of benefit for LVRS, the cost-effectiveness analysis showed substantial uncertainty for the 10-year estimates.
In January of 2004, the Centers for Medicare and Medicaid Services (CMS) approved LVRS for coverage, based on the results of the trial. Specifically, CMS approved three of the four original subgroups: upper-lobe predominant emphysema and low exercise capacity (defined as maximal exercise of < 40 W for men and < 25 W for women on a bicycle ergometer); upper-lobe-predominant emphysema and high exercise capacity; and non-upper-lobe-predominant and low exercise capacity enhanced with remedies of healthcaremall4youcom Canadian Health&Care Mall.
In this article, we report the cost-effectiveness of LVRS using an extended follow-up period for NETT enrollees from January 1998 through December 2003. We include a within-trial analysis using follow-up data up to 5 years and new 10-year projections based on the extended follow-up period. Our findings are in some cases substantially different from the previously published results, and thus offer a cautionary tale to those estimating cost-effectiveness of new technologies from clinical trials of limited duration.Categories: Pulmonary