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Sensitivity and cost-effectiveness of fine-needle aspiration with immunocytochemistry in the evaluation of patients with a pulmonary malignancy and a history of cancer |
Raab S S, Slagel D D, Hughes J H, Thomas P A, Silverman J F |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Using fine-needle aspiration (FNA) with immunocytochemistry (ICC), versus bronchoscopy, or thoracoscopy to separate a primary from metastatic pulmonary malignancy in patients with ahistory of cancer.
Economic study type Cost-effectiveness analysis.
Study population Patients with a pulmonary malignancy and a history of cancer.
Setting Hospital. The economic study was carried out in Iowa, USA.
Dates to which data relate The effectiveness data for the sensitivity of pulmonary FNA were collected from 1989 to 1993. The previously published papers used to determine the values for some of the clinical outcomes (test complication rates and the range of test sensitivities) were published between 1983 and 1994. 1996 prices were used.
Source of effectiveness data The evidence for final outcomes was derived from a single retrospective study and a MEDLINE search.
Link between effectiveness and cost data The costing was not performed on the same sample as that used in the assessment of the sensitivity of FNA. The costing was carried out retrospectively.
Study sample A power calculation were not used to determine the sample size. As the purpose of the review of the clinical files was to evaluate the sensitivity of pulmonary FNA, only the files relating to 89 cases (87 patients, 38 men and 49 women) of FNA testing were reviewed.
Study design The study was a retrospective case series carried out at two centres. The duration of the follow-up was not specified.
Analysis of effectiveness It is not clear whether the analysis of the clinical study was based on intention to treat or treatment completers only. The subclassification of each FNA case into the categories of primary, metastasis, and indeterminate was carried out by light microscopy, direct comparison with previous material, and ICC studies. The main outcome measures were the overall rate of FNA sensitivity of tumour classification, and the sensitivity rates using light microscopy alone, direct comparison alone, ICC alone, and the survival rate.
Effectiveness results The overall rate of FNA sensitivity of tumour classification was 87%. The corresponding rates for light microscopy alone ,comparison alone, or ICC alone was 25%, 96%, and 78% respectively. There were no significant differences between the primary and metastasis groups in terms of survival rate.
Clinical conclusions The study of the sensitivity of FNA revealed that light microscopy, direct comparison with previous materials, and ICC studies, all had a valuable contribution to make in the classification of lung malignancies. There were no discrepancies between the three methods employed to determinethe sensitivity of FNA.
Modelling A decision analytic model was used to estimate costs and to integrate costs and effectiveness aspects of the three testing strategies.
Outcomes assessed in the review The clinical outcomes determined in the review were test complication rates and the range of test sensitivities.
Study designs and other criteria for inclusion in the review Sources searched to identify primary studies A MEDLINE search was used to identify primary studies.
Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Number of primary studies included Fifteen published papers were included in the review.
Methods of combining primary studies Investigation of differences between primary studies Results of the review The range of test sensitivities adopted for FNA was from 85% to 95%. The complication rate for all testing procedures was deemed to be 15%.
Measure of benefits used in the economic analysis The benefit measures used in the economic analysis were survival rate, test complication rates, and the test sensitivity rates.
Direct costs Total costs of FNA,bronchoscopy, thoracoscopy, the range of complication costs, and ICC charge per case were reported. Total charge for all 89 cases for each testing procedure was estimated based on a decision analytic model. Professional fees, the costs of pathology bronchoscopy for brushing, washing, and lavage were omitted, as were staging, hospitalization and adjuvant charges. The cost data were obtained from the hospital. The costing was undertaken from the payer's point of view. Costs, and some of the quantities, were reported separately. 1996 prices were used.
Sensitivity analysis A threshold analysis was performed by varying the test sensitivity and the pretest probability of cancer. Cut-off points were identified at which one test became more cost-effective than the other.
Estimated benefits used in the economic analysis In the economic analysis, it was assumed that all three testing strategies had identical survival rates. The sensitivity of thoracoscopy was assumed to be 1. The range of test sensitivities adopted for FNA, was from 85% to 95%. The complication rate for all testing procedures was deemed to be 15%.
Cost results The total charge for FNA with ICC for 89 cases was estimated to be $150,873. The corresponding values for bronchoscopy and thoracoscopy were $193,949, and $354,665, respectively.
Synthesis of costs and benefits A threshold analysis was carried out to identify the cut-off points at which one testing procedure became more cost-effective than the other.
Authors' conclusions Pulmonary fine-needle aspiration with immunocytochemistry is sensitive and cost-effective in subclassifying malignancies in patients with a history of cancer. With a pretest probability of cancer assumed to be 0.6, FNA was more cost-effective than bronchoscopy for identical sensitivity, and more cost-effective than thoracoscopyfor FNA sensitivity values greater than 0.7. In the scenario in which FNA sensitivity was 0.9, FNA was more cost-effective than thoracoscopy for all pretest probabilities of cancer above 0.5.
CRD COMMENTARY - Selection of comparators No justification was given for the choice of the comparators. You should consider whether these are widely used health technologies in your own setting.
Validity of estimate of measure of benefit As there is no evidence of a systematic search of the literature, the extent to which all relevant studies were included can not be assessed.
Validity of estimate of costs Not all quantities were reported separately from the costs. Adequate details of the methods of estimation of charges were not given. Some important cost items might have been omitted.
Other issues The issue of generalisability to other settings was addressed in the threshold analysis.
Bibliographic details Raab S S, Slagel D D, Hughes J H, Thomas P A, Silverman J F. Sensitivity and cost-effectiveness of fine-needle aspiration with immunocytochemistry in the evaluation of patients with a pulmonary malignancy and a history of cancer. Archives of Pathology and Laboratory Medicine 1997; 121(7): 695-700 Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Aged, 80 and over; Biopsy, Needle /economics /standards; Bronchoscopy; Cost-Benefit Analysis; Decision Trees; Diagnosis, Differential; Female; Humans; Immunohistochemistry; Lung Neoplasms /diagnosis /secondary; Male; Middle Aged; Retrospective Studies; Sensitivity and Specificity; Thoracoscopy AccessionNumber 21997001047 Date bibliographic record published 31/12/1998 Date abstract record published 31/12/1998 |
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