Cost-Effectiveness of Alternative Management Strategies for Patients with Solitary Pulmonary Nodules.

Background: Positron emission tomography (PET) with 18-flu-orodeoxyglucose (FDG) is a potentially useful but expensive test to diagnose solitary pulmonary nodules. Objective: To evaluate the cost-effectiveness of strategies for pulmonary nodule diagnosis and to specifically compare strategies that did and did not include FDG-PET. Design: Decision model. Data Sources: Accuracy and complications of diagnostic tests were estimated by using meta-analysis and literature review. Modeled survival was based on data from a large tumor registry. Cost estimates were derived from Medicare reimbursement and other sources. Target Population: All adult patients with a new, noncalcified pulmonary nodule seen on chest radiograph. Time Horizon: Patient lifetime. Perspective: Societal. Intervention: 40 clinically plausible combinations of 5 diagnostic interventions, including computed tomography, FDG-PET, transthoracic needle biopsy, surgery, and watchful waiting. Outcome Measures: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: The cost-effectiveness of strategies depended critically on the pretest probability of malignancy. For patients with low pretest probability (26), strategies that used FDG-PET selectively when computed tomography results were possibly malignant cost as little as $20 000 per QALY gained. For patients with high pretest probability (79), strategies that used FDG-PET selectively when computed tomography results were benign cost as little as $16 000 per QALY gained. For patients with intermediate pretest probability (55), FDG-PET strategies cost more than $220 000 per QALY gained because they were more costly but only marginally more effective than computed tomography-based strategies. Results of Sensitivity Analysis: The choice of strategy also depended on the risk for surgical complications, the probability of nondiagnostic needle biopsy, the sensitivity of computed tomography,... [ABSTRACT FROM AUTHOR]