Cost-effectiveness of Rapid On-site Evaluation During Navigational Bronchoscopy

Peripheral pulmonary lesions (PPLs) are common, with > 1.6 million PPLs incidentally identified in the United States annually. Navigational bronchoscopy (NB) is a cornerstone of the diagnostic evaluation of PPLs. Intraprocedural rapid on-site evaluation (ROSE) of biopsies obtained during NB is widely used, but the data for its utility are contradictory. The cost-effectiveness of ROSE has yet to be established; as such, ROSE currently has variable implementation between institutions and is not adequately reimbursed by payors. Is ROSE cost-effective during NB for PPLs from a third-party payor perspective? A cost-effectiveness model was constructed comparing NB for PPLs with vs without ROSE from a third-party payor perspective. The base case is a 60-year-old operative candidate with a 2-cm pulmonary nodule without radiographic mediastinal or hilar lymphadenopathy referred for NB. Cost per quality-adjusted life year gained was the primary outcome. Inputs for the model were estimated from published literature. One-way deterministic sensitivity analyses were conducted on all parameters. Probabilistic sensitivity analysis was performed. The use of ROSE resulted in a gain of 0.01 quality-adjusted life years and cost an additional $466. At a willingness-to-pay threshold of $100,000/life year, ROSE was cost-effective with an incremental cost-effectiveness ratio of $44,465.88. Sensitivity analyses on the sensitivity of NB with and without ROSE show that ROSE must increase the diagnostic sensitivity of the procedure by 3% to become cost-effective. The use of ROSE during NB for PPLs is cost-effective for third-party payors at a willingness-to-pay threshold of $100,000/life year and should be reimbursed at a higher rate. The cost-effectiveness of ROSE hinges on the additional diagnostic sensitivity gained by using ROSE.