Pre-surgical lung biopsy in management of solitary pulmonary nodules: a cost effectiveness analysis

Figures & data

Table 1. List of model assumptions and sources for data.

Parameter	Value used	Source
Clinical
Proportion of PLB resulting in pneumothorax	17.8%	Tavare et al.^6
Proportion of patients with pneumothorax discharged  without intervention	40%	Tavare et al.^6
Proportion of patients with chest drain requiring admission
Underwater drain	100%	Manhire et al.^7
HVCD	1%	Tavare et al.^6
Mean length of stay for admitted patients
Underwater drain	4 days	Hospital Admitted Patient Care 2016–17 (HRG DZ26B) [NHS Digital 2016]
HVCD	1 day	Tavare et al.^6
Proportion of surgically diagnosed patients  having frozen section prior to resection	75%	Marchevsky et al.12 Clinician advice
Duration of pre-resection procedure
With frozen section	80 mins	Clinician advice
Without frozen section	35 mins	Clinician advice
Rate of benign lesions	20%	Ginsberg and Rubinstein^17, Aberle et al.^10, van’t Westeinde et al.^11
Costs
PLB (outpatient procedure)	£194	NHS Reference costs 2016–17 (HRG YD03Z) [NHS Improvement]
Hospital stay (per night)	£389	NHS Reference costs 2016–17 (HRGs DX26G-P) [NHS Improvement]
Theatre time (per hour)	£1,200	Theatre – direct costs per hour Thoracic surgery 2016–17 [ISD Scotland]
Chest drain acquisition cost
Underwater drain	£98	Local Trust inventory
HVCD	£50	Local Trust Inventory
Frozen section	£136	Clinician advice: 1 h lab technician time (band 4) + 1 h consultant  pathologist time. Unit costs from [PSSRU]

Table 2. Results of base case.

	Strategy 1	Strategy 2	Strategy 3
Patients entering pathway (N)	100	100	100
Pneumothorax (N)	18	18	n/a
Chest drain required (N)	7.2	7.2	n/a
Hospital admission required (N)	7.2	0.07	n/a
Proportion proceeding to surgery (%)	80	80	100
Frozen section required (%)	n/a	n/a	75
Cost of procedure (£)
Biopsy without pneumothorax	£194	£194	n/a
Biopsy with pneumothorax	£1,186	£226	n/a
Resection without frozen section	£700	£700	£700
Resection with frozen section	n/a	n/a	£1,736
Mean expected cost (£)
Overall	£93,065	£75,976	£147,700
Per patient	£931	£760	£1,477

Table 3. Deterministic sensitivity analysis.

Variable	Lower estimate	Upper estimate	Range
Strategy 1
Cost of hospital stay (per night)	£89,741	£96,388	£6,647
Mean length of stay	£89,741	£96,388	£6,647
Cost of biopsy (OP procedure)	£89,185	£96,945	£7,760
Cost of underwater drain	£92,855	£93,274	£419
% resulting in pneumothorax	£89,532	£96,598	£7,066
% of patients with underwater drain requiring admission*	£89,741	£93,065	£6,294
% of pneumothorax discharged without intervention	£90,709	£95,420	£4,711
% of benign lesions	£90,265	£95,865	£5,600
Strategy 2
Mean length of stay	£75,967	£75,984	£17
Cost of hospital stay (per night)	£75,967	£75,984	£17
Cost of biopsy (OP procedure)	£72,096	£79,856	£7,760
Cost of Heimlich drain	£75,869	£76,082	£213
% resulting in pneumothorax	£75,860	£76,091	£231
% of patients with Heimlich valve requiring admission	£75,967	£75,984	£17
% of pneumothorax discharged without intervention	£75,899	£76,052	£153
% of benign lesions	£73,176	£78,776	£5,600
Strategy 3
Cost of theatre time (per hour)	£120,200	£175,200	£55,000
% of VATS patients having frozen section	£131,160	£163,240	£32,080
Duration of biopsy procedure (mins)	£133,700	£161,700	£28,000
Waiting time for frozen section (mins)	£134,200	£161,200	£27,000
Cost of frozen section	£145,660	£149,740	£4,080
% of benign lesions	Not relevant to strategy 3

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