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Previous Volume 348:2092-2102 May 22, 2003 Number 21 Next

	Full Text PDF PDA Full Text Supplementary Material Editorial by Drazen, J. M. Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background The National Emphysema Treatment Trial, a randomized clinical trial comparing lung-volume–reduction surgery with medical therapy for severe emphysema, included a prospective economic analysis.

Methods After pulmonary rehabilitation, 1218 patients at 17 medical centers were randomly assigned to lung-volume–reduction surgery or continued medical treatment. Costs for the use of medical care, medications, transportation, and time spent receiving treatment were derived from Medicare claims and data from the trial. Cost effectiveness was calculated over the duration of the trial and was estimated for 10 years of follow-up with the use of modeling based on observed trends in survival, cost, and quality of life.

Results Interim analyses identified a group of patients with excess mortality and little chance of improved functional status after surgery. When these patients were excluded, the cost-effectiveness ratio for lung-volume–reduction surgery as compared with medical therapy was $190,000 per quality-adjusted life-year gained at 3 years and $53,000 per quality-adjusted life-year gained at 10 years. Subgroup analyses identified patients with predominantly upper-lobe emphysema and low exercise capacity after pulmonary rehabilitation who had lower mortality and better functional status than patients who received medical therapy. The cost-effectiveness ratio in this subgroup was $98,000 per quality-adjusted life-year gained at 3 years and $21,000 at 10 years. Bootstrap analysis revealed substantial uncertainty for the subgroup and 10-year estimates.

Conclusions Given its cost and benefits over three years of follow-up, lung-volume–reduction surgery is costly relative to medical therapy. Although the predictions are subject to substantial uncertainty, the procedure may be cost effective if benefits can be maintained over time.

Source Information

The writing committee for the National Emphysema Treatment Trial Cost Effectiveness Study (Scott D. Ramsey, M.D., Ph.D., Kristin Berry, M.S., and Ruth Etzioni, Ph.D., Fred Hutchinson Cancer Research Center, Seattle; Robert M. Kaplan, Ph.D., University of California, San Diego, La Jolla; and Sean D. Sullivan, Ph.D., and Douglas E. Wood, Ph.D., University of Washington, Seattle) takes responsibility for the content of this article.

This article was published at www.nejm.org on May 20, 2003.

Address reprint requests to Dr. Ramsey at the Fred Hutchinson Cancer Research Center, Public Health Sciences Division, 1100 Fairview Ave. N. (MP-900), Seattle, WA 98109, or at sramsey{at}fhcrc.org.

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