Respiratory Medicine (2010) 104, 1387 available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/rmed
LETTER TO THE EDITOR
Response to Leiro et al. We are very grateful for the comments to our article1 regarding the choice of sampling techniques for visible lesions. The comments focus on the fact that we did not take in to account the appearance of the endobronchial lesions. Endobronchial visible lesions have a higher diagnostic yield than constriction and compression.2 There has been some disagreement as how to classify visible lesions. Dasgupta et al.3 includes constriction and compression in visible lesions, while Jones et al.4 only includes exophytic and submucosal lesions. We excluded constriction and compression, but we were not able to distinguish between exophytic and submucosal lesions due to the retrospective nature of our study. The primary aim of our study was to build a model for evaluating different combinations of sampling techniques in bronchoscopy. A cost-effectiveness analysis compares the increase in cost to the increase in effectiveness. Two previous papers have presented cost-effectiveness analyses in bronchoscopy. Govert et al.5 performed a cost-effectiveness analysis with quality-reduced days as an end point. Van der Drift et al.6 wrote about cost-effectiveness of endobronchial washing, but performed a cost minimization analysis where only the costs of different strategies are compared. We presented a cost-effectiveness analysis in ERS, Berlin, 2008. Our end point was the diagnostic yield, though the use of this end point in a cost-effectiveness study is controversial. The willingness to pay for one additional positive sample was calculated based on the cost of the delay and the cost of the diagnostic procedure that had to be repeated to get the diagnosis. When all patients get the diagnosis, a cost minimization analysis is suggested to be more appropriate. The costs of different strategies are compared to find the strategy that is cheapest. Sensitivity analyses can be performed to find the threshold values for all costs and all diagnostic yields. There has been a discussion about the use of cost minimization analyses.7 A cost-effectiveness analysis is preferable, but we need a common end point. We would like others opinions on the possibility to use the diagnostic yield as the end point in clinical cost-effectiveness studies of diagnostic methods.
In your letter you say that your opinion about the most cost effective strategy is EBNA for submucosal lesions. You might be right, but we think that the use of the phrase “cost effective strategy” should only be used when an actual cost-effectiveness analysis has been performed.
References 1. Roth K, Hardie JA, Andreassen AH, Leh F, Eagan TML. Cost minimization analysis for combinations of sampling techniques in bronchoscopy of endobronchial lesions. Respiratory Medicine 2009;103(6):888e94. 2. Roth K, Hardie J, Andreassen AH, Leh F, Eagan TM. Predictors of diagnostic yield in bronchoscopy: a retrospective cohort study comparing different combinations of sampling techniques. BMC Pulmonary Medicine 2008;8(2). 3. Dasgupta A, Jain P, Minai OA, Sandur S, Meli Y, Arroliga AC, et al. Utility of transbronchial needle aspiration in the diagnosis of endobronchial lesions. Chest 1999;115(5):1237e41. 4. Jones AM, Hanson IM, Armstrong GR, O’Driscoll BR. Value and accuracy of cytology in addition to histology in the diagnosis of lung cancer at flexible bronchoscopy. Respiratory Medicine 2001;95(5):374e8. 5. Govert JA, Kopita JM, Matchar D, Kussin PS, Samuelson WM. Cost-effectiveness of collecting routine cytologic specimens during fiberoptic bronchoscopy for endoscopically visible lung tumor. Chest 1996;109(2):451e6. 6. van der Drift MA, van der Wilt GJ, Thunnissen FBJM, Janssen JP. A prospective study of the timing and cost-effectiveness of bronchial washing during bronchoscopy for pulmonary malignant tumors. Chest 2005;128(1):394e400. 7. Briggs AH, O’Brien BJ. The death of cost-minimization analysis? Health Economics 2001;10(2):179e84.
Kjetil Roth* Tomas Eagan Jon Hardie Haukeland university hospital, Dept. of Thoracic Medicine, Jonas Lies vei 65, 5021 Bergen, Hordaland, Norway *Corresponding author. Tel.: þ47 70147115. E-mail addresses:
[email protected],
[email protected] (K. Roth)
DOI of original article: 10.1016/j.rmed.2009.09.024. 0954-6111/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2010.04.020
12 April 2010 Available online 15 May 2010
