Surgical disinvestment: endobronchial ultrasound for lung cancer diagnosis and staging. A/Professor Richard King Chair, Victorian Policy Advisory Committee on Technology Department of Health, Victoria, Australia

1. Surgical disinvestment:
endobronchial ultrasound for lung cancer
diagnosis and staging
A/Professor Richard King
Chair, Victorian Policy Advisory Committee on Technology
Department of Health, Victoria, Australia
26 June 2012

2. Clinical problem
• Detect problems of lungs and mediastinum (e.g. sarcoidosis)
• Diagnose lung cancer or lymphoma
• Check lymph nodes before considering lung removal surgery
to treat lung cancer
• Diagnose certain types of infection, especially those that can
affect the lungs (e.g. tuberculosis)
• Recommend appropriate treatment (e.g. surgery, radiation,
chemotherapy) for lung cancer

3. Standard clinical practice
Mediastinoscopy:
• A surgical procedure to examine the inside of the upper chest
between and in front of the lungs (mediastinum)
• Used to biopsy lymph nodes in mediastinum to stage and
diagnose lung cancer and other conditions
• Requires a general anaesthetic and ~2 day hospital stay
• Low, but significant, complications (e.g. hospital-acquired
infection, collapsed lung, heart and great vessel damage)
• Biopsy: Sn 40-80%, Sp %50-100

4. New health technology
Endobronchial ultrasound-guided FNA:
• Same day procedure
• Can be performed in outpatient setting, not operating theatre
(i.e. no surgery required)
• Eliminates complications (almost)
• Rapid and accurate diagnosis (often same day vs. weeks)
• Immediate commencement of treatment
• Accurate results reduces need for some lung surgeries

5. EBUS in practice

6. EBUS costs
Capital medical equipment:
• Ultrasound tower/workstation ($55,000)
• EBUS-capable bronchoscope (@ $80,000)
Training
• Surgeons, physicians, nurses (@ $15,000)
Activity
• Cost per case (procedure, consumables) @ $2,300

7. EBUS Results
• Sensitivity 91%, Specificity 100%
• No significant procedure-related complications
• Operating theatre time freed up by providing EBUS in
outpatient setting
• Immediate pathology results: quicker & targeted treatment
• Reduced referrals for lung resection surgery
• Significant learning curve
• Additional costs re maintaining & repairing fragile endoscopes

8. EBUS-driven disinvestment
EBUS has significantly reduced need for mediastinoscopy:
• >50% after 12 months (some hospitals report >90%)
• 80% after 24 months
• 95% after 36 months
EBUS has significantly reduced need for lung resections:
• Frees up operating theatre time and associated hospital costs

9. Return on investment for EBUS
Surgical mediastinoscopy ~ $7,300 per procedure
Health department capital investment in EBUS = $400,000
90% substitution of surgical mediastinoscopy:
• ‘Released savings’ from non-admitted setting per patient ~ $3,000
• ‘Released savings’ from non-use of OR per patient ~ $2,100
• Total ‘released savings’ per EBUS procedure ~ $5,100
• Literature reports per patient cost saving of EBUS cf. surgical
mediastinoscopy @ >$5,000
‘Released value’ to hospital:
• Year 1 > $800,000/year per site; Year 2, @ n=4 sites, > $3.2M/year

10. Health system impact
• EBUS is a safe, minimally invasive, cost effective procedure with
high sensitivity and specificity for Dx and staging of lung cancer
• EBUS procedure costs are adequately funded through casemix
• EBUS has had a major impact on clinical practice with almost
100% disinvestment of mediastinoscopy/surgical procedure
• Estimated released value of $3.2M per year across four hospitals
• Public hospital system investment also driving private patient
revenue generation for public hospitals

11. Acknowledgements
Department of Health
• Dr Paul Fennessy
• Ms Suzanne Byers
Monash Medical Centre
• Dr Michael Farmer, Professor Bill Sievert
Austin Hospital
• Professor Simon Knight, Ms Leanne Turner