B-1 OPTIMIZATION OF FOLLOW-UP GUIDELINES FOR CLINICAL MANAGEMENT OF PULMONARY NODULES USING A LUNG CANCER MODEL

Thursday, October 18, 2012: 1:30 PM
Regency Ballroom C (Hyatt Regency)
INFORMS (INF), Health Services, and Policy Research (HSP)

Vidit Munshi, MA, Michael E. Gilmore, MBA, Alexander Goehler, MD, MSc, MPH, G. Scott Gazelle, MD, MPH, PhD and Pamela McMahon, PhD, Massachusetts General Hospital, Boston, MA

Purpose:    Repeated follow-up imaging examinations for indeterminate pulmonary nodules can have a large impact on patient outcomes, radiation risk, and healthcare costs through resource utilization and physician burden.  A pre-existing lung cancer model was used to assess comparative effectiveness and cost-effectiveness of an older follow-up program with standard Fleischner Society guidelines for management of pulmonary nodules, including and in the absence of screening.

Method:   The Lung Cancer Policy Model (LCPM) is a microsimulation model that simulates individuals’ lung cancer development, progression, detection, follow-up, and survival, while accumulating healthcare-related costs.  Benign pulmonary nodules and risks of radiation-induced lung cancer from imaging exams are also simulated. Patients with CT or CXR-detected nodules (4-8mm diameter) undergo follow-up CTs at 1-, 3-, 6-, 9-, 12-, and 24-months.  Using the LCPM, trial runs of 500,000 individuals born in 1930 (with US-representative smoking histories) were conducted utilizing the old follow-up program and a newly designed program based on Fleischner Society’s recommendations. The baseline risk factor threshold (5 pack-years) in the Fleischner guidelines was varied to include 10, 20, and 30 pack-years. All programs were simulated with no screening, as well as with 1, 3, and 10-CT screen programs at yearly intervals beginning at age 65. We compared the outcomes of the various follow-up protocols on the basis of life-years saved and healthcare-related costs. 

Result:    In the absence of screening, the older follow-up program was strictly dominated by the Fleischner Society guidelines (all thresholds), which yielded 93,187 additional life years and reduced costs by over $996 million (baseline threshold, cohort size of 500,000).  The total number of CTs for the cohort was reduced by 5.7% (422,763 to 398,684) by switching to the Fleischner follow-up.  Fleischner guidelines also strictly dominated the old follow-up in the presence of screening, with gains in LY and more cost-savings (2.4%, 2.8%, and 3.5% decrease in total costs with 1.5%, 1.4%, and 1.3% increase in life-years for 1, 3, and 10-year screening programs respectively).

Conclusion:    Follow-up strategies involving targeted management of pulmonary nodules dominate more aggressive strategies with numerous follow-up CTs, particularly in the presence of screening.  While compliance to guidelines varies across institutions, models are an effective tool to compare current and hypothetical guidelines for clinical and cost-effectiveness and develop efficient protocols for management of pulmonary nodules.