Chest
Volume 157, Issue 3, March 2020, Pages 686-693
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Thoracic Oncology: Original Research
Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy

https://doi.org/10.1016/j.chest.2019.09.021Get rights and content

Background

There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort.

Methods

We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis.

Results

Among 30,570 patients, 49% underwent EBUS. Severe adverse events—pneumothorax, hemothorax, airway/vascular injuries, or death—were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776).

Conclusions

When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.

Section snippets

Study Design, Population, and Data Source

We conducted a retrospective cohort study of adults who underwent EBUS or mediastinoscopy between January 1, 2007 and June 30, 2015. The data source was MarketScan—a database of inpatient and outpatient claims for US workers and their dependents with employer-provided commercial insurance.15 We excluded patients older than 64 years because we did not have access to claims for beneficiaries dually enrolled in commercial insurance and Medicare. In addition, we excluded individuals with less than

Results

Among 30,570 patients undergoing mediastinal nodal evaluation, 49% underwent EBUS. The frequency of EBUS increased from 14% in 2007 to 79% by 2015 (P < .001). Patients undergoing EBUS tended to be older; to reside in the south; and to have a high-deductible health plan, higher comorbidity index, and lung cancer diagnosis (Table 1). Compared with mediastinoscopy, EBUS was associated with a higher rate of concomitant bronchoscopic procedures and a lower rate of hospitalization.

Severe adverse

Discussion

We compared the risks and costs of EBUS with mediastinoscopy in a national cohort of patients undergoing mediastinal nodal evaluation for any indication. EBUS was associated with a lower risk of severe adverse events and vocal cord paralysis as well as costs when compared with mediastinoscopy.

The frequency of severe adverse events following EBUS and mediastinoscopy in this study were similar to prior investigations. EBUS complication rates ranged from 0.06% to 1.4%,17,23, 24, 25, 26 whereas

Conclusions

We demonstrate an association between EBUS and greater safety and lower costs compared with mediastinoscopy when performed as standalone procedures for any indication. Our unique contribution to this body of evidence is (1) a data source less susceptible to reporting bias; (2) findings generalizable to a heterogeneous group of patients and providers outside the trial setting; and (3) a study with sufficient power to detect small but important differences in rare outcomes. Future studies should

Acknowledgments

Author contributions: F. F. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. F. C. V., K. S. B., D. E. W., M. S. M., J. A. R., D. O. F., and F. F. made substantial contributions to conception and design and interpretation of data; revised it critically and substantially for important intellectual content; provided final approval of the version to be published; and agree to be accountable for all aspects of

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  • Cited by (0)

    FUNDING/SUPPORT: F. C. V. was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health [Award T32DK070555].

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