Follow-up costs outweigh benefits for nodule findings on CCTA

Follow-up of incidental findings of pulmonary nodules (PN) during coronary CT angiography (CCTA) reduces deaths from lung cancer but at the price of increased downstream testing, making the practice of dubious value, researchers reported online July 11 in Circulation.

The research team lead by Alexander Goehler, MD, PhD, MSc, MPH, from Yale University’s Department of Radiology in New Haven, Conn., used the Massachusetts General Hospital Lung Cancer Policy Model to simulate outcomes in 591 patients referred for CCTA with suspected coronary artery disease found to have PN. These patients represented 16 percent of CCTAs performed at the hospital between 2005 and 2008.

In simulation, Goehler et al reviewed what would happen if the patients did or did not follow up on the PN diagnosis. Lung cancer incidence in one year was predicted to be 0.36 percent if not followed up, and 0.77 percent with follow-up.

In two years, they predicted 0.73 percent lung cancer incidence without follow-up and 1.05 percent with follow-up. At three years, the decision to not follow up had a 1.07 percent chance of lung cancer incidence while following-up had a chance of 1.2 percent of lung cancer incidence.

Total lifetime detection for not following up with the PN diagnosis vs. following up had little difference, being 5.8 percent and 5.9 percent, respectively. In both outcomes, mortality was more likely due to cardiovascular disease or some other cause.

The life expectancy for following up was 0.02 quality adjusted life years, or seven days. The increase in the number of tests a patient experienced due to follow-up ultimately led to greater costs: $154,700 per quality adjusted life year gained. Costs for follow-up were 2.8 times the costs calculated while not following up with small gains in life expectancy.

They determined that there were no major differences in longevity between the two potential outcomes except among smokers. Smokers had a 6.36 percent cancer mortality rate if not followed up. While the costs increased per person by $745, they gained additional days and had an ultimately lower cost of quality adjusted life year, around $129,800.

While simulated, these findings are generalizable to the greater patient population, they wrote, and they provide physicians with tools to assess the added benefit to the patient against the financial and health costs associated with the procedure.