Cost-effectiveness of KRAS, EGFR and ALK testing for decision making in advanced nonsmall cell lung carcinoma: the French IFCT-PREDICT.amm study.

ALK rearrangement and EGFR/KRAS mutations constitute the primary biomarkers tested to provide targeted or nontargeted therapies in advanced nonsmall cell lung cancer (NSCLC) patients. Our objective was to assess the cost-effectiveness of biomarker testing for NSCLC.Between 2013 and 2014, 843 treatment-naive patients were prospectively recruited at 19 French hospitals into a longitudinal observational cohort study. Two testing strategies were compared, i.e. with "at least one biomarker status known" and "at least KRAS status known", in addition to "no biomarker testing" as the reference strategy. The Kaplan-Meier approach was employed to assess restricted mean survival time. Direct medical costs incurred by hospitals were estimated with regard to treatment, inpatient care and biomarker testing.Compared with "no biomarker testing", the "at least one biomarker status known" strategy yielded an incremental cost-effectiveness ratio of EUR13 230 per life-year saved, which decreased to EUR7444 per life-year saved with the "at least KRAS status known" testing strategy. In sensitivity analyses, biomarker testing strategies were less costly and more effective in 41% of iterations.In summary, molecular testing prior to treatment initiation proves to be cost-effective in advanced NSCLC management and may assist decision makers in defining conditions for further implementation of these innovations in general practice.

Tele-monitoring of ventilator-dependent patients: a European Respiratory Society Statement.

The estimated prevalence of ventilator-dependent individuals in Europe is 6.6 per 100 000 people. The increasing number and costs of these complex patients make present health organisations largely insufficient to face their needs. As a consequence, their burden lays mostly over families. The need to reduce healthcare costs and to increase safety has prompted the development of tele-monitoring for home ventilatory assistance.A European Respiratory Society Task Force produced a literature research based statement on commonly accepted clinical criteria for indications, follow-up, equipment, facilities, legal and economic issues of tele-monitoring of these patients.Many remote health monitoring systems are available, ensuring safety, feasibility, effectiveness, sustainability and flexibility to face different patients' needs. The legal problems associated with tele-monitoring are still controversial. National and European Union (EU) governments should develop guidelines and ethical, legal, regulatory, technical, administrative standards for remote medicine. The economic advantages, if any, of this new approach must be compared to a "gold standard" of home care that is very variable among different European countries and within each European country.Much more research is needed before considering tele-monitoring a real improvement in the management of these patients.

Direct ultrasound localisation for pleural aspiration: translating evidence into action.

BACKGROUND: There is strong evidence that direct ultrasound localisation for pleural aspiration reduces complications, but this practice is not universal in Australia and New Zealand. AIMS: To describe the current utilisation and logistical barriers to the use of direct ultrasound localisation for pleural aspiration by respiratory physicians from Australia and New Zealand, and to determine the cost benefits of procuring equipment and training resources in chest ultrasound. METHODS: We surveyed all adult respiratory physician members of the Thoracic Society of Australia and New Zealand regarding their use of direct ultrasound localisation for pleural aspiration. We performed a cost-benefit analysis for acquiring bedside ultrasound equipment and estimated the capacity of available ultrasound training. RESULTS: One hundred and forty-six of 275 respiratory physicians responded (53% response). One-third (33.6%) of respondents do not undertake direct ultrasound localisation. Lack of training/expertise (44.6%) and lack of access to ultrasound equipment (41%) were the most frequently reported barriers to performing direct ultrasound localisation. An average delay of 2 or more days to obtain an ultrasound performed in radiology was reported in 42.7% of respondents. Decision-tree analysis demonstrated that clinician-performed direct ultrasound localisation for pleural aspiration is cost-beneficial, with recovery of initial capital expenditure within 6 months. Ultrasound training infrastructure is already available to up-skill all respiratory physicians within 2 years and is cost-neutral. CONCLUSION: Many respiratory physicians have not adopted direct ultrasound localisation for pleural aspiration because they lack equipment and expertise. However, purchase of ultrasound equipment is cost-beneficial, and there is already sufficient capacity to deliver accredited ultrasound training through existing services.

An official American Thoracic Society policy statement: pay-for-performance in pulmonary, critical care, and sleep medicine.

RATIONALE: Pay-for-performance is a model for health care financing that seeks to link reimbursement to quality. The American Thoracic Society and its members have a significant stake in the development of pay-for-performance programs. OBJECTIVES: To develop an official ATS policy statement addressing the role of pay-for-performance in pulmonary, critical care and sleep medicine. METHODS: The statement was developed by the ATS Health Policy Committee using an iterative consensus process including an expert workshop and review by ATS committees and assemblies. MEASUREMENTS AND MAIN RESULTS: Pay-for-performance is increasingly utilized by health care purchasers including the United States government. Published studies generally show that programs result in small but measurable gains in quality, although the data are heterogeneous. Pay-for-performance may result in several negative consequences, including the potential to increase costs, worsen health outcomes, and widen health disparities, among others. Future research should be directed at developing reliable and valid performance measures, increasing the efficacy of pay-for-performance programs, minimizing negative unintended consequences, and examining issues of costs and cost-effectiveness. The ATS and its members can play a key role in the design and evaluation of these programs by advancing the science of performance measurement, regularly developing quality metrics alongside clinical practice guidelines, and working with payors to make performance improvement a routine part of clinical practice. CONCLUSIONS: Pay-for-performance programs will expand in the coming years. Pulmonary, critical care and sleep practitioners can use these programs as an opportunity to partner with purchasers to improve health care quality.

[Economic valuation of physician contacts in German outpatient care of COPD. Results from a survey of general practitioners and respiratory specialists]. / Ökonomische Bewertung ambulanter Arztkontakte von COPD-Patienten in Deutschland. Ergebnisse einer Befragung von Allgemeinmedizinern und Pneumologen.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with considerable morbidity and mortality and features a substantial economic burden. METHODS: This article analyses the frequency of physician contacts and commonly provided services in the outpatient care of patients with COPD in Germany. Information on characteristic health care delivery in case of patients with COPD has been further used to construct basic scenarios of outpatient resource use. RESULTS: Altogether, 34 out of 150 respiratory specialists and 55 out of 350 general practitioners participated in the survey (response rates of 22.7 and 15.7%, respectively). Results point out, that the number of commonly provided services (a) is limited to a very basic set, (b) does not differ substantially according to severity of COPD, and (c) does not substantially vary between the stable phase of the disease and the presence of exacerbations. CONCLUSIONS: Despite its low level of evidence, the use of expert opinion can serve as a valuable and legitimate tool; especially when the literature does not provide any or only outdated information.

Financial Justification for Interventional Pulmonology Programs: Terminology and Programmatic Models.

Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. Command of such vocabulary and its application is crucial for interventional pulmonologists to successfully establish financially sustainable bronchoscopy programs. Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value.

Funding sources and effects of limited funding in pediatric pulmonology fellowship programs.

BACKGROUND: The pediatric pulmonology workforce is at risk. Access to pediatric pulmonologists to meet patient needs is limited and recruitment of new trainees to replace the aging, retiring physician population may be inadequate. Furthermore, sources of funding for graduate medical education are insecure. However, no prior studies have identified the funding sources of pediatric pulmonology fellowships or the effects of funding constraints. METHODS: We conducted a national survey of pediatric pulmonology training directors (PPTD) in the United States between 1 November, 2016 and 9 February, 2017 to examine the sources of funding for pediatric pulmonary fellows and the effect of funding limitations. RESULTS: We obtained data from 48 PPTD, representing 89% of pediatric pulmonology programs (N = 54). Limitations in funding restricted program size in 31% of programs. A significant number of programs had no funding to cover educational resources such as advanced degrees (38%), courses (23%), society membership (25%), and journals and books (15%). Twenty seven percent of PPTD perceived their program as financially insecure for academic year 2019 and beyond. CONCLUSIONS: Insufficient funding has limited the size of pediatric pulmonology programs and access to important educational resources. It is critical to ensure that there is adequate funding for pediatric pulmonology fellowship programs, as insecurity further endangers the pediatric pulmonology workforce and future provision of care for children with respiratory diseases.

Basic Primer for Finances in Academic Adult and Pediatric Pulmonary Divisions.

The finances of academic medical centers (AMCs) are complex and rapidly evolving. This financial environment can have important effects on faculty expectations, compensation, and the work environment. This article describes the commonly used concepts and models related to financial decision-making in Pulmonology and Critical Care divisions across AMCs in the United States. Faculty clinical productivity is often measured by work relative value units, which are set nationally for a discrete piece of physician work and attempt to equilibrate aspects of care across specialties. The expected clinical productivity and salary for a given faculty member are often determined relative to one or more national benchmarks developed from data submitted by departments and schools across the country. The most commonly used benchmarks include those from the Association of American Medical Colleges and the Medical Group Management Association. Changes to the paradigm of fee for service reimbursement are beginning to change physician compensation and incentive structures. In addition, research and education are key academic missions for faculty. It is important to understand the limitations of extramural research funding and implications for the support of research infrastructure. Measurements of productivity within education have been less codified, but some centers are attempting to create educational relative value units similar to those used in clinical productivity. In summary, faculty should understand basic concepts of finances. This knowledge includes a common set of terms and concepts that can help all faculty understand basic financial considerations in their work and lead to success for their divisions.

Basic and Advanced Pleural Procedures: Coding and Professional Fees Update for Pulmonologists.

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Direct costs of overdiagnosed asthma: a longitudinal, population-based cohort study in British Columbia, Canada.

OBJECTIVES: A current diagnosis of asthma cannot be objectively confirmed in many patients with physician-diagnosed asthma. Estimates of resource use in overdiagnosed cases of asthma are necessary to measure the burden of overdiagnosis and to evaluate strategies to reduce this burden. We assessed differences in asthma-related healthcare resource use between patients with a confirmed asthma diagnosis and those with asthma ruled out. DESIGN: Population-based, prospective cohort study. SETTING: Participants were recruited through random-digit dialling of both landlines and mobile phones in the province of British Columbia, Canada. PARTICIPANTS: We included 345 individuals ≥12 years of age with a self-reported physician diagnosis of asthma. The diagnosis of asthma was reassessed at the end of 12 months of follow-up using a structured algorithm, which included a bronchodilator reversibility test, methacholine challenge test, and if necessary medication tapering and a second methacholine challenge test. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported annual asthma-related direct healthcare costs (2017 Canadian dollars), outpatient physician visits and medication use from the perspective of the Canadian healthcare system. RESULTS: Asthma was ruled out in 86 (24.9%) participants. The average annual asthma-related direct healthcare costs for participants with confirmed asthma were $C497.9 (SD $C677.9) and for participants with asthma ruled out, $C307.7 (SD $C424.1). In the adjusted analyses, a confirmed diagnosis was associated with higher direct healthcare costs (relative ratio (RR)=1.60, 95% CI 1.14 to 2.22), increased rate of specialist visits (RR=2.41, 95% CI 1.05 to 5.40) and reliever medication use (RR=1.62, 95% CI 1.09 to 2.35), but not primary care physician visits (p=0.10) or controller medication use (p=0.11). CONCLUSIONS: A quarter of individuals with a physician diagnosis of asthma did not have asthma after objective re-evaluation. These participants still consumed a significant amount of asthma-related healthcare resources. The population-level economic burden of asthma overdiagnosis could be substantial.

Investigating the cost implications of including all respiratory medicines in PCRS schemes.

AIM: This study estimates the additional cost to the State to pay for all respiratory medicines through the Primary Care Reimbursement Service (PCRS) schemes, reducing cost barriers to medication as a complement to existing chronic disease management programmes. Previous literature found higher medication adherence rates amongst medical card patients than those that had to pay or co-pay themselves. METHOD: A review of medication expenditure on the PCRS schemes from 2005 to 2015. Data on medicines sold into and out of pharmacies was used to estimate the proportion to PCRS schemes or private. Scenario analyses were conducted to estimate what the cost to the State would be to provide funding for all respiratory medicines. RESULTS: Trend analysis findings showed that respiratory medicines have been less than 10% of total PCRS medicine expenditure for the years reviewed. The largest portion of the respiratory medicine expenditure is allocated to 'drugs for obstructive pulmonary disorder' (OPD), ranging from 90% in 2005 to 69% in 2015. Eighty-seven per cent of drugs to treat OPD are dispensed publicly and 13% privately. A scenario analysis estimated that the extra cost to the State to be €20.2 m. CONCLUSIONS: Respiratory disease is included in the Irish Government's chronic disease management programme. This aims to deliver optimal care in the most appropriate setting so as to improve health outcomes and quality of life. Medication adherence is imperative to achieving these aims. Reducing cost barriers as a complement to other initiatives may improve medicine adherence thereby improving the effectiveness of disease management and patient outcomes.

Value-Based Proposition for a Dedicated Interventional Pulmonology Suite: An Adaptable Business Model.

Value-based care is evolving with a focus on improving efficiency, reducing cost, and enhancing the patient experience. Interventional pulmonology has the opportunity to lead an effective value-based care model. This model is supported by the relatively low cost of pulmonary procedures and has the potential to improve efficiencies in thoracic care. We discuss key strategies to evaluate and improve efficiency in interventional pulmonology practice and describe our experience in developing an interventional pulmonology suite. Such a model can be adapted to other specialty areas and may encourage a more coordinated approach to specialty care.

Respiratory polygraphy in sleep apnoea diagnosis. Report of the Swiss respiratory polygraphy registry and systematic review of the literature.

BACKGROUND: Sleep related breathing disorders (SBD) are common and associated with morbidity and mortality. Since polysomnography, the conventional diagnostic gold standard is costly and not generally available, ambulatory respiratory polygraphic sleep studies (RP) are used. To evaluate whether RP reimbursement by health insurance companies was justified, the Swiss Federal Office of Public Health (FOPH) requested registration of RP during 36 months and a literature review on RP. The results are reported here. METHODS: RP reimbursed from July 2002 to December 2005 by Swiss health insurance companies were analysed. A review of the literature from 2003 comparing RP with PSG was updated. The outcome of interest was the apnoea/hypopnoea index. RESULTS: Datasets on 11,485 RP were evaluated, 8179 were performed to evaluate suspected obstructive sleep apnoea syndrome (OSAS). In patients with snoring, witnessed apnoea and hypersomnia (n = 4180), 80.2% of RP confirmed OSAS, 3.5% of RP were inconclusive prompting polysomnography. Six studies published between 2003 and 2005 were pooled with a former review of 12 studies. With a mean pre-test probability of 64% for OSAS, the post-test probability after a negative result ranged from 8% (negative likelihood ratio of 0.05) to 23% (negative likelihood ratio of 0.20). The post-test probability after a positive result was within a range of 98% (positive likelihood ratio of 23.8) to 90% (positive likelihood ratio of 5.7). CONCLUSIONS: In selected patients with clinically suspected OSAS RP allows accurate and simple diagnosis of OSAS. According to the practice in Switzerland as reflected by the registry additional PSG are rarely required, suggesting relevant cost savings by RP. Granting reimbursement for RP as introduced in the meantime by the FOPH seems justified.

NSFC spurs significant basic research progress of respiratory medicine in China.

Over the years, research in respiratory medicine has progressed rapidly in China. This commentary narrates the role of the National Natural Science Foundation of China (NSFC) in supporting the basic research of respiratory medicine, summarizes the major progress of respiratory medicine in China, and addresses the main future research directions sponsored by the NSFC.

Bronchoscopy in Nigerian Clinical Practice: A Survey of Medical Doctors' Perception, Use and Associated Challenges.

BACKGROUND: Bronchoscopy is a vital diagnostic and therapeutic procedure in pulmonological practice. The aim of this study was to determine the perception, use and challenges encountered by Nigerian medical doctors involved in this procedure. MATERIALS AND METHODS: A cross-sectional study was conducted among 250 medical doctors recruited from three major tertiary institutions in Nigeria between September 2013 and June 2014. A semi-structured questionnaire was self-administered to adult physicians, paediatricians, and surgeons as well as their trainees to obtain their perception, use and associated challenges in the use of bronchoscopy in clinical practice. RESULTS: The majority (91.6%) of the respondents perceived bronchoscopy as a beneficial procedure to respiratory medicine. However, 59.2% of them were not aware of the low mortality rate associated with this procedure. The commonest indications for bronchoscopic use were foreign body aspiration (88.8%) and management of lung tumors (75.6%). Only 21 (8.4%) of the respondents had received formal training in bronchoscopy. Very few procedures (1-5 cases per month) were performed. The respondents identified the lack of formal training in the art of bronchoscopy as the foremost challenge facing its practice in Nigeria. In addition, availability of bronchoscopes, level of awareness, knowledge of the procedure among medical doctors and the cost of the procedure were the challenges faced by the medical doctors. CONCLUSION: There is an urgent need to equip training centers with modern bronchoscopic facilities. In addition,well-structured bronchoscopic training programme is imperative to enhance the trainees' proficiency for the furtherance of bronchoscopic practice.

Pulmonary practice profiles: Results of a practice performance survey.

OBJECTIVES: Physician productivity, practice expense, resource allocation, facilities, staff, and malpractice are variables in medical practice profitability. The ongoing challenge of collecting reliable and consistent data created an opportunity in 2001 for the American College of Chest Physicians (ACCP) Practice Administration Network (PAN) to develop a practice-based survey that measured the variables most related to the bottom line. METHODS: The PAN designed a comprehensive practice survey in 2001 that has been distributed to > 2,000 ACCP members each year. The specialty-specific survey differed from those offered in the market, as its aim was to capture information about pulmonary, critical care, and sleep practices. The single-answer survey included practice expense categories and those related to accounts receivable management. An on-line survey vendor (www.surveymonkey.com) was selected as the platform based on broad functionality and a flexible architecture. RESULTS: The survey was conducted each June for 5 consecutive years. In 2001, survey respondents represented 68 pulmonary physicians. By 2005, 229 practices responded representing 774 individual physicians. Participants included members of ACCP Leadership, ACCP Committees, and related networks, and past survey participants. The data are presented in graphic format as a percentage of total respondents. CONCLUSION: The survey offered participants a mechanism to contrast and compare specialty-based trends in practice expense, staffing levels, clinical services, malpractice cost, facilities utilization, and financial management strategies of "better performing" practices. It has served as the groundwork for related Practice Management Committee and Practice Management Department initiatives. The ACCP anticipates future survey collaboration with the Medical Group Management Association.

Rapid onsite evaluation: A comparison of cytopathologist and pulmonologist performance.

BACKGROUND: Rapid onsite evaluation (ROSE) has several potential benefits but also can prolong procedures if one must wait for a cytopathologist, and it can involve a considerable time commitment on the part of the cytopathologist. At the University of Arkansas for Medical Sciences, interventional pulmonologists have routinely reviewed cytology specimens. This study was performed to determine prospectively how accurately pulmonologists could perform ROSE and whether they could contribute to the efficiency of the process. METHODS: For sequential cases, the procedural pulmonologist documented a ROSE reading before the reading by the cytopathologist. Readings were compared between the two for agreement and for accuracy. The time commitment for the cytopathologist was also recorded. RESULTS: One hundred sixty-four sites were biopsied in 102 patients. With respect to onsite adequacy, there was a high level of concordance between pulmonology and cytopathology as evidenced by the κ score ( ± standard error) of 0.72 ± 0.15 and by disagreement in only 3 cases (2%). For the diagnostic category, there was once again a high level of concordance; there was agreement in 141 of the 164 cases (86%), and the weighted κ score was 0.89 ± 0.02. The cytopathologist's time in the endoscopy suite averaged 4.02 ± 6.9 minutes per procedure. CONCLUSIONS: Procedural pulmonologists can effectively learn enough cytology to be able to make ROSE a collaborative process and to greatly increase the efficiency of the cytopathologist.

Reducing maintenance and repair costs in an interventional pulmonology program.

BACKGROUND: In the current economic climate, hospitals and academic institutions demand that medical departments function in an efficient and cost-effective manner. Detailed business plans are necessary to build new clinical programs, and institutions have learned that new programs are associated with significant costs for purchasing and maintaining equipment. We report our experience with repairs to equipment before and after starting our interventional pulmonary (IP) program, and with the effect of an educational program on reducing these costs. METHODS: We retrospectively studied the costs of equipment repair in the 3 years preceding and in the 5 years following the development of an IP program in our institution, a university-based tertiary referral center. We also studied the effect of an educational program that was designed to enhance the skills of physicians and technical staff in handling the equipment. RESULTS: The cost of repairs to the equipment during the 3 years prior to the development of the IP program was $42 (US dollars) per procedure. In the initial 3 years following the start of the IP program, the yearly average cost rose 21% to $51 per procedure. After the introduction of the educational program, the yearly repair costs decreased by 84% to $8 per procedure. Based on our experience, we estimate that a reasonable budget for the cost of repairs is $50 per procedure. CONCLUSIONS: An educational program was effective in dramatically decreasing the costs of equipment repair after initiating an IP program. This is the first study to offer budgetary guidelines for equipment repair in an IP program and to demonstrate that an educational program can effectively reduce costs.