Lung volume reduction surgery (LVRS) has been advanced as a therapy to significantly improve quality of life in patients with COPD, but to date no controlled studies have evaluated the impact of LVRS.
Evaluate cost-effectiveness of LVRS compared to current therapy for COPD.
This is a case control study in which veterans undergoing LVRS at VA Puget Sound Health Care System (VAPSHCS) are compared to patients with a similar severity of disease at Boise VAMC who are not undergoing LVRS. Changes in health related quality of life are being evaluated using three instruments: the SF-36, the St. George’s Respiratory Questionnaire, and the Quality of Well-Being Scale, the latter to calculate utility associated with different health states. Costs will be determined using utilization data on outpatient visits, medications, oxygen use, inpatient days, radiology tests, laboratory tests, and emergency room visits are being collected for the twelve months before and after surgery. Costs will be calculated according to VA and community standards.
Eighteen patients were enrolled in the surgery group and 17 patients in the control group. The two groups were generally comparable with respect to baseline pulmonary function and health- related quality of life. There were two deaths in the surgery group (one peri-operatively) and one death in the control group. LVRS resulted in significant improvements in health- related quality of life as measured by the SF-36 and SGRQ. Comparison of pre-operative and one year follow-up data for the surgery group demonstrated clinically meaningful and statistically significant improvements in the SF-36 domains of general health (32.29 baseline vs. 50.18), physical functioning (21.0 vs. 43.5), role physical (5.36 vs. 29.55) vitality (29.29 vs. 55.9) and social functioning (36.61 vs. 75.00). The SGRQ total score improved from a mean of 65.14 pre-operatively to 45.15 at one-year follow-up. Pulmonary function test results were unchanged with the exception of modest decreases in residual volume and total lung capacity. Mean forced expiratory volume in one second (FEV1) was unchanged. In the control group, pulmonary function and health–related quality of life remained stable or declined slightly. Compared to the control group at one year, patients in the surgery group had improvements in the SF-36 physical component summary score (5.93 vs. -4.28, p <.005) and in the SGRQ total score (-20.01 vs. 5.9,p<0.001) as well as in the individual component scales of the summary measures. No improvements were identified in the mental component summary score. No improvements in health utility as measured by the QWB were detected in either the within groups or between groups analyses. Baseline mean annual care costs were $7,232 and $3,013 for the surgery and control groups respectively. One-year mean follow-up costs were $46,819 (surgery) and $4,529 (control). Based upon a comprehensive review of pulmonary function test results and medical charts from two centers, an estimated one percent of veterans with COPD would be candidates for LVRS.
LVRS is a promising therapy for veterans with COPD and results in short-term improvements in health-related quality of life. These improvements come at considerable cost. This pilot study was not able to identify any improvement in health utility attributable to LVRS and therefore the cost-effectiveness of LVRS compared to standard therapy remains unknown.
- Huizenga HF, Ramsey SD, Albert RK. Estimated growth of lung volume reduction surgery among Medicare enrollees: 1994 to 1996. Chest. 1998 Dec 1; 114(6):1583-7.