The Authors' Reply: We appreciate the insightful comments from Dr. Detterbeck and colleagues, which certainly enrich a timely discussion about the economic implications of lung cancer screening with low-dose computed tomography (LDCT).1 To place their comments in the appropriate context, we want to point out some basic principles of economic evaluations of health care interventions.
As stated by Detterbeck et al, our analysis is “still missing several critical components of CT screening that add cost.” However, this statement does not acknowledge the principle of economic perspective, a key element of any health care economic evaluation.2 Our evaluation took the perspective of health care payers—public and private health insurances collectively. In other words, we projected the costs that national insurance payers will incur if screening becomes standard practice. Health insurances will not pay for the costs of implementation of screening infrastructure or collection of quality metrics; hospitals or clinics offering screening will. To capture these costs, an economic evaluation would have to take the perspective of hospitals instead of insurances, making for a completely different study.
To project the net costs of LDCT screening for hospitals, the evaluation would need to account not only for the implementation and quality metrics costs, but also for the revenues generated by the LDCT scans and downstream tests, procedures, and treatments. Most healthcare institutions interested in screening are internally conducting this type of analysis. We believe that, from a societal standpoint, the payer perspective is more informative.
We do not disagree that clinician visits will be critical for the selection and counseling of appropriate candidates for screening, and that these visits will add costs to payers. We did not account for these costs because no straightforward methods exist to model outpatient physician time spent in counseling patients before and during the screening process. Therefore any assumptions about visit costs would be too uncertain. Physician costs will likely be measurable if and when healthcare payers include LDCT screening in their benefit packages.
From the payer and societal perspectives, we argue that a careful implementation plan will actually promote cost-effective use of health care resources related to lung cancer screening.3 The important elements of an implementation plan include the development of standardized screening practices (eg, protocols for imaging acquisition, reporting of results); processes for careful selection of candidates; creation of registries for continuous data collection and reassessment of outcomes in real practices, including false-positive rates, costs, and patient-reported outcomes.4 By promoting standardized practices and continuously monitoring outcomes, health care institutions will ensure that patients realize the benefits of screening while avoiding unnecessary escalation in costs.
Goulart BH, Bensink ME, Mummy DG. Lung cancer screening with low-dose computed tomography: costs, national expenditures, and cost-effectiveness. J Natl Compr Canc Netw 2012;10:267–275.
Weinstein MC, Siegel JE, Gold MR. Recommendations of the panel on cost-effectiveness in health and medicine. JAMA 1996;276:1253–1258.