Comparative cost analysis of endobronchial ultrasound-guided and blind TBNA in the evaluation of hilar and mediastinal lymphadenopathy

Background: The superior accuracy of endobronchial ultrasound (EBUS) averts many diagnostic surgical procedures. This likely leads to significant cost savings despite an increased per procedure cost. We sought to compare the true costs of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) compared with "blind" fiberoptic bronchoscopy-transbronchial needle aspiration (FB-TBNA) factoring in the impact of diagnostic surgical procedures in the diagnosis of mediastinal lymphadenopathy. Methods: In this retrospective case study, we selected 294 patients with thoracic lymphadenopathy as diagnosed by computed tomography at a university hospital. Information was extracted from the electronic record. Costs were determined from the Centers for Medicare and Medicaid Services resource-based relative value scale. We defined a positive diagnosis as one where benign or malignant disease was found. A negative biopsy was one where lymph node sampling was confirmed, but no pathology (benign or malignant) was seen. A nondiagnostic biopsy was one where no pathology was seen and lymph node sampling could not be confirmed. The total cost of endoscopic and surgical diagnostic procedures was tallied for each patient to obtain mean costs per patient. Results: Thirty-seven patients underwent FB-TBNA and 257 underwent EBUS-TBNA. A diagnosis was found in 90% of patients in the EBUS group and 62.2% of patients in the FB-TBNA group (P <0.001). More patients in the FB-TBNA group underwent a diagnostic surgical procedure (HR = -0.1573, 95% confidence interval, -0.30 to -0.15; P < 0.001). After accounting for all diagnostic procedures, the mean savings with EBUS was $1071.09 (P = 0.09) per patient. Conclusions: EBUS-TBNA is less expensive than blind FB-TBNA in the evaluation of thoracic lymphadenopathy when accounting for diagnostic surgical procedures.