Introducing a network of chronic obstructive pulmonary disease (COPD) multi-disciplinary teams (MDTs) linked to lung volume reduction services in Ireland: analysis of health economic implications

Background: Emphysema, a form of chronic obstructive pulmonary disease (COPD), is an irreversible, incapacitating illness characterised by the ongoing destruction of lung tissue. This destruction results in progressive hyperinflation and air-trapping. Subsequently, patients experience dyspnoea from airflow obstruction, which leads to limited exercise tolerance and patients with COPD report poor health-related quality of life. Lung Volume Reduction (LVR) encompasses both surgical and bronchoscopic methods, and it aims to palliate dyspnoea by reducing air trapping for patients with advanced emphysema. Patients referred for this treatment have failed optimal medical therapy for their dyspnoea. LVR can be carried out via bronchoscopic insertion of endobronchial valves (EBV-LVR) to induce lobe collapse or through minimally invasive surgery (Video-assisted thoracoscopy surgery; VATS or robotic-assisted thoracic surgery; RATS) with resection of hypo-perfused tissue. In Ireland, 500,000 people aged 40 or more in Ireland have COPD. The Health Service Executive (HSE)'s estimates that almost two hundred thousand have moderate to severe disease, and diagnosis of half of this number is likely. Economic evaluations are increasingly applied in healthcare with the principle aim of improving efficiency in resource allocation. This thesis will explore the health-economic implications of implementing a network of multi-disciplinary teams (MDTs) for patients with chronic obstructive pulmonary disease (COPD) in Ireland. 

Methods: A Delphi Consensus was used to develop a comprehensive multidisciplinary guideline by enabling experts in this field to reach a formal consensus surrounding the introduction of LVR on a national level in Ireland. The results of this study identified several concerning issues in setting up an LVR network in an Irish context. Commentary from the expert participants raised concerns in several key areas, namely 1) level of expertise on a national level; 2) funding from the HSE; and 3) access for patients to essential investigations, including pulmonary function tests (PFTs) and mandatory radiological testing. This Delphi study reached a consensus on key guidelines for LVR in an Irish context for referral criteria, MDT membership and patient pathways. A set of guidelines have been formulated based on recommendations from this group. The cost-effectiveness of LVR needs to be established prior to these guidelines being implemented. A scoping review was used to assess the methodology used in papers evaluating the cost-effectiveness of LVR in literature. It identified substantial variations in methods applied to assess the potential long-term effects and costs. The results from this scoping review informed the basis and data collection in our prospective patient cohort.  

A detailed, deterministic cost analysis was conducted to compare different methods of LVR, namely endobronchial valve LVR, video-assisted thoracoscopic surgery LVR and robotic-assisted thoracoscopic surgery(EBV-LVRS, VATS-LVRS and RATS-LVRS). This analysis captured costs from intervention start to 90 days post-operation, giving an in-depth analysis of costs associated with these procedures.  

A prospective observational study was carried out from 2020-2022, evaluating health-related quality (HRQoL) of life for patients who were under consideration for LVRS in a single surgeon practice. This included 35 patients who underwent EBV-LVRS, VATS-LVRS or RATS-LVRS.  

Conclusion: A Delphi protocol was successfully used to create 31consensus guidelines on the provision of LVR in Ireland. The cost-effectiveness of the different modalities used was then explored in a micro-costing analysis which presents a comprehensive analysis of the cost drivers for LVR, modelled for the three surgical modalities: EBV-LVRS, VATS-LVRS, and RATS-LVRS. VATS-LVR has been found to be the cheapest, at €12,896per patient. Lastly, this thesis includes a prospective observational study of patients with end-stage COPD with significantly adversely affected QoL in which there was a prospective collection of lung function, HrQol scores, and clinical outcomes data. This is the first Irish database to monitor patients referred to a national tertiary centre and treated using a single surgeon protocol. From the results, it is clear that there is a positive HrQoL effect from each of the LVR modalities –EBV-LVRS, VATS-LVRS, and RATS-LVRS –as measured using SGRQ and EQ-5D. 

Recommendations: A longer-term clinical trial is recommended to capture HRQoL data at different time points post-intervention. LVR has clear quality-of-life benefits, across all modalities and has been found to be cost-effective at an unofficial Irish threshold.