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Original article

Vol. 152 No. 4546 (2022)

Cost-effectiveness analysis of surgical lung volume reduction compared with endobronchial valve treatment in patients with severe emphysema

  • Daniel Franzen
Cite this as:
Swiss Med Wkly. 2022;152:40008


BACKGROUND: Lung volume reduction, either by surgery or bronchoscopically  by endobronchial valve treatment have been shown to be a cost-effective alternative compared with conservative therapy. However, there is no comparative analysis of lung volume reduction by surgery and bronchoscopic lung volume reduction using endobronchial valves.

OBJECTIVES: The aim of this retrospective study was to provide a cost-effectiveness analysis of lung volume reduction by surgery compared with bronchoscopic lung volume reduction using endobronchial valves.

METHODS: The effectiveness of lung volume reduction was assessed using forced expiratory volume in the first second (FEV1), residual volume (RV) and 6-minute walking distance (6MWD), measured at baseline and at 4 to 12 weeks. Cost unit accounting derived from SwissDRG was used as a surrogate of the costs from the payer’s perspective.

RESULTS: In total, 67 patients (37 men and 30 women) with a mean age of 68.3 ± 7.4 years were included. Both clinical effectiveness and costs were comparable between surgical and bronchoscopic lung reduction. The incremental cost-effectiveness ratios (ICERs) for bronchoscopic compared with lung volume reduction by surgery for FEV1, RV and 6MWD were –101, 4 and 58, respectively. For RV and 6MWD, it could be shown that endobronchial valve  treatment is justified as a probably cost-effective alternative to lung volume reduction by surgery. Endobronchial valve  treatment resulted in an improvement of 0.25 quality-adjusted life years (QALYs) and an ICER of € 7657 per QALY gained.

CONCLUSION: A robust statement on the superiority of one of the two procedures in terms of cost-effectiveness cannot be made from the present study. Therefore, the study is not suitable for resource allocation. Two upcoming trials comparing lung volume reduction surgery and endobronchial valve treatment may be able to answer this question.</p>


  1. Soriano JB, Abajobir AA, Abate KH, Abera SF, Agrawal A, Ahmed MB, et al.; GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med. 2017 Sep;5(9):691–706. 10.1016/S2213-2600(17)30293-X
  2. Jones PW, Agusti AG. Outcomes and markers in the assessment of chronic obstructive pulmonary disease. Eur Respir J. 2006 Apr;27(4):822–32. 10.1183/09031936.06.00145104 DOI:
  3. Kaplan RM, Atkins CJ, Timms R. Validity of a quality of well-being scale as an outcome measure in chronic obstructive pulmonary disease. J Chronic Dis. 1984;37(2):85–95. 10.1016/0021-9681(84)90050-X DOI:
  4. Kaplan RM, Anderson JP, Patterson TL, McCutchan JA, Weinrich JD, Heaton RK, et al.; HNRC Group. HIV Neurobehavioral Research Center. Validity of the Quality of Well-Being Scale for persons with human immunodeficiency virus infection. Psychosom Med. 1995 Mar-Apr;57(2):138–47. 10.1097/00006842-199503000-00006 DOI:
  5. Ganiats TG, Palinkas LA, Kaplan RM. Comparison of Quality of Well-Being scale and Functional Status Index in patients with atrial fibrillation. Med Care. 1992 Oct;30(10):958–64. 10.1097/00005650-199210000-00008 DOI:
  6. Iheanacho I, Zhang S, King D, Rizzo M, Ismaila AS. Economic Burden of Chronic Obstructive Pulmonary Disease (COPD): A Systematic Literature Review. Int J Chron Obstruct Pulmon Dis. 2020 Feb;15:439–60. 10.2147/COPD.S234942 DOI:
  7. Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care Med. 2017 Mar;195(5):557–82. 10.1164/rccm.201701-0218PP DOI:
  8. Global Initiative for Obstructive Lung Disease. GOLD. Pocket guide to COPD for diagnosis, management, and prevention. A Guide for Health Care Professionals. 2017; Accessed 26 June 2021.
  9. Kemp SV, Polkey MI, Shah PL. The epidemiology, etiology, clinical features, and natural history of emphysema. Thorac Surg Clin. 2009 May;19(2):149–58. 10.1016/j.thorsurg.2009.03.003 DOI:
  10. Brantigan OC, Mueller E. Surgical treatment of pulmonary emphysema. Am Surg. 1957 Sep;23(9):789–804.13470332
  11. Fishman A, Martinez F, Naunheim K, Piantadosi S, Wise R, Ries A, et al.; National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003 May;348(21):2059–73. 10.1056/NEJMoa030287 DOI:
  12. van Geffen WH, Slebos DJ, Herth FJ, Kemp SV, Weder W, Shah PL. Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. Lancet Respir Med. 2019 Apr;7(4):313–24. 10.1016/S2213-2600(18)30431-4 DOI:
  13. Garner J, Kemp SV, Toma TP, Hansell DM, Polkey MI, Shah PL, et al. Survival after Endobronchial Valve Placement for Emphysema: A 10-Year Follow-up Study. Am J Respir Crit Care Med. 2016 Aug;194(4):519–21. 10.1164/rccm.201604-0852LE DOI:
  14. Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, et al. Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA. 2016 Sep;316(10):1093–103. 10.1001/jama.2016.12195 DOI:
  15. Fleck LM. Controlling Healthcare Costs: Just Cost Effectiveness or “Just” Cost Effectiveness? Camb Q Healthc Ethics. 2018 Apr;27(2):271–83. 10.1017/S0963180117000603 DOI:
  16. Ramsey SD, Berry K, Etzioni R, Kaplan RM, Sullivan SD, Wood DE,. National Emphysema Treatment Trial Research Group. Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema. N Engl J Med. 2003 May;348(21):2092–102. 10.1056/NEJMsa030448 DOI:
  17. Ramsey SD, Shroyer AL, Sullivan SD, Wood DE. Updated evaluation of the cost-effectiveness of lung volume reduction surgery. Chest. 2007 Mar;131(3):823–32. 10.1378/chest.06-1790 DOI:
  18. Bulsei J, Leroy S, Perotin JM, Mal H, Marquette CH, Dutau H, et al.; REVOLENS study group. Cost-effectiveness of lung volume reduction coil treatment in patients with severe emphysema: results from the 2-year follow-up crossover REVOLENS study (REVOLENS-2 study). Respir Res. 2018 May;19(1):84. 10.1186/s12931-018-0796-x DOI:
  19. Pietzsch JB, Garner A, Herth FJ. Cost-effectiveness of endobronchial valve therapy for severe emphysema: a model-based projection based on the VENT study. Respiration. 2014;88(5):389–98. 10.1159/000368088 DOI:
  20. Hartman JE, Klooster K, Groen H, Ten Hacken NH, Slebos DJ. Cost-effectiveness of endobronchial valve treatment in patients with severe emphysema compared to standard medical care. Respirology. 2018 Mar;23(9):835–41. 10.1111/resp.13295; Online ahead of print.29575395 DOI:
  21. Jones PW, Beeh KM, Chapman KR, Decramer M, Mahler DA, Wedzicha JA. Minimal clinically important differences in pharmacological trials. Am J Respir Crit Care Med. 2014 Feb;189(3):250–5. 10.1164/rccm.201310-1863PP DOI:
  22. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al.; ISPOR Health Economic Evaluation Publication Guidelines-CHEERS Good Reporting Practices Task Force. Consolidated Health Economic Evaluation Reporting Standards (CHEERS)—explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force. Value Health. 2013 Mar-Apr;16(2):231–50. 10.1016/j.jval.2013.02.002 DOI:
  23. Bundesamt für Gesundheit [German Federal Institute for Health]. URL: [Accessed 26 June 2021].
  24. Swiss DR. URL: [Accessed 26 June 2021].
  25. Zusatzentgeltkatalog Swiss DR. URL: [Accessed 25 June 2021]
  26. van Agteren JE, Carson KV, Tiong LU, Smith BJ. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev. 2016 Oct;10(10):CD001001. 10.1002/14651858.CD001001.pub3 DOI:
  27. van Agteren JE, Hnin K, Grosser D, Carson KV, Smith BJ. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2017 Feb;2:CD012158. 10.1002/14651858.CD012158.pub2 DOI:
  28. Drummond M, Sculpher M, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. Oxford University Press, 4th Edition; 2015, Oxford.
  29. Martin AL, Marvel J, Fahrbach K, Cadarette SM, Wilcox TK, Donohue JF. The association of lung function and St. George’s respiratory questionnaire with exacerbations in COPD: a systematic literature review and regression analysis. Respir Res. 2016 Apr;17(1):40. 10.1186/s12931-016-0356-1 DOI:
  30. Donohue JF, Jones PW, Bartels C, Marvel J, D’Andrea P, Banerji D, et al. Correlations between FEV1 and patient-reported outcomes: A pooled analysis of 23 clinical trials in patients with chronic obstructive pulmonary disease. Pulm Pharmacol Ther. 2018 Apr;49:11–9. 10.1016/j.pupt.2017.12.005 DOI:
  31. Starkie HJ, Briggs AH, Chambers MG, Jones P. Predicting EQ-5D values using the SGRQ. Value Health. 2011 Mar-Apr;14(2):354–60. 10.1016/j.jval.2010.09.011 DOI:
  32. Afonso AS, Verhamme KM, Sturkenboom MC, Brusselle GG. COPD in the general population: prevalence, incidence and survival. Respir Med. 2011 Dec;105(12):1872–84. 10.1016/j.rmed.2011.06.012 DOI:
  33. Flynn RW, MacDonald TM, Chalmers JD, Schembri S. The effect of changes to GOLD severity stage on long term morbidity and mortality in COPD. Respir Res. 2018 Dec;19(1):249. 10.1186/s12931-018-0960-3 DOI:
  34. Shavelle RM, Paculdo DR, Kush SJ, Mannino DM, Strauss DJ. Life expectancy and years of life lost in chronic obstructive pulmonary disease: findings from the NHANES III Follow-up Study. Int J Chron Obstruct Pulmon Dis. 2009;4:137–48. 10.2147/COPD.S5237 DOI:
  35. Miller JD, Malthaner RA, Goldsmith CH, Goeree R, Higgins D, Cox PG, et al.; Canadian Lung Volume Reduction Surgery Study. A randomized clinical trial of lung volume reduction surgery versus best medical care for patients with advanced emphysema: a two-year study from Canada. Ann Thorac Surg. 2006 Jan;81(1):314–20. 10.1016/j.athoracsur.2005.07.055 DOI:
  36. Ramsey SD, Sullivan SD, Kaplan RM. Cost-effectiveness of lung volume reduction surgery. Proc Am Thorac Soc. 2008 May;5(4):406–11. 10.1513/pats.200707-095ET DOI:
  37. Herth FJ, Noppen M, Valipour A, Leroy S, Vergnon JM, Ficker JH, et al.; International VENT Study Group. Efficacy predictors of lung volume reduction with Zephyr valves in a European cohort. Eur Respir J. 2012 Jun;39(6):1334–42. 10.1183/09031936.00161611 DOI:
  38. Klooster K, ten Hacken NH, Hartman JE, Kerstjens HA, van Rikxoort EM, Slebos DJ. Endobronchial Valves for Emphysema without Interlobar Collateral Ventilation. N Engl J Med. 2015 Dec;373(24):2325–35. 10.1056/NEJMoa1507807 DOI:
  39. Ramsey S, Willke R, Briggs A, Brown R, Buxton M, Chawla A, et al. Good research practices for cost-effectiveness analysis alongside clinical trials: the ISPOR RCT-CEA Task Force report. Value Health. 2005 Sep-Oct;8(5):521–33. 10.1111/j.1524-4733.2005.00045.x DOI:
  40. Neumann PJ. Why don’t Americans use cost-effectiveness analysis? Am J Manag Care. 2004 May;10(5):308–12.15152700
  41. Schöffski O, Graf von der Schulenberg JM. Gesundheitsökonomische Evaluationen. Springer Verlag, 4th Edition; 2011, Berlin. DOI:

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