0
Correspondence |

ResponseResponse FREE TO VIEW

Gerard A. Silvestri, MD, FCCP; Nicholas J. Pastis, MD, FCCP
Author and Funding Information

From the Department of Pulmonary and Critical Care Medicine, Medical University of South Carolina.

Correspondence to: Gerard A. Silvestri, MD, FCCP, Department of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 171 Ashley Ave, Room 812-CSB, Charleston, SC 29425; e-mail: silvestri@musc.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Silvestri received an Olympus grant for this study and other research projects, and an Allegro Diagnostics Corp research grant. Dr Pastis received a consultant fee from Olympus America.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(2):539-540. doi:10.1378/chest.12-0873
Text Size: A A A
Published online

To the Editor:

We appreciate the interest of Dr Fadul and colleagues in our article in CHEST1 but are disheartened by their conclusions, particularly the blanket, sweeping, and unsubstantiated statements suggesting a “disservice to the field of interventional pulmonology and, most importantly, the patients.” Paradoxically, they praised the clinical usefulness of endobronchial ultrasound (EBUS), its benefit beyond the clinical scope of patients, and its lowering of the cost burden on the health-care system.

The correspondence cites weaknesses we identified in our discussion. We agree that the value of EBUS to our institution should not be generalized and even suggested that using our dollar amount may translate to financial loss in certain institutions. We offered assessment steps (outlined in Table 3 in the article) and feel that by doing their homework, some institutions will discover they are better off not adopting a new procedure. We also designed the study to be conservative in estimates of downstream revenue by excluding patients already in the system, capturing actual collections, and only including collections related to the reason for EBUS. Furthermore, our collections are likely less in relation to other practices because our payer mix includes a substantial percentage of unfunded or underfunded patients. Our institution is a tertiary care center with pulmonologists trained in EBUS, but our catchment area contains hospitals with mediastinoscopy, endoscopic ultrasound fine needle aspiration, and traditional transbronchial needle aspiration, and EBUS and medical oncologists, thoracic surgeons, and radiation oncologists.

Opportunity costs are a concern for physicians devoting time away from higher-paying endeavors, and, for that reason, downstream revenue is a consideration for them as well. Although this article focused on downstream revenue to a health-care system, future evaluations may include downstream revenue to the individual.

A discount method was not needed, because we limited collections to 1 year after the procedure (month by month would be desired when there are tight margins and seasonal variation of cases). Furthermore, a discount rate is not practical given the variety of services received by these patients, each with its own discount rate based on cost of capital.

We are disappointed with the assertion of Dr Fadul and colleagues that our analysis may not be free of “real or perceived conflicts of interest” without offering a reason. Potential conflicts of interest permeate the medical literature, but we remind them that this is a peer-reviewed manuscript and throughout the review process the issue of conflict never arose. Like them, we disclosed all conflicts of interest in the published article. The study was supported by an unrestricted industry grant, and the company had no influence whatsoever over the design, analysis, or manuscript preparation. We believe the readership of CHEST is savvy enough to decide whether to accept the results based on the disclosed funding source.

Obviously, our institution’s monetary gain is not applicable to all hospitals, but the concepts presented should be considered and may prevent ill-advised expenditures. The only complication of transbronchial needle aspiration is failure to make a diagnosis when it can be made. It is time to take the next step and say the only disservice is not to use a procedure like EBUS when patients and a health-care system can benefit.

Pastis NJ, Simkovich S, Silvestri GA. Understanding the economic impact of introducing a new procedure: calculating downstream revenue of endobronchial ultrasound with transbronchial needle aspiration as a model. Chest. 2012;141(2):506-512.
 

Figures

Tables

References

Pastis NJ, Simkovich S, Silvestri GA. Understanding the economic impact of introducing a new procedure: calculating downstream revenue of endobronchial ultrasound with transbronchial needle aspiration as a model. Chest. 2012;141(2):506-512.
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543