Outcomes of Thoracentesis for Acute Heart Failure in Hospitals.

Data on in-hospital outcomes for hospitalizations undergoing thoracentesis (THR) for any cause has been conflicting. For hospitalizations with acute heart failure (HF), however, to date, no study has evaluated the outcomes of THR. Accordingly, our current study addresses this knowledge gap. We analyzed data from the Nationwide Inpatient Sample (2005-14). The study population included all adults (>18 years) with the principal discharge diagnosis of HF and the presence of procedure code for THR. Hospitalizations with pneumonia, acute kidney injury, and co-morbidities such as malignancy, lymphoma, liver disease, end-stage renal disease, metastatic disease, and tuberculosis were excluded. Propensity matching was performed to identify a similar cohort of admissions that did not undergo THR. Primary outcome of interest was in-hospital mortality and length of hospitalization. During the study period, 2,251,927 hospitalizations for HF were found from the database; of which, 70,823 (3.14%) had THR. After propensity matching, a matched cohort of 70,785 hospitalizations for HF was identified. In-hospital mortality was higher for those who underwent THR (2.5% vs 1.6%; p <0.001). In-hospital complications and procedures including cardiac arrest, sepsis, pneumothorax and hemothorax were more frequent in the THR group. Those who underwent THR had a longer mean length of stay (6.9 vs 4.5 days; p <0.01) and higher cost of hospitalization ($13,448 vs $ 8940; p <0.01). The trend analysis demonstrated a steady increase in the performance of THR in hospitalized HF between 2005 and 2014. In conclusion, THR performed during HF hospitalizations were associated with higher rates of in-hospital mortality, complications and increased healthcare utilization in the form of longer length of stay and higher costs.

Healthcare Costs and Utilization among Patients Hospitalized for Malignant Pleural Effusion.

BACKGROUND: Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. OBJECTIVE: We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. METHODS: We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. RESULTS: We analyzed 92,034 hospital discharges spanning a decade (2004-2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). CONCLUSIONS: The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame.

Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission.

BACKGROUND AND AIM: Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS: A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS: Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION: When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.

The Role of Ultrasound-Guided Therapeutic Thoracentesis in an Outpatient Transitional Care Program: A Case Series.

BACKGROUND: Symptomatic pleural effusions create discomfort and are a frequent cause of hospitalization. Ultrasound-guided thoracentesis is a key palliative intervention to assist in the management of this vulnerable population. Our institution has created a multidisciplinary transitional care program to address the needs of those discharged from the hospital with chronic complex conditions, including symptomatic pleural effusions. METHODS: This case series was performed in a transitional care clinic between May 8, 2017, and December 11, 2018. Eight unique patients with symptomatic pleural effusions were referred to our clinic posthospital discharge and treated with ultrasound-guided thoracentesis. A retrospective review was performed to assess procedure details, complications, and follow-up emergency department visits or hospital readmissions. Additionally, cost comparison data were obtained from the hospital financial system. RESULTS: Of the 8 unique patients, 15 thoracenteses were performed over the 19-month period in the transitional care clinic. The median age of the cohort was 56 years old (range: 39-92 years). All patients reported an immediate relief of symptoms (dyspnea and/ or pain) and no procedural complications. The total cost of performing an ultrasound-guided thoracentesis in the transitional care clinic was 61.8% that of performing the procedure in the hospital (US$537.61 vs US$869.65). CONCLUSION: All 8 patients experienced an immediate relief in pleural effusion-related symptoms following thoracentesis. Our experience helps reveal the safety, efficacy, and cost-efficiency of ultrasound-guided thoracentesis in providing symptom management for patients with pleural effusions in a transitional care clinic.

Examining Invasive Bedside Procedure Performance at an Academic Medical Center.

OBJECTIVES: Explore the performance patterns of invasive bedside procedures at an academic medical center, evaluate whether patient characteristics predict referral, and examine procedure outcomes. METHODS: This was a prospective, observational, and retrospective chart review of adults admitted to a general medicine service who had a paracentesis, thoracentesis, or lumbar puncture between February 22, 2013 and February 21, 2014. RESULTS: Of a total of 399 procedures, 335 (84%) were referred to a service other than the primary team for completion. Patient characteristics did not predict referral status. Complication rates were low overall and did not differ, either by referral status or location of procedure. Model-based results showed a 41% increase in the average length of time until procedure completion for those referred to the hospital procedure service or radiology (7.9 vs 5.8 hours; P < 0.05) or done in radiology instead of at the bedside (9.0 vs 5.8 hours; P < 0.001). The average procedure cost increased 38% ($1489.70 vs $1023.30; P < 0.001) for referred procedures and 56% ($1625.77 vs $1150.98; P < 0.001) for radiology-performed procedures. CONCLUSIONS: Although referral often is the easier option, our study shows its shortcomings, specifically pertaining to cost and time until completion. Procedure performance remains an important skill for residents and hospitalists to learn and use as a part of patient care.

Management of Malignant Pleural Effusion: A Cost-Utility Analysis.

BACKGROUND: Malignant pleural effusion (MPE) is associated with a significant impact on health-related quality of life. Palliative interventions abound, with varying costs and degrees of invasiveness. We examined the relative cost-utility of 5 therapeutic alternatives for MPE among adults. METHODS: Original studies investigating the management of MPE were extensively researched, and the most robust and current data particularly those from the TIME2 trial were chosen to estimate event probabilities. Medicare data were used for cost estimation. Utility estimates were adapted from 2 original studies and kept consistent with prior estimations. The decision tree model was based on clinical guidelines and authors' consensus opinion. Primary outcome of interest was the incremental cost-effectiveness ratio for each intervention over a less effective alternative over an analytical horizon of 6 months. Given the paucity of data on rapid pleurodesis protocol, a sensitivity analysis was conducted to address the uncertainty surrounding its efficacy in terms of achieving long-term pleurodesis. RESULTS: Except for repeated thoracentesis (RT; least effective), all interventions had similar effectiveness. Tunneled pleural catheter was the most cost-effective option with an incremental cost-effectiveness ratio of $45,747 per QALY gained over RT, assuming a willingness-to-pay threshold of $100,000/QALY. Multivariate sensitivity analysis showed that rapid pleurodesis protocol remained cost-ineffective even with an estimated probability of lasting pleurodesis up to 85%. CONCLUSIONS: Tunneled pleural catheter is the most cost-effective therapeutic alternative to RT. This, together with its relative convenience (requiring neither hospitalization nor thoracoscopic procedural skills), makes it an intervention of choice for MPE.