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.

Pleural effusions in hematologic malignancies and their management with indwelling pleural catheters.

PURPOSE OF REVIEW: Pleural effusions in patients with hematologic malignancy may represent malignant pleural effusion (MPE) or occur secondary to infection, treatment effects, and other common causes. The impact of MPE on prognosis in this cohort remains unclear. Indwelling pleural catheters (IPCs) are routinely placed for palliation of recurrent symptomatic MPEs, but perceived concerns over infection and bleeding may limit their use in patients with hematologic malignancies. However, recent evidence suggests IPCs are both well tolerated and effective in this cohort. In this review, the evaluation of pleural effusions in hematologic malignancies and their management with an IPC are outlined. RECENT FINDINGS: Two retrospective studies have been published regarding the use of IPCs in hematologic malignancies. Lymphomatous effusions are the most common cause of MPE in this cohort. The rates of complications and pleurodesis with IPC in hematologic malignancies are similar to those with solid organ tumors. SUMMARY: Pleural effusions in patients with hematologic malignancies may be managed safely with an IPC. Sterile technique, barrier protection, standardized algorithms for placement and removal, and quality assurance initiatives are crucial to centers that place IPCs for all patients. The safety of IPC in hematologic malignancies warrants a paradigm shift in the management of pleural disease for this cohort.

[Chest tube management following lung resections]. / Drainagemanagement nach Lungenresektionen.

The wide variability in postoperative chest tube management following lung resections is based on the fact that nearly no reproducible treatment parameters were available in the past. New electromechanical suction devices, however, providing continuous objective flow values seem to have induced a change in postoperative chest tube management. Thoracic surgeons have become more and more aware that components and parameters of chest tube systems are actuators and regulators of a closed loop system. This concept is the basis for multicentre trials leading to evidence-based options. Initial results from international single centre studies, logical physical considerations of pleural pressure combined with our own experience over decades form the basis for new recommendations to optimise postoperative chest tube management. Main criteria are safety, patient comfort, workload and costs.

Impact of the learning curve in the use of a novel electronic chest drainage system after pulmonary lobectomy: a case-matched analysis on the duration of chest tube usage.

The objective of this investigation was to verify the impact of the learning curve involved after the introduction of a novel electronic chest drainage device on the duration of chest tube usage following pulmonary lobectomy. Propensity score case-matched analysis was used to compare the first consecutive 51 lobectomy patients managed with an electronic chest drainage (E) device with 51 controls managed with a traditional device (T). There was no difference in the characteristics of the two matched groups. Compared with patients managed with a traditional device, those with the electronic one had 1.9-day shorter duration of chest tube drainage (2.5 vs. 4.4 days; P<0.0001) and a 1.5-day shorter hospital stay (4.5 vs. 6 days; P=0.0003). Consequently, they had an average reduction in hospital costs of €751 (€1802 vs. €2553; P=0.0002). Compared with those in group T, patients in group E had a consistently shorter duration of chest tube use in relation to the very first patients treated. The learning curve sloped down for the first 40 patients before reaching a plateau, when the maximum benefit of using the electronic device was evident. Compared with traditional devices, the use of a novel electronic chest drainage system was beneficial from its initial application. The inherent learning curve was short and did not affect the efficiency of the system.

Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients.

BACKGROUND: Definitive practice guidelines regarding the utility of chest x-ray (CXR) following chest tube removal in trauma patients have not been established. The authors hypothesized that the selective use of CXR following chest tube removal is safe and cost effective. METHODS: A retrospective review of chest tube insertions performed at a level I trauma center was conducted. RESULTS: Patients who underwent chest tube removal without subsequent CXR had a lower mean Injury Severity Score and were less likely to have suffered penetrating thoracic injuries. These patients received fewer total CXRs and had shorter durations of chest tube therapy and shorter lengths of stay following tube removal. Subsequent reinterventions were performed more frequently in the CXR group. The annual decrease in hospital charges by foregoing a CXR was $16,280. CONCLUSIONS: The selective omission of CXR following chest tube removal in less severely injured, nonventilated patients does not adversely affect outcomes or increase reintervention rates. Avoiding unnecessary routine CXR after chest tube removal could provide a significant reduction in total hospital charges.

Costs of treating children with complicated pneumonia: a comparison of primary video-assisted thoracoscopic surgery and chest tube placement.

OBJECTIVES: To describe charges associated with primary video-assisted thoracoscopic surgery (VATS) and primary chest tube placement in a multicenter cohort of children with empyema and to determine whether pleural fluid drainage by primary VATS was associated with cost-savings compared with primary chest tube placement. STUDY DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Administrative database containing inpatient resource utilization data from 27 tertiary care children's hospitals. Patients between 12 months and 18 years of age diagnosed with complicated pneumonia were eligible if they were discharged between 2001 and 2005 and underwent early (within 2 days of index hospitalization) pleural fluid drainage. MAIN EXPOSURE: Method of pleural fluid drainage, categorized as VATS or chest tube placement. RESULTS: Pleural drainage in the 764 patients was performed by VATS (n = 50) or chest tube placement (n = 714). There were 521 (54%) males. Median hospital charges were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiologic imaging charges were $5,884 (IQR, $3,142-$11,357) and $2,875 (IQR, $1,703-$4,950), respectively. Adjusting for propensity score matching, patients undergoing primary VATS did not have higher charges than patients undergoing primary chest tube placement. CONCLUSIONS: In this multicenter study, we found that the charges incurred in caring for children with empyema were substantial. However, primary VATS was not associated with higher total or pharmacy charges than primary chest tube placement, suggesting that the additional costs of performing VATS are offset by reductions in length of stay (LOS) and requirement for additional procedures.

Survey on chest drainage systems adopted in Europe.

The aim of this survey, promoted by the European Society of Thoracic Surgeons, was to acquire information and advice from 'the field' in order to promote development of technology for thoracic surgery and to provide information for future guidelines on chest drainage. Society members were offered a questionnaire on the European Society of Thoracic Surgeons website (November 2006) composed of seven sections comprehending 21 detailed items. The questionnaire was completed by 120 centres, 100% performed lung surgery, 91.6% mediastinal surgery, 54.1% oesophageal surgery, 10% cardiothoracic surgery. The PVC straight drain (mean 55.9%) and silicon drain (mean 38.4%), water-valve/water suction disposable chest drainage collection system (mean 43.4%), one bottle (mean 24.8%), and two bottles with suction control (mean 18.2%), were the most frequently used. After pneumonectomy 51.2% used a balanced drainage system, 9% periodical thoracocentesis, 39.8% others. In 57.5-92% drainage suction was stopped 4 postoperative days. In 17.6-60.7% drains were removed 4 postoperative days. The survey demonstrates a trend toward the use of updated technical devices, high consideration of the costs, and clinical practice based on personal preferences.

Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage?

BACKGROUND: Simple aspiration is recommended as first-line treatment for all primary spontaneous pneumothoraces requiring intervention. However, the optimal salvage treatment remains unclear when simple aspiration is unsuccessful for controlling symptoms. In this study, the safety, efficacy, and estimated costs of video-assisted thoracoscopic surgery (VATS) and chest tube drainage (CTD) were compared. METHODS: Between 2002 and 2007, 164 patients with a first episode of spontaneous pneumothorax were managed by simple aspiration. Among them, 52 patients underwent subsequent VATS (30 patients) or CTD (22 patients) due to unsuccessful aspiration. The demographic data and treatment outcomes of the two groups were collected through retrospective chart review. RESULTS: Postoperative analgesics use did not differ between groups. Complications developed in 2 of the VATS group (6.7%) and 6 of the CTD group (27.3%), with mean hospital stays of 4.8 and 6.1 days, respectively (p = 0.034). Patients in the VATS group had lower rates of overall failure, although the rates of immediate failure were not significantly different. After a mean follow-up of 16 months, recurrent ipsilateral pneumothorax was noted in 1 VATS patient and 5 CTD individuals (p = 0.038). The estimated total costs per patient were $1,273 in the VATS group and $865 in the CTD group. CONCLUSIONS: Although associated with higher costs, VATS rather than CTD is the preferred salvage treatment for unsuccessful aspiration of the first episode of primary spontaneous pneumothorax, because of shorter hospital stay and lower rates of overall failure and recurrence.

Cost-effectiveness of competing strategies for the treatment of pediatric empyema.

BACKGROUND: The optimal management of pediatric empyema is controversial. The purpose of this decision analysis was to assess the relative merits in terms of costs and clinical outcomes associated with competing treatment strategies. METHODS: A cost-effectiveness analysis was conducted using a Bayesian tree approach. Probability and outcome estimates were derived from the published literature, with preference given to data derived from randomized trials. Costing was based on published estimates from Great Ormond Street Hospital (London, United Kingdom), supplemented by American and Canadian data. Five strategies were evaluated: (1) nonoperative; (2) chest tube insertion; (3) repeated thoracentesis; (4) chest tube insertion with instillation of fibrinolytics; or (5) video-assisted thorascopic surgery. The model was used to project overall costs, survival in life-years, and incremental cost-effectiveness ratios for competing strategies. RESULTS: In the base-case analysis, chest tube with instillation of fibrinolytics was the least expensive therapy, at $7787 per episode. This strategy was projected to cost less but provide equivalent health benefit when compared with all of the competing strategies except repeated thoracentesis, which had an incremental cost-effectiveness ratio of approximately $6,422,699 per life-year gained relative to chest tube with instillation of fibrinolytics. In univariable and multivariable sensitivity analyses, thorascopic surgery was preferred only when the length of stay associated with chest tube with instillation of fibrinolytics exceeded 10.3 days or when the probability of dying as a result of this strategy exceeded 0.2%, assuming a threshold willingness to pay of $75,000 per life-year gained. Chest tube with instillation of fibrinolytics was preferred in >58% of Monte Carlo simulations. CONCLUSIONS: On the basis of the best available data, chest tube with instillation of fibrinolytics is the most cost-effective strategy for treating pediatric empyema. Video-assisted thorascopic surgery would be preferred to chest tube with instillation of fibrinolytics if the differential in length of stay between these 2 strategies were proven to be greater than that suggested by currently available data.

Do the benefits of shorter hospital stay associated with the use of fleece-bound sealing outweigh the cost of the materials?

OBJECTIVES: To compare the cost of materials and hospitalization for standard techniques (suturing, stapling and electrocautery) for sealing the lung after pulmonary resection with those for a fleece-bound sealing procedure. METHODS: This cost comparison analysis uses as its basis a prospective randomised clinical trial involving 152 patients with pulmonary lobectomy/segmentectomy (standard technique group: 77 patients; fleece-bound sealing group: 75 patients). The cost comparison was performed from the economic perspective of Austrian and German hospitals, taking into consideration the cost of materials for the two alternatives as well as the mean time to hospital discharge. RESULTS: The clinical study found significantly smaller postoperative air leaks in the fleece-bound sealing group. The mean times to chest drain removal and to hospital discharge were also significantly reduced after application of fleece-bound sealing [5.1 vs. 6.3 days (P=0.022) and 6.2 vs. 7.7 days (P=0.01), respectively]. The cost of materials for sealing air leaks amounted to euro47 per patient in the standard technique group and euro410 per patient in the fleece-bound sealing group. The 1.5-day reduction in the length of hospital stay associated with fleece-bound sealing represents a saving of euro462 per patient. CONCLUSIONS: There was an overall saving of euro99 for the fleece-bound sealing procedure compared to standard techniques for sealing the lung following pulmonary resection.

One or two drains after lobectomy? A comparison of both methods in the immediate postoperative period.

BACKGROUND: The conventional method of double chest tube drainage after lobectomy is well established. The aim of the study was to compare the efficacy of the two-drain versus the single-drain approach after this procedure. METHODS: The data of 183 consecutive patients who underwent lobectomy between January 2000 and May 2005 were analyzed: 93 had two drains and 90 had a single, midposition drain. All patients were operated on by one surgeon with the same surgical technique. RESULTS: Patients with one drain had a shorter hospital stay (7.6 days vs. 9.0 days; P = 0.001). There were no significant differences in the amount of drainage, the necessity of redrainage or broncho-aspiration, and postoperative mortality or complications. The period in which opioids (4.8 days vs. 5.6 days; P = 0.0001) and nonsteroidal anti-inflammatory drugs (6.8 days vs. 7.7 days; P = 0.002) were required was shorter in patients with one drain. The fourth postoperative day was more painful for patients with a double drain. The cost savings in the one-drain group were approximately 125 Euros per patient. CONCLUSION: A single-drain method is effective, reduces hospitalization times and the cost of treatment in patients who undergo lobectomy.

Modified central line for pneumothorax.

Pneumothoraxes, whether spontaneous or iatrogenic, frequently require drainage. Although the recent trend has been toward a catheter-based approach, many thoracic surgeons continue to use chest tubes. Tube thoracostomy is associated with significant pain at the time of insertion and during continued drainage. Pneumothorax catheters are less painful but more expensive, and some have been associated with significant failure. After disappointing experience with pneumothorax catheters, we have modified a central line to use in lieu of a pneumothorax kit. We have found this technique to be effective, safe, reliable, and inexpensive.

Pigtail tube drainage in the treatment of spontaneous pneumothorax.

We report our experience in using pigtail tube drainage in the treatment of spontaneous pneumothorax compared with traditional chest tube thoracotomy. One hundred two patients were included and analyzed. Fifty patients were treated with the pigtail tube and 52 patients were treated with the traditional chest tube. The extubation time, mean hospital stay, evacuation rate, and total cost were similar without a significant statistical difference. Among the chest tube group, 15 underwent surgical intervention as a result of delayed resolution and hemopneumothorax; and among the pigtail group, 15 had other procedures for pneumothorax, including chest tube insertion and surgical intervention. This verifies our initial suspicion that the effectiveness of the pigtail drainage system is no less than that of the chest tube. Therefore, when considering ambulatory ability and good patient compliance, the pigtail tube drainage system can be considered as the treatment of choice for spontaneous pneumothorax.

Rational treatment of empyema in children.

HYPOTHESIS: Efficacious and cost-effective treatment of pediatric empyema can be accomplished following a protocol based on its radiographic appearance. Therapeutic modalities include thoracostomy tube drainage (TTD) with or without fibrinolytic therapy (FT) and video-assisted thoracoscopic debridement (VATD). DESIGN: Retrospective case series. SETTING: Tertiary referral center. RESULTS: From 1995 through 1999, 31 children were treated ranging in age from 11 months to 18 years (mean age, 5.1 years). Twenty-seven (87.1%) underwent TTD; of these, 22 (81.5%) received FT with urokinase. The TTD failed in 4 children (14.8%) who required salvage VATD. Primary VATD was performed in another 4 children (12.9%). The mean length of stay was 14.6 days (TTD, 14.1 days; salvage VATD, 20. 0 days; primary VATD, 11.5 days), ranging from 8.0 to 30.0 days. Complications included readmission for fever (2 patients [6.5%]) and gastrointestinal bleeding (1 patient [3.2%]). There were no anaphylactic reactions or bleeding episodes due to urokinase. Two patients (7.4%) treated with TTD and FT developed an air leak that resolved spontaneously. The mean hospital charges were $78,832 (TTD with or without FT, $75,450; salvage VATD, $107,476; primary VATD, $69,634). The procedural charges were highest for salvage VATD. CONCLUSIONS: Most cases of pediatric empyema can be treated by TTD with or without FT. This therapy is safe and effective for children with nascent disease. Primary VATD is preferred in children with advanced disease. Cost-effectiveness could be further improved through better prediction of those patients likely to fail TTD and require salvage VATD. An algorithmic approach based on findings from computed tomography or (better) ultrasonography of the chest may be the best way to make this distinction and rationalize care.