Etiology of Malignant Pleural Effusion and Utilization of Diagnostic and Therapeutic Procedures: A Nationwide Analysis

Resource Use and Costs of Indwelling Pleural Catheters versus Pleurodesis for Malignant Pleural Effusions: A Population-based Study

Rationale: Malignant pleural effusions (MPEs) are associated with significant health service use and healthcare costs, but the current evidence is limited. Objectives: To compare 12-month post-procedure: 1) health service utilization; and 2) healthcare costs after indwelling pleural catheter (IPC) insertion with at-home drainage performed by home care nursing services, versus in-hospital chemical pleurodesis. Methods: We performed a retrospective population-based study on a cohort of adults with MPEs who underwent IPC insertion or chemical pleurodesis between January 1, 2015 and December 31, 2019 using provincial health administrative data (Ontario, Canada). Patients were followed from the procedure date until death or until 12 months after the procedure. Inverse probability of treatment weighting was performed to adjust for imbalances in baseline characteristics. Differences in length of stay, readmissions, emergency department visits, home care visits, and healthcare costs were estimated using weighted regression analysis. Results: Of 5,752 included individuals, 4,432 (77%) underwent IPC insertion and 1,320 (23%) had pleurodesis. In the weighted sample, individuals who received an IPC had fewer inpatient days (12.4 d vs. 16 d; standardized mean difference, 0.229) but a higher proportion of subsequent admissions for empyema (2.7% vs. 1.1%; P = 0.0002) than those undergoing pleurodesis. Individuals with IPCs received more hours of nursing home care (41 h vs. 21.1 h; standardized mean difference, 0.671) but overall had lower average healthcare costs ($40,179 vs. $46,640 per patient; standardized mean difference, 0.177) than those receiving pleurodesis. Conclusions: IPCs with home nursing drainage are associated with reduced health resource use compared with pleurodesis in adults with MPEs, even after controlling for important baseline and clinical characteristics. Given that both procedures have similar health outcomes, our findings support the ongoing promotion of IPCs to increase outpatient management of patients with MPEs.

Epidemiologic evaluation of pleurisy diagnosed by surgical pleural biopsy using data from a nationwide administrative database

Background

Pleural biopsies for investigating the causes of pleurisy are performed through modalities including needle biopsies, local anesthetic thoracoscopic procedures, and surgery (video‐assisted thoracoscopic surgery and open thoracotomy). To date, there have been no large‐scale nationwide epidemiological studies regarding pleurisy diagnosed via surgical pleural biopsy. This study examined the epidemiology of pleurisy diagnosed via surgical pleural biopsy in a Japanese nationwide administrative database.

Methods

We evaluated Japanese Diagnosis Procedure Combination data of 24 173 patients who underwent video‐assisted thoracoscopic surgery or open thoracotomy and received a diagnosis of pleurisy between April 2014 and March 2020. In addition to pleurisy diagnoses, the patients' clinical information, including age, sex, smoking status (pack‐years), dyspnea grade, length of in‐hospital stay, and comorbidities, were extracted from the dataset.

Results

This study included data from 1699 patients. The most frequent causes of pleurisy were neoplastic diseases (55.9%; malignant mesothelioma 22.5%, lung cancer 15.7%, lymphoma 2.5%), followed by infectious diseases (24.0%; tuberculosis 16.2%, parapneumonic pleural effusion 3.6%, empyema 3.5%, nontuberculous mycobacteriosis 0.5%), collagen vascular diseases (2.8%; rheumatoid arthritis 1.3%, immunoglobulin G4‐related diseases 0.7%, systemic lupus erythematosus 0.3%), and paragonimiasis (0.1%).

Conclusions

Neoplastic diseases, including malignant mesothelioma and lung cancer, were frequently and accurately diagnosed as pleurisy via surgical pleural biopsy. The next leading cause was infectious diseases such as mycobacterial infections. Physicians should consider performing surgical biopsy in light of the knowledge regarding the etiology of pleurisy when a definitive diagnosis cannot be made via needle pleural biopsy.

Quality Gaps and Comparative Effectiveness of Management Strategies for Recurrent Malignant Pleural Effusions

BACKGROUND

Guidelines for recurrent malignant pleural effusions (MPEs) recommend definitive procedures, such as indwelling pleural catheters (IPCs) or pleurodesis, over repeat thoracentesis. We hypothesized that many patients have multiple thoracenteses rather than definitive procedures and that this results in more procedures and complications.

METHODS

Retrospective cohort study using SEER-Medicare data from 2007 to 2011. Patients 66 to 90 years of age with an MPE were included. The primary outcome was whether patients with rapidly recurring MPE, defined as recurrence within 2 weeks of first thoracentesis, received guideline consistent care. Guideline consistent care was defined as a definitive second pleural procedure.

RESULTS

Thoracentesis for MPE was performed in 23,431 patients. A second pleural procedure because of recurrence was required in 12,967 (55%). Recurrence was rapid in 7,565 (58%) of the 12,967 patients that had a recurrence. Of the 7,565 patients with rapid recurrence, 1,811 (24%) received guideline consistent care. Definitive pleural procedures compared with repeat thoracentesis resulted in fewer subsequent pleural procedures (0.62 vs 1.44 procedures per patient, respectively; P < .0001), fewer pneumothoraxes (< 0.0037 vs 0.009 pneumothoraxes per patient, respectively; P = .001), and fewer ED procedures (0.02 vs 0.04 ED procedures per patient, respectively; P < .001). Repeat thoracentesis and IPCs resulted in fewer inpatient days compared with chest tube or thoracoscopic pleurodesis (0.013 vs 0.013 vs 0.085 vs 0.097 inpatient days per day of life, respectively; P < .001).

CONCLUSIONS

Guideline consistent care using definitive procedures compared with repeat thoracentesis was associated with fewer subsequent procedures and complications; however, pleurodesis resulted in more inpatient days.