Cost-Effectiveness Analysis of Fibrinolysis versus Thoracoscopic Decortication for Early Empyema.

BACKGROUND: Surgical decortication is recommended by national guidelines for management of early empyema, but intrapleural fibrinolysis is frequently used as a first-line therapy in clinical practice. This study compared the cost effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema.
METHODS: A decision analysis model was developed. The base clinical case was a 65-year-old male with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease. The likelihood of key outcomes occurring was derived from the literature. Medicare diagnosis-related groups and manufacturers' drug prices were used for cost estimates. Successful treatment was defined as complete or near-complete resolution of empyema on imaging. Effectiveness was defined as health utility one-year post-empyema.
RESULTS: Intrapleural tPA and deoxyribonuclease was more cost-effective than VATS decortication for treating early empyema for the base scenario. Surgical decortication had a slightly lower cost than fibrinolysis ($13,345 vs $13,965), but fibrinolysis had a marginally higher effectiveness at one year (health utility of 0.80 vs. 0.71) resulting in fibrinolysis being the more cost-effective option. Sensitivity analyses found that fibrinolysis as the initial therapy was more cost-effective when the probability of success was greater than 60% or the initial cost was less than $13,000.
CONCLUSIONS: Surgical decortication and intrapleural fibrinolysis have nearly equivalent cost-effectiveness for early empyema in patients that can tolerate both procedures. Surgeons should consider patient-specific factors as well as the cost and effectiveness of both modalities when deciding the initial treatment for early empyema.