Optimal strategy for the first episode of primary spontaneous pneumothorax in young men. A decision analysis.
OBJECTIVE
Primary spontaneous pneumothorax (PSP) is not uncommon in young men and is associated with frequent recurrence. The frequent recurrence after conservative treatment and resultant anxiety for recurrence are sources of disability. We explored which procedure is more appropriate as the initial therapy in terms of quality-adjusted life expectancy (QALE).


METHODS
Decision analysis using a Markov model.


METHODS
Structured literature review for clinical probability. Utility derived from patients and medical staff using time trade-off method.


METHODS
Hypothetical cohort.


METHODS
Twenty-year-old men with a first episode of PSP for which simple aspiration was ineffective.


METHODS
One of the following treatment options: 1) thoracoscopic surgery, 2) pleural drainage followed by thoracoscopic surgery for recurrence, 3) pleural drainage followed by thoracoscopic surgery for the second recurrence, 4) pleurodesis followed by thoracoscopic surgery for recurrence, 5) pleurodesis followed by thoracoscopic surgery for the second recurrence, 6) pleural drainage followed by pleurodesis for the first recurrence and thoracoscopic surgery for the second recurrence.


RESULTS
During the 1-year period after one of the initial treatments, the QALE was 9.49 months for thoracoscopic surgery, 9.47 for pleurodesis, and 7.80-7.99 for pleural drainage. The QALE for thoracoscopic surgery was the longest among the 6 strategies during the period from 5 to 24 months. None of the variables in sensitivity analyses altered the main results except for thoracoscopic surgical death rate. When it exceeds 0.3%, pleurodesis becomes the preferred strategy.


CONCLUSIONS
On the basis of the current best available data and patients' preference, thoracoscopic surgery can be considered the treatment of choice for the first episode of PSP.
Morimoto
Takeshi
T
Department of Clinical Epidemiology, Kyoto University Graduate School of Medicine, Japan.
Fukui
Tsuguya
T
Koyama
Hiroshi
H
Noguchi
Yoshinori
Y
Shimbo
Takuro
T
D000328:Adult; D015331:Cohort Studies; D003661:Decision Support Techniques; D006801:Humans; D008297:Male; D008390:Markov Chains; D018700:Pleurodesis / Q000401:mortality*; D011030:Pneumothorax / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D015203:Reproducibility of Results; D013396:Suction / Q000401:mortality*; D020775:Thoracic Surgery, Video-Assisted / Q000401:mortality*; D016896:Treatment Outcome