Management of the second episode of spontaneous pneumothorax: a decision analysis.
BACKGROUND
Optimal management for patients presenting a second episode of spontaneous pneumothorax remains controversial. The aim of this study was to compare two possible treatment strategies, video-assisted thoracic surgery (VATS) and conservative management, in order to assess which of the two was better adapted for the treatment of the second episode of spontaneous pneumothorax.


METHODS
The authors propose a decision analytic model including a cost-effectiveness study to compare two clinical strategies: VATS (reference strategy) and conservative management (alternative strategy). Data were obtained from a Medline search for English language articles and cost estimates were derived from the financial and public health departments of our hospital. The model was analyzed to determine the baseline strategy leading to the highest expected effectiveness and the lowest expected cost.


RESULTS
Conservative management offered a slight advantage in expected effectiveness value (99.99 vs 99.93 for VATS). VATS produced the lowest expected cost (4347 vs 7536 for conservative management). The incremental cost-effectiveness ratio was 57,750. Within the ranges tested, the sensitivity analysis presented consistent results in terms of effectiveness and advocated conservative management as the best strategy. In terms of cost, with the exception of length of stay, the sensitivity analysis was insensitive in estimating the different probabilities, and favored VATS over conservative management.


CONCLUSIONS
In the management of the second episode of spontaneous pneumothorax, VATS offers substantial savings in cost for only a slight decrease in effectiveness, when compared with conservative management.
Falcoz
Pierre Emmanuel
PE
Department of Thoracic and Cardiovascular Surgery, Jean-Minjoz Hospital, Besançon, France. pierre-emmanuel.falcoz@wanadoo.fr
Binquet
Christine
C
Clement
François
F
Kaili
Djamel
D
Quantin
Catherine
C
Chocron
Sidney
S
Etievent
Joseph Philippe
JP
D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D006801:Humans; D007902:Length of Stay; D011030:Pneumothorax / Q000191:economics / Q000601:surgery / Q000628:therapy*; D012008:Recurrence; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects / Q000191:economics