title: Treatment of malignant pleural effusion: a cost-effectiveness analysis.
abstract: BACKGROUND
  Patients with malignant pleural effusion (MPE) have varied expected survival and treatment options. We studied the relative cost-effectiveness of various interventions.
  
  
  METHODS
  Decision analysis was used to compare repeated thoracentesis (RT), tunneled pleural catheter (TPC), bedside pleurodesis (BP), and thoracoscopic pleurodesis (TP). Outcomes and utility data were obtained from institutional data and review of literature. Medicare allowable charges were used to ensure uniformity. Base case analysis was performed for two scenarios: expected survival of 3 months and expected survival of 12 months. The incremental cost-effectiveness ratio (ICER) was estimated as the cost per quality-adjusted life-year gained over the patient's remaining lifetime.
  
  
  RESULTS
  Under base case analysis for 3-month survival, RT was the least expensive treatment ($4,946) and provided the fewest utilities (0.112 quality-adjusted life-years). The cost of therapy for the other options was TPC $6,450, BP $11,224, and TP $18,604. Tunneled pleural catheter dominated both pleurodesis arms, namely, TPC was both less expensive and more effective. The ICER for TPC over RT was $49,978. The ICER was sensitive to complications and ability to achieve pleural sclerosis with TPC. Under base case analysis for 12-month survival, BP was the least expensive treatment ($13,057) and provided 0.59 quality-adjusted life-years. The cost of treatment for the other options was TPC $13,224, TP $19,074, and RT $21,377. Bedside pleurodesis dominated TPC and thoracentesis. Thoracoscopic pleurodesis was more effective than BP but the ICER for TP over BP was greater than $250,000.
  
  
  CONCLUSIONS
  Using decision analysis, TPC is the preferred treatment for patients with malignant pleural effusion and limited survival; BP is the most cost-effective treatment for patients with more prolonged expected survival.
authors.affiliation: Department of Surgery, Washington University at St. Louis, St. Louis, Missouri 63110, USA. puriv@wudosis.wustl.edu
authors.forename: Varun
authors.initials: V
authors.lastname: Puri
authors.forename: Tanya L
authors.initials: TL
authors.lastname: Pyrdeck
authors.forename: Traves D
authors.initials: TD
authors.lastname: Crabtree
authors.forename: Daniel
authors.initials: D
authors.lastname: Kreisel
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Krupnick
authors.forename: Graham A
authors.initials: GA
authors.lastname: Colditz
authors.forename: G Alexander
authors.initials: GA
authors.lastname: Patterson
authors.forename: Bryan F
authors.initials: BF
authors.lastname: Meyers
mesh_terms: D002404:Catheterization; D003362:Cost-Benefit Analysis; D006801:Humans; D016066:Pleural Effusion, Malignant / Q000191:economics* / Q000628:therapy*; D018700:Pleurodesis; D013906:Thoracoscopy