title: Management of Malignant Pleural Effusion: A Cost-Utility Analysis.
abstract: BACKGROUND
  Malignant pleural effusion (MPE) is associated with a significant impact on health-related quality of life. Palliative interventions abound, with varying costs and degrees of invasiveness. We examined the relative cost-utility of 5 therapeutic alternatives for MPE among adults.
  
  
  METHODS
  Original studies investigating the management of MPE were extensively researched, and the most robust and current data particularly those from the TIME2 trial were chosen to estimate event probabilities. Medicare data were used for cost estimation. Utility estimates were adapted from 2 original studies and kept consistent with prior estimations. The decision tree model was based on clinical guidelines and authors' consensus opinion. Primary outcome of interest was the incremental cost-effectiveness ratio for each intervention over a less effective alternative over an analytical horizon of 6 months. Given the paucity of data on rapid pleurodesis protocol, a sensitivity analysis was conducted to address the uncertainty surrounding its efficacy in terms of achieving long-term pleurodesis.
  
  
  RESULTS
  Except for repeated thoracentesis (RT; least effective), all interventions had similar effectiveness. Tunneled pleural catheter was the most cost-effective option with an incremental cost-effectiveness ratio of $45,747 per QALY gained over RT, assuming a willingness-to-pay threshold of $100,000/QALY. Multivariate sensitivity analysis showed that rapid pleurodesis protocol remained cost-ineffective even with an estimated probability of lasting pleurodesis up to 85%.
  
  
  CONCLUSIONS
  Tunneled pleural catheter is the most cost-effective therapeutic alternative to RT. This, together with its relative convenience (requiring neither hospitalization nor thoracoscopic procedural skills), makes it an intervention of choice for MPE.
authors.affiliation: *Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA †Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health ‡Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Majid
authors.initials: M
authors.lastname: Shafiq
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Frick
authors.forename: Hans
authors.initials: H
authors.lastname: Lee
authors.forename: Lonny
authors.initials: L
authors.lastname: Yarmus
authors.forename: David J
authors.initials: DJ
authors.lastname: Feller-Kopman
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D016066:Pleural Effusion, Malignant / Q000000981:diagnostic imaging / Q000191:economics* / Q000628:therapy*; D018700:Pleurodesis / Q000009:adverse effects / Q000191:economics / Q000379:methods / Q000592:standards; D011030:Pneumothorax / Q000209:etiology; D017410:Practice Guidelines as Topic; D011788:Quality of Life; D000069258:Thoracentesis / Q000009:adverse effects / Q000191:economics / Q000379:methods / Q000592:standards; D018084:Ultrasonography, Interventional / Q000009:adverse effects / Q000191:economics / Q000379:methods / Q000592:standards; D014481:United States