Management of Primary Spontaneous Pneumothorax in the Emergency Department: A Cost-Effectiveness Analysis

Primary spontaneous pneumothorax (PSP) is a common emergency condition among healthy individuals that presents significant management challenges, particularly in cases of moderate-to-large collapse, which have traditionally required intervention. Recent trials, including a landmark-randomized trial, have demonstrated effectiveness in 4 separate strategies: (1) observation only, (2) needle aspiration, (3) small-bore chest tubes with a 1-way valve, and (4) small-bore chest tubes with continuous suction. We compare the cost-effectiveness of these 4 strategies.

We conducted a cost-effectiveness analysis from a US healthcare system perspective to compare 4 management strategies for moderate-to-large PSP in stable adult emergency department patients. Using published randomized controlled trials and secondary data, we developed a decision-analytic model with a lifetime horizon. Costs (2022 USD), quality-adjusted life-years, and net monetary benefit (NMB) were calculated at a $50,000/quality-adjusted life-years willingness-to-pay threshold and 3% annual discount. We performed 1-way and probabilistic sensitivity analyses to test the robustness of findings.

Base case analysis identified observation only as the most cost-effective strategy, achieving the highest NMB ($43,696). The NMB values for small-bore chest tubes with a 1-way valve, needle aspiration, and small-bore chest tube with continuous suction were $33,520, $29,465, and $12,831, respectively. Sensitivity analyses indicated that factors such as initial success rates for observation and needle aspiration influenced model outcomes, whereas probabilistic simulations confirmed observation only as the dominant strategy.

Observation alone is the most cost-effective initial strategy for stable moderate-to-large PSP, although its feasibility may be limited. Among interventional options, a small-bore chest tube with a 1-way valve offers the best value and enables outpatient management. Further studies in diverse settings are needed to confirm the practicality of observation only care and consider individual patient factors.