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Recurrent Malignant Pleural Effusion Management: Evaluating Quality Gaps, Outcomes, Costs, and Adherence to
Michael J Wright1, Phuong H Nguyen2, Elliot D Backer3
1Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Background:
Guidelines recommend early definitive management (indwelling pleural catheter, pleurodesis, decortication, or combination approach) for patients with symptomatic, rapidly recurrent malignant pleural effusion (MPE). This study evaluates health care utilization among patients who received early definitive management (EDM), defined as definitive management at first episode of rapidly recurrent MPE, compared with patients who do not (no early definitive management [NEDM]).
Research Question:
What percentage of patients with rapidly recurrent symptomatic MPE receive guideline-consistent EDM and are there differences in care outcomes?
Study Design And Methods:
This retrospective cohort study analyzed medical records from Dartmouth-Hitchcock Medical Center (a 500-bed primary teaching hospital) from 2018 to 2022. The cohort included patients with biopsy-proven MPE and rapid recurrence within 14 days of the initial thoracentesis, requiring a second pleural procedure. We compared the outcomes between patients who received EDM and those with NEDM.
Results:
A total of 133 patients met the inclusion criteria: confirmed malignancy on initial thoracentesis and rapid recurrence requiring repeat pleural procedure within 14 days. Of these, 52 patients (39%) received EDM, whereas 81 (61%) underwent repeat thoracentesis or chest tube drainage (NEDM). Compared with patients with NEDM, patients with EDM had fewer total pleural procedures (2.08 vs 3.51; P < .01), a lower rate of MPE-related emergency department visits (events per patient, 0.23 vs 1.31; P < .01), and a lower rate of MPE-related hospitalizations (events per patient, 0.23 vs 0.99; P < .01). A cost analysis of MPE-related hospitalizations revealed substantially lower MPE-related hospitalization costs for patients with EDM compared with patients with NEDM ($9,857 vs $39,497 per patient). No significant differences in survival were observed (P = .80).
Interpretation:
Less than one-half of eligible patients received guideline-consistent EDM for rapidly recurrent MPE. Those not receiving EDM required more health care resources, including pleural procedures, emergency department visits, and hospitalizations. These findings underscore the importance of EDM in reducing health care utilization and improving patient care outcomes.
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