Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. e1250-e1257 (doi:10.1542/peds.2007-1886)
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ARTICLE

Cost-effectiveness of Competing Strategies for the Treatment of Pediatric Empyema

Eyal Cohen, MD, MSca,b, Michael Weinstein, MDa,b and David N. Fisman, MD, MPHb,c

a Department of Pediatrics
b Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
c Ontario Central Public Health Laboratory, Toronto, Ontario, Canada

BACKGROUND. The optimal management of pediatric empyema is controversial. The purpose of this decision analysis was to assess the relative merits in terms of costs and clinical outcomes associated with competing treatment strategies.

METHODS. A cost-effectiveness analysis was conducted using a Bayesian tree approach. Probability and outcome estimates were derived from the published literature, with preference given to data derived from randomized trials. Costing was based on published estimates from Great Ormond Street Hospital (London, United Kingdom), supplemented by American and Canadian data. Five strategies were evaluated: (1) nonoperative; (2) chest tube insertion; (3) repeated thoracentesis; (4) chest tube insertion with instillation of fibrinolytics; or (5) video-assisted thorascopic surgery. The model was used to project overall costs, survival in life-years, and incremental cost-effectiveness ratios for competing strategies.

RESULTS. In the base-case analysis, chest tube with instillation of fibrinolytics was the least expensive therapy, at $7787 per episode. This strategy was projected to cost less but provide equivalent health benefit when compared with all of the competing strategies except repeated thoracentesis, which had an incremental cost-effectiveness ratio of approximately $6 422 699 per life-year gained relative to chest tube with instillation of fibrinolytics. In univariable and multivariable sensitivity analyses, thorascopic surgery was preferred only when the length of stay associated with chest tube with instillation of fibrinolytics exceeded 10.3 days or when the probability of dying as a result of this strategy exceeded 0.2%, assuming a threshold willingness to pay of $75 000 per life-year gained. Chest tube with instillation of fibrinolytics was preferred in >58% of Monte Carlo simulations.

CONCLUSIONS. On the basis of the best available data, chest tube with instillation of fibrinolytics is the most cost-effective strategy for treating pediatric empyema. Video-assisted thorascopic surgery would be preferred to chest tube with instillation of fibrinolytics if the differential in length of stay between these 2 strategies were proven to be greater than that suggested by currently available data.

Key Words: empyema • video-assisted thoracic surgery • chest tubes • decision analysis • cost-effectiveness

Abbreviations: VATS—video-assisted thorascopic surgery • CT—chest tube • CTWF—chest tube with instillation of fibrinolytics • ICER—incremental cost-effectiveness ratio • tPA—tissue plasminogen activator • RCT—randomized, controlled trial • WTP—willingness to pay

Accepted Oct 19, 2007.


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