EVALUATION OF TREATMENT MODALITIES FOR THORACIC EMPYEMA - A COST-EFFECTIVENESS ANALYSIS

Background. Empyema thoracis is treated with a multitude of therapeuti c options. Optimal therapy and cost-containment requires selection of the most appropriate initial intervention. Methods. A retrospective re view of treatment modalities was performed on 77 patients diagnosed wi th empyema thoracis from 1990 to 1997 at one institution. Mean age was 59 years (range, 21 to 90 years); 52 were men and 25 were women. Resu lts. Sixty-five percent (50/77) were parapneumonic and 68% (52/77) wer e multiloculated. Treatment modalities were as follows: group 1, antib iotics only (n = 4); group 2, primary intervention: image-directed cat heter (n = 20) or tube thoracostomy (n = 24); and group 3, secondary i ntervention: decortication (n = 17), rib resection or muscle interposi tion (n = 12). Thirty-four percent (9/20 image-directed catheter and 8 /24 tube thoracostomy) had failure of initial intervention. Patients u ndergoing decortication more often had multiloculated empyema thoracis (16 of 17) compared with those undergoing image-directed catheters (8 of 20) or tube thoracotomy (16 of 24). Length of stay was reduced for decortication patients (17 days) compared with those having image-dir ected catheters (21.8 days), failed image-directed catheters (29.7 day s), or tube thoracostomies (19.6 days). Hospital charges per patient b etween decortication and image-directed catheter ($34,770.79 versus $3 7,869.41) were comparable, but charges were significantly decreased in decortication patients as compared with failed image-directed cathete rs ($55,609.32; p < 0.05). Conclusions. Our series revealed that early decortication has charges similar to those of primary intervention (i mage-directed catheter or tube thoracostomy) but is more cost-effectiv e than failed image-directed catheter. We advocate the use of early su rgical intervention as the most optimal and cost-effective initial mod ality for the treatment of empyema thoracis. (Ann Thorac Surg 1998;66: 1121-7) (C) 1998 by The Society of Thoracic Surgeons.