Malignant Pleural Effusions: Management Options

David J. McCracken, MRCP; Jose M. Porcel, MD; Najib M. Rahman, DPhil


Semin Respir Crit Care Med. 2018;39(6):704-712. 

In This Article

Health Care Burden and Cost Considerations

It has been estimated that per-patient costs associated with pleurodesis and the accompanying inpatient stay are approximately £1320. This results in an approximate cost of £33 million per year in the United Kingdom alone based on an estimate of the number of procedures performed.[23]

One of the significant benefits of IPCs is the initial reduction in time spent in hospital at the time of the procedure. The TIME2 trial confirmed this finding which has advantageous consequences for patients with limited life expectancy, but also may result in advantages for hospital services under pressure by reducing bed occupancy. The TIME2 trial also found that IPCs reduced the number of subsequent pleural procedures required. These findings led to the hypothesis that IPCs may offer cost advantages over traditional pleurodesis.[8]

Thomas et al published the AMPLE study in 2017 as a follow on study from TIME2. This was a randomized controlled trial designed to investigate the impact of IPC versus pleurodesis in MPE, specifically focusing on inpatient days with the primary end point set as the total number of days spent as an inpatient up to 12 months or death. This end point was chosen as an appropriate patient-centered outcome given that reducing inpatient stays in patients with limited prognosis is a valuable objective. Inpatient bed days may also be used to consider the financial impact and organizational or structural implications within the health care system. Even so, the trial was only designed to record those whose inpatient stay crossed midnight and consequently did not take into account patients undergoing day procedures and, therefore, may have underestimated the amount of time spent in hospital by those with known poor median survival.

This study demonstrated that there was a statistically significant reduction in the number of inpatient days in patients managed with an IPC when compared with those receiving standard traditional care of a drain and talc pleurodesis. During trial development, an arbitrary clinically significant difference of 5 days was selected. The median difference of 2 days between the two groups failed to meet this cut off.

This study, therefore, demonstrated that there was a considerable requirement for inpatient management in MPE in both the IPC and pleurodesis groups. Combined figures showed median stays of 10 days and a mean of 14.5. IPC patients had a median of 10 inpatient days and a mean of 12.7 when compared with 12 and 16.3 for the talc pleurodesis group. There was also no statistically significant difference between the numbers of inpatient days in each group once the admission for initial management was excluded. Despite statistically significant reductions in inpatient bed days in the IPC group, these data question the perception of IPCs as providing a true ambulatory management option given the high number of inpatient bed days in both groups and the lack of clinical significance demonstrated. Results may also be confounded further by not accounting for day case admissions as days spent in hospital.[9]

The authors suggest that health economic analysis was not carried out due to a worldwide variance in equipment, procedural, and inpatient costs. Still, it has been possible to perform cost analysis on the comprehensive TIME2 dataset. Overall, this showed no significant difference in cost between the IPC and talc pleurodesis groups, although this was performed prior to the publication of ASAP or IPC-PLUS. A higher initial cost was incurred in the pleurodesis group due to a longer initial inpatient hospital stay, but regular IPC drainage led to significantly higher ongoing costs. Subsequent further analysis suggested that IPCs were a less costly alternative in patients with limited survival. IPC cost effectiveness is therefore influenced by patient longevity and autopleurodesis rates which are now known to be modifiable via increased frequency of drainage or outpatient talc instillation. It was suggested that in a patient population with a median survival of 6 months, both treatment options are similarly cost effective. Within a health economic context, talc pleurodesis would appear to be superior if median patient survival is extended to 12 months.[29]