Management of the second episode of spontaneous pneumothorax: a decision analysis

Background Optimal management for patients presenting a second episode of spontaneous pneumothorax remains controversial. The aim of this study was to compare two possible treatment strategies, video-assisted thoracic surgery (VATS) and conservative management, in order to assess which of the two was better adapted for the treatment of the second episode of spontaneous pneumothorax. Methods The authors propose a decision analytic model including a cost-effectiveness study to compare two clinical strategies: VATS (reference strategy) and conservative management (alternative strategy). Data were obtained from a Medline search for English language articles and cost estimates were derived from the financial and public health departments of our hospital. The model was analyzed to determine the baseline strategy leading to the highest expected effectiveness and the lowest expected cost. Results Conservative management offered a slight advantage in expected effectiveness value (99.99 vs 99.93 for VATS). VATS produced the lowest expected cost (€4347 vs €7536 for conservative management). The incremental cost-effectiveness ratio was €57,750. Within the ranges tested, the sensitivity analysis presented consistent results in terms of effectiveness and advocated conservative management as the best strategy. In terms of cost, with the exception of length of stay, the sensitivity analysis was insensitive in estimating the different probabilities, and favored VATS over conservative management. Conclusions In the management of the second episode of spontaneous pneumothorax, VATS offers substantial savings in cost for only a slight decrease in effectiveness, when compared with conservative management.