Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score

PURPOSE

Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections.

METHODS

In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups.

RESULTS

Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively).

CONCLUSION

Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

Healthcare and economic burden of adverse events among patients with chronic myelogenous leukemia treated with BCR-ABL1 tyrosine kinase inhibitors

OBJECTIVES

BCR-ABL1 tyrosine kinase inhibitors (TKIs) are established treatments for chronic myelogenous leukemia (CML); however, they are associated with infrequent, but clinically serious adverse events (AEs). The objective of this analysis was to assess healthcare resource utilization and costs associated with AEs, previously identified using the FDA Adverse Event Reporting System (FAERS) in another study, among TKI-treated patients.

METHODS

Adult patients with ≥1 inpatient or ≥2 outpatient ICD-9-CM diagnosis codes for CML and ≥1 claim for a TKI treatment between January 1, 2006 and September 30, 2012 were identified from the Commercial and Medicare MarketScan databases. The first claim for a TKI was designated as the index event. Patients were required to have no TKI treatment during a 12-month baseline period. Healthcare resource utilization and costs associated with select AEs having the strongest association with TKI treatment (femoral arterial stenosis [FAS], peripheral arterial occlusive disease [PAOD], intermittent claudication, coronary artery stenosis [CAS], pericardial effusion, pleural effusion, malignant pleural effusion, conjunctival hemorrhage) were evaluated during a 12-month follow-up period.

RESULTS

The study sample included 2,005 CML patients receiving TKI therapy (mean age = 56 years; 56% male). Among all evaluated AEs, the highest mean inpatient healthcare costs were observed for FAS ($16,800 per patient) and PAOD ($14,263 per patient), which had total mean medical costs (inpatient + outpatient) of $17,015 and $15,154 per patient, respectively. Mean outpatient healthcare costs were highest for CAS ($1,861 per patient), followed by intermittent claudication ($947 per patient), PAOD ($891 per patient), and pleural effusion ($890 per patient). Total mean medical costs for fluid retention-related AEs, including pericardial effusion and pleural effusion, were $2,797 and $1,908 per patient, respectively.

CONCLUSIONS

The healthcare costs of AEs identified in the FAERS as having the strongest association with TKI treatment are substantial. Vascular stenosis-related AEs, including FAS and PAOD, have the highest cost burden.

Chest radiograph after fluoroscopic guided line placement: No longer necessary

PURPOSE

Historically, a chest radiograph was obtained after central line placement in the operating room. Recent retrospective studies have questioned the need for this radiograph. The prevailing current practice at our center is to order chest radiograph only for symptomatic patients. This study examines the outcomes of selective chest radiography after fluoroscopic guided central line placement.

METHODS

After obtaining institutional review board approval, a single institution retrospective chart review of patients undergoing central venous catheter placement by the pediatric surgery or interventional radiology service between January 2010 and July 2014 was performed. Outcome measures included CXR within 24h of catheter placement, reason for chest radiograph, complication, and complication requiring intervention.

RESULTS

In the study population 622 catheters were placed under fluoroscopy. A chest radiograph was performed in 118 (19%) patients within 24h of the line placement with 25 (4%) of these patients being symptomatic in the recovery room. One patient required chest tube for shortness of breath and pleural effusion. Four symptomatic patients (0.6%) were found to have a pneumothorax, none of which required chest tube placement. There were no re-operations because of mal-position of the catheter. In the 504 patients with no postoperative chest x-ray, there were no adverse outcomes. At our institution the current average charge of a chest radiograph is $283, thus we produced savings of $142,632 for the study period without adverse events.

CONCLUSION

After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient.

The economic burden of pleural effusions in patients with chronic myeloid leukemia treated with tyrosine kinase inhibitors

OBJECTIVE

Tyrosine kinase inhibitors (TKI), the standard of care for patients with chronic myeloid leukemia (CML) patients, may in some cases lead to the development of pleural effusion (PE). The purpose of this study is to compare healthcare resource utilization and costs associated with PE among CML patients treated with a TKI therapy.

METHODS

Two large retrospective claims databases (1999-2009) were combined to identify adult CML patients who received ≥1 TKI prescription before the index date, which was defined as 30 days before the first PE diagnosis for patients with PE and a randomly selected date for PE-free patients. Patients were followed for 6 months after the index date. PE and PE-free patients were matched on a 1:1 ratio. PE-related resource utilization and costs (measured in 2009 US dollars) were estimated for PE patients. All-cause and CML-related resource utilization and costs were compared between PE and PE-free patients. Multivariate regression models were used to control for confounding factors.

RESULTS

The study included 186 matched pairs. PE-free and PE patients were on average 65.4 and 63.6 years old and 39.8% and 48.9% were female, respectively. PE patients had a significantly higher number of inpatient (IP) days, IP admissions, outpatient (OP) visits and emergency room (ER) visits than PE-free patients (all p < 0.01). All-cause medical services costs were $88,526 and $30,434 for PE and PE-free patients, respectively. After adjusting for confounding factors, the PE-related total medical costs were $47,288 (p < 0.01), which was mostly accounted for by higher IP (difference: $34,123, p < 0.01) and OP (difference: $9563, p < 0.05) costs. PE patients also incurred higher CML-related medical costs compared to PE-free patients (difference: $39,599; p < 0.01).

CONCLUSION

PE presents a substantial economic burden for CML patients treated with TKI.

Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures

PURPOSE.: We performed an analysis of hospitalizations involving thoracentesis procedures to determine whether the use of ultrasonographic (US) guidance is associated with differences in complications or hospital costs as compared with not using US guidance. METHODS.: We used the Premier hospital database to identify patients with ICD-9 coded thoracentesis in 2008. Use of US guidance was identified using CPT-4 codes. We performed univariate and multivariable analyses of cost data and adjusted for patient demographics, hospital characteristics, patient morbidity severity, and mortality. Logistic regression models were developed for pneumothorax and hemorrhage adverse events, controlling for patient demographics, morbidity severity, mortality, and hospital size. RESULTS.: Of 19,339 thoracentesis procedures, 46% were performed with US guidance. Mean total hospitalization costs were $11,786 (±$10,535) and $12,408 (±$13,157) for patients with and without US guidance, respectively (p < 0.001). Unadjusted risk of pneumothorax or hemorrhage was lower with US guidance (p = 0.019 and 0.078, respectively). Logistic regression analyses demonstrate that US is associated with a 16.3% reduction likelihood of pneumothorax (adjusted odds ratio 0.837, 95% CI: 0.73-0.96; p= 0.014), and 38.7% reduction in likelihood of hemorrhage (adjusted odds ratio 0.613, 95% CI: 0.36-1.04; p = 0.071). CONCLUSIONS.: US-guided thoracentesis is associated with lower total hospital stay costs and lower incidence of pneumothorax and hemorrhage. © 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011.

Isolated pleural fluid lactic dehydrogenase level: a cost effective way of characterizing pleural effusions

BACKGROUND

Characterization of pleural effusion into an exudate or transudate is usually the first step in diagnostic evaluation. Light's criteria have been universally accepted as gold standard in this regard. We wanted to see the utility of isolated pleural fluid lactic dehydrogenase level (representing one of Light's classical criteria) in characterizing pleural effusion in our setting. We also wanted to compare the accuracy of commonly used conventional criteria with Light's criteria of isolated pleural fluid lactic dehydrogenase.

METHODS

Patients who underwent diagnostic thoracentesis for one-year period were studied. Characterization of pleural effusions using biochemical criteria including pleural fluid protein, lactic dehydrogenase level (LDH), red blood cell (RBC) count and white blood cell (WBC) count were identified and compared with predetermined clinical criteria (gold standard). For each biochemical criteria sensitivity, specificity, positive predictive value and negative predictive value were calculated.

RESULTS

Sixty-two patients underwent diagnostic thoracentesis. Sixteen were excluded, as they did not fulfill predetermined clinical criteria. Eight patients had transudative effusion vs. 38 exudates. LDH was found to be the most sensitive (97.2%) while WBC > 1000/mm3 was the most specific (100%) of all the criteria looked at. The overall accuracy was highest for Light's criteria of isolated LDH > 200 IU/litre (95.6%) followed by pleural fluid protein, WBC count and RBC count.

CONCLUSION

We conclude that isolated pleural fluid LDH, as a representative of classical Light's criteria, is the most accurate criteria for characterizing pleural effusions. Due to its low accuracy isolated pleural fluid protein should not be ordered routinely. This approach may result into potential cost savings in our economically restraint society.

Pleural space disease in pediatric patients: a retrospective analysis

Pleural space disease, pleural effusions, and parapneumonic empyema present a therapeutic dilemma regarding the most appropriate medical and surgical management (i.e., performing a thoracentesis on admission versus delayed, placing a pigtail catheter versus a regular chest tube, and performing early versus late thoracoscopy). Other questions remain about early surgical intervention to decrease morbidity, shorten hospital stay, and produce cost-effective results. To define a clinical approach for a prospective study, the charts of all patients who were discharged with ICD-9 codes 511.8, 511.9, and 510.9, between June 5, 1991, and May 7, 1995, were reviewed. Thirty-one patients were identified. A database was developed and the results were analyzed. This paper presents a clinical pathway suggested by this retrospective study with cost analysis.

Routine measurement of pleural fluid amylase is not indicated

BACKGROUND

The routine measurement of pleural fluid amylase is frequently recommended, but the cost-effectiveness of this procedure is unknown.

METHODS

To assess the utility of routine measurement of pleural fluid amylase in evaluating pleural effusions, we measured amylase, glucose, lactate dehydrogenase, and protein levels and blood cell counts in 379 patients undergoing thoracentesis during a 22-month period from 1997 to 1999. Of these, 199 had effusions after cardiac surgery; 61, malignant; 48, transudative; 28, parapneumonic; 2, chylous; 2, rheumatoid; 1, tuberculous; and 1, from chronic pleuritis. There were 37 exudates of unknown origin.

RESULTS

Measurement of pleural fluid amylase levels did not assist in determining the origin of the effusion in any of the patients. Amylase levels greater than 100 U/L (normal serum level in our laboratory is 30-110 U/L) were found in 5 (1.3%) of 379 patients: 1 patient with congestive heart failure (amylase, 173 U/L), 2 with post-cardiac surgery effusions (144 U/L and 130 U/L), 1 with pneumonia (109 U/L), and 1 with lung cancer (105 U/L).

CONCLUSIONS

The routine measurement of pleural fluid amylase levels is neither clinically indicated nor cost-effective. We suggest that pleural fluid serum amylase levels be measured only if there is a pretest suspicion of acute pancreatitis, chronic pancreatic disease, or esophageal rupture.

Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double-blind study

Intrapleural administration of fibrinolytics has been shown in small numbers of patients with complicated parapneumonic effusions (CPE) and pleural empyema to be effective and relatively safe. Although streptokinase (SK) is recommended as the fibrinolytic of choice, there are no comparative studies among fibrinolytics. We therefore compared the efficacy, safety, and the cost of treatment two of the most used thrombolytics, SK and urokinase (UK). Fifty consecutive patients with CPE or empyema were randomly allocated to receive either SK (25 patients) or UK, in a double-blind fashion. All patients had inadequate drainage through chest tube (< 70 ml/24 h). Both drugs were diluted in 100 ml normal saline and were infused intrapleurally through the chest tube in a daily dose of 250,000 IU of SK or 100,000 IU of UK. The chest tube was clamped for 3 h after instillation. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasound, and/or computed tomography. Clinical and radiologic improvement was noted in all but two patients in each group, who required surgical intervention. The mean volume drained during the first 24 h after instillation was significantly increased; 380 +/- 99 ml for the SK group (p < 0.001) and 420.8 +/- 110 ml for the UK group (p < 0.001). The total volume (mean +/- SD) of fluid drained after treatment was 1,596 +/- 68 ml for the SK group, and 1,510 +/- 55 ml for the UK group (p > 0.05). The SK instillations (mean +/- SD) were 6 +/- 2.16 (range, 3 to 10) and those of UK 5.92 +/- 2.05 (range, 3 to 8). High fever as adverse reaction to SK was observed in two patients. The total cost of the drug in the UK group was two times higher than that of SK ($180 +/- 47 for SK and $320 +/- 123 for UK). The mean total hospital stay after beginning fibrinolytic therapy was 11.28 +/- 2.44 d (range, 7 to 15) for the SK group and 10.48 +/- 2.53 d (range, 6 to 18) for the UK group (p = 0.32). We conclude that intrapleural SK or UK is an effective adjunct in the management of parapneumonic effusions and may reduce the need for surgery. UK could be the thrombolytic of choice given the potentially dangerous allergic reactions to SK and relatively little higher cost of UK.

[Percutaneous transthoracic drainage in pleural collections--the pros and cons from the surgical viewpoint]

An attempt is made at specifying the indications for inserting percutaneous transthoracic drain after Seldinger's method. The clinical case material analyzed for the purpose covers 761 patients over a three-year period (1993 through 1995), with 329 of them drained for pneumothorax, 266--hemothorax, and 66--hemopneumothorax. In 54 cases (7.1 percent) switching to surgical draining is necessitated, in 41 (5.39 percent) correction of the drain is done because of inefficiency, and in 96 (12.61 percent)--patency checking and its restoration on the serioscope table. A classification of pathological pleural collections is suggested which proves helpful in estimating whether or not a tube thoracic or percutaneous drain should be employed. The surgeon is cautioned that his assessment should be by no means influenced by the easier procedure under the excuse that it is the method of choice for the patient. Last but not least, one should give due consideration to the financial aspects: percutaneous drainage of the pleural cavity costs about 80 DM, whereas a cigarette thoracic drain costs about 100 leva at the time of analyzing the material.