Quality Gaps and Comparative Effectiveness of Management Strategies for Recurrent Malignant Pleural Effusions

Abstract

Background: Guidelines for recurrent malignant pleural effusions (MPEs) recommend definitive procedures, such as indwelling pleural catheters (IPCs) or pleurodesis, over repeat thoracentesis. We hypothesized that many patients have multiple thoracenteses rather than definitive procedures and that this results in more procedures and complications.

Methods: Retrospective cohort study using SEER-Medicare data from 2007 to 2011. Patients 66 to 90 years of age with an MPE were included. The primary outcome was whether patients with rapidly recurring MPE, defined as recurrence within 2 weeks of first thoracentesis, received guideline consistent care. Guideline consistent care was defined as a definitive second pleural procedure.

Results: Thoracentesis for MPE was performed in 23,431 patients. A second pleural procedure because of recurrence was required in 12,967 (55%). Recurrence was rapid in 7,565 (58%) of the 12,967 patients that had a recurrence. Of the 7,565 patients with rapid recurrence, 1,811 (24%) received guideline consistent care. Definitive pleural procedures compared with repeat thoracentesis resulted in fewer subsequent pleural procedures (0.62 vs 1.44 procedures per patient, respectively; P < .0001), fewer pneumothoraxes (< 0.0037 vs 0.009 pneumothoraxes per patient, respectively; P = .001), and fewer ED procedures (0.02 vs 0.04 ED procedures per patient, respectively; P < .001). Repeat thoracentesis and IPCs resulted in fewer inpatient days compared with chest tube or thoracoscopic pleurodesis (0.013 vs 0.013 vs 0.085 vs 0.097 inpatient days per day of life, respectively; P < .001).

Conclusions: Guideline consistent care using definitive procedures compared with repeat thoracentesis was associated with fewer subsequent procedures and complications; however, pleurodesis resulted in more inpatient days.

Keywords: indwelling pleural catheter; malignant pleural effusion; pleural effusion; pleurodesis; thoracentesis; thoracoscopy.

Figure 1

Study cohort selection results: SEER Cancer registry 2007-2011. HMO = Health Maintenance Organization; MPE = malignant pleural effusion; SEER = Surveillance, Epidemiology, and End Results.

Figure 2

A, Histogram showing the number of thoracenteses patients received. B, Histogram showing the total number of pleural procedures (thoracenteses, chest tubes, indwelling pleural catheters, and thoracoscopic procedures).

Figure 3

Competing risk model: cumulative incidence of recurrent pleural effusion requiring a procedure vs death (n = 23,431).

Figure 4

Cumulative incidence of second pleural procedures after a first thoracentesis by cancer type (n = 23,431).

Figure 5

Survival time after a second pleural procedure comparing those that had thoracentesis (blue line) with a definitive pleural procedure as their second pleural procedure (n = 12,967). Note that patients with thoracentesis had slightly longer survival times (P = .04), but the absolute magnitude of the difference is small.

Figure 6

Competing risk of pleural fluid recurrence vs death after second pleural procedure in patients that had their second recurrence within 14 days of their first thoracentesis (n = 7,565). Time zero is the time of the second pleural procedure.

Figure 7

Time to death after a second pleural procedure among patients that had their second pleural procedure within 14 days of their first pleural procedure (n = 7,565). Consistent (red line) = guideline consistent, meaning second pleural procedure was a definitive pleural procedure such as an indwelling pleural catheter, a thoracoscopic pleurodesis, or a chest tube pleurodesis; Inconsistent (blue line) = guideline inconsistent, meaning the second pleural procedure was a thoracentesis.