Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pa USA.
Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, Pa USA.
Injury. 2022 Sep;53(9):2930-2938. doi: 10.1016/j.injury.2022.07.021. Epub 2022 Jul 16.
Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies.
A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy.
In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900.
Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.
早期视频辅助胸腔镜手术（VATS）是创伤患者血胸残留的推荐治疗方法。避免手术的替代方案，如溶栓治疗，仍然存在争议。本决策分析的目的是评估治疗策略相关的预期成本。
决策树分析估计了三种初始治疗策略的预期成本：1）VATS，2）胸腔内组织纤溶酶原激活剂（tPA）溶栓治疗，3）胸腔内非 tPA 溶栓治疗。概率参数是根据已发表的文献估计的。成本基于国家住院患者样本数据和已发表的估计。我们的模型比较了每种策略的总体预期住院费用。进行了敏感性分析，以探讨参数不确定性对最佳策略的影响。
在基本情况分析中，与 VATS（38588 美元）相比，使用 tPA 作为初始方法的总成本（37007 美元）最低。无论 VATS 后并发症的概率如何，TPA 仍然是最佳的初始方法。如果 TPA 成功率>83%，而 VATS 的失败率无论如何，TPA 都是初始治疗的最佳方法。如果 VATS 的入院总成本<33900 美元，则 VATS 是最佳的初始策略。
溶栓治疗的治疗费用较低并不意味着创伤住院的总费用显著降低。然而，鉴于 TPA 溶栓治疗避免手术室的可能性很高，并且会增加成本，因此对于创伤性血胸残留，TPA 溶栓治疗可能是首选的初始治疗方法，以降低入院总成本。未来的研究应确定从竞争干预措施中恢复后的生活质量差异。
