Indwelling Pleural Catheter Drainage Strategy for Malignant Effusion: A Cost-Effectiveness Analysis

Abstract

Rationale: The likelihood of achieving pleurodesis following indwelling pleural catheter (IPC) placement for malignant pleural effusion (MPE) varies with the specific drainage strategy employed: Symptom-guided drainage, daily drainage, or talc instillation through the IPC (IPC + talc). The relative cost-effectiveness of one strategy over the other is unknown. Objectives: We performed a decision tree model-based analysis in order to ascertain the cost-effectiveness of each IPC drainage strategy from a healthcare system perspective. Methods: We developed a decision tree model using theoretical event probability data derived from the ASAP, AMPLE-2, and IPC-Plus randomized clinical trials and used 2019 Medicare reimbursement data for cost estimation. The primary outcome was incremental cost-effectiveness ratio (ICER) over an analytical horizon of six months with a willingness-to-pay threshold of $100,000/QALY (quality-adjusted life-year). Monte Carlo probabilistic sensitivity analysis and one-way sensitivity analyses were conducted to measure the uncertainty surrounding base case estimates. Results: IPC + talc was a cost-effective alternative to symptom-guided drainage with an ICER of $59,729/QALY. Monte Carlo probabilistic sensitivity analysis revealed that this strategy was favored in 54% of simulations. However, symptom-guided drainage was cost-effective for pleurodesis rates over 20% and for life expectancy under four months. Daily drainage was not cost-effective in any scenario, including for patients with non-expandable lung in whom it had an ICER of $2,474,612/QALY over symptom-guided drainage. Conclusions: For patients with MPE and an expandable lung, IPC + talc may be cost-effective relative to symptom-guided drainage although considerable uncertainty exists around this estimation. Daily IPC drainage is not a cost-effective strategy under any circumstance.