Management of Primary Spontaneous Pneumothorax in the Emergency Department: A Cost-Effectiveness Analysis

Abstract

Objectives: Primary spontaneous pneumothorax (PSP) is a common emergency condition among healthy individuals that presents significant management challenges, particularly in cases of moderate-to-large collapse, which have traditionally required intervention. Recent trials, including a landmark-randomized trial, have demonstrated effectiveness in 4 separate strategies: (1) observation only, (2) needle aspiration, (3) small-bore chest tubes with a 1-way valve, and (4) small-bore chest tubes with continuous suction. We compare the cost-effectiveness of these 4 strategies. Methods: We conducted a cost-effectiveness analysis from a US healthcare system perspective to compare 4 management strategies for moderate-to-large PSP in stable adult emergency department patients. Using published randomized controlled trials and secondary data, we developed a decision-analytic model with a lifetime horizon. Costs (2022 USD), quality-adjusted life-years, and net monetary benefit (NMB) were calculated at a $50,000/quality-adjusted life-years willingness-to-pay threshold and 3% annual discount. We performed 1-way and probabilistic sensitivity analyses to test the robustness of findings. Results: Base case analysis identified observation only as the most cost-effective strategy, achieving the highest NMB ($43,696). The NMB values for small-bore chest tubes with a 1-way valve, needle aspiration, and small-bore chest tube with continuous suction were $33,520, $29,465, and $12,831, respectively. Sensitivity analyses indicated that factors such as initial success rates for observation and needle aspiration influenced model outcomes, whereas probabilistic simulations confirmed observation only as the dominant strategy. Conclusions: Observation alone is the most cost-effective initial strategy for stable moderate-to-large PSP, although its feasibility may be limited. Among interventional options, a small-bore chest tube with a 1-way valve offers the best value and enables outpatient management. Further studies in diverse settings are needed to confirm the practicality of observation only care and consider individual patient factors.