Primary Operative Management vs Medical Management of Pediatric Empyema

William T. Basco, Jr., MD, FAAP


July 03, 2008

Primary Operative Management for Pediatric Empyema: Decreases in Hospital Length of Stay and Charges in a National Sample

Li ST, Gates RL
Arch Pediatr Adolesc Med. 2008;162:44-48

This study used nationally representative data from the 2003 Healthcare Cost and Utilization Project -- KID to compare outcomes from patients who had initial primary operative management of empyema compared to medical management as first-line treatment.

Primary operative management included antibiotics and/or chest tube along with either open or thoracoscopic surgical procedure within 48 hours of admission to the hospital. Primary medical management included just antibiotics with or without chest tube. The subjects were all younger than 19 years old.

Empyema patients with the following were excluded: tuberculous empyema; chronic medical conditions such as heart and lung problems (predisposing to empyema); and patients who were transferred from different hospitals. The sample included children who died during the admission. The outcome of interest was length of stay, but the authors also evaluated rates of therapeutic failure and complication rates.

Failure of primary operative management occurred when the subject required chest tube placement after the initial surgical procedure or required a second surgical procedure. Failure of nonoperative management occurred with any surgical procedure or the placement of a second chest tube.

The analyses controlled for the following potential confounding variables: patient age, gender, insurance type, weekday vs weekend admission, hospital characteristics, and region of the country.

There were 2078 patients with empyema in the dataset, but 264 were excluded for having medical conditions that placed children at increased risk for empyema, 502 were excluded for having been transferred between hospitals or other facilities, and another 129 had missing data (113 with missing data on surgical procedure timing).

There were 1173 subjects in the final dataset. Of these, 67.5% had a chest tube and 43.1% had a surgical procedure. However, roughly 44% of these surgical procedures were performed within the first 2 days, leaving 220 patients labeled as having "primary operative management." Primary operative management was more likely to be used if a patient was privately insured, treated at an urban teaching hospital, or treated at a hospital in the Northeast.

After controlling for confounders, subjects who had primary operative management were discharged 4.3 days sooner (95% confidence interval: -2.3 to -6.4 days). They also had hospital charges that were over $21,000 lower. The children with primary operative management were less likely to experience therapeutic failure at 5.5% vs 39.3%. Otherwise, the complication rates were similar.

The authors conclude that primary operative treatment of empyema is associated with shorter hospitalizations and overall decreased cost.

This was a good study because there were many subjects, and, as the authors point out, the 1-year time frame of the dataset allowed researchers to get away from the problem posed by temporal trends (for example, if primary operative management were becoming more common with each passing year). One of the biggest limitations of a study like this is that the unit of care is a hospital, and the general approach of the providers in it, and those factors determine to a large degree whether a patient receives or does not receive primary operative management. It is difficult to fully control for the bias that might be introduced by this clustering, and a clinical trial comparing primary operative to medical management might result very different findings. These data do support the need for such a trial, as these data alone can't say which approach is better.



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