Chest
Volume 160, Issue 4, October 2021, Pages 1534-1551
Journal home page for Chest

Thoracic Oncology: Original Research
Epidemiology of Adult Pleural Disease in the United States

This article was presented at the Fifth European Congress for Bronchology and Interventional Pulmonology (ECBIP), Dubrovnik, Croatia, May 11, 2019; and at the American Thoracic Society Annual Meeting, May 17, 2015, Denver, CO.
https://doi.org/10.1016/j.chest.2021.05.026Get rights and content

Background

Comprehensive US epidemiologic data for adult pleural disease are not available.

Research Question

What are the epidemiologic measures related to adult pleural disease in the United States?

Study Design and Methods

Retrospective cohort study using Healthcare Utilization Project databases (2007-2016). Adults (≥ 18 years of age) with malignant pleural mesothelioma, malignant pleural effusion, nonmalignant pleural effusion, empyema, primary and secondary spontaneous pneumothorax, iatrogenic pneumothorax, and pleural TB were studied.

Results

In 2016, ED treat-and-discharge (T&D) visits totaled 42,215, accounting for charges of $286.7 million. In 2016, a total of 361,270 hospitalizations occurred, resulting in national costs of $10.1 billion. A total of 64,174 readmissions contributed $1.16 billion in additional national costs. Nonmalignant pleural effusion constituted 85.5% of ED T&D visits, 63.5% of hospitalizations, and 66.3% of 30-day readmissions. Contemporary sex distribution (male to female ratio) in primary spontaneous pneumothorax (2.1:1) differs from older estimates (6.2:1). Decadal analyses of annual hospitalization rates/100,000 adult population (2007 vs 2016) showed a significant (P < .001) decrease for malignant pleural mesothelioma (1.3 vs 1.09, respectively), malignant pleural effusion (33.4 vs 31.9, respectively), iatrogenic pneumothorax (17.9 vs 13.9, respectively), and pleural TB (0.20 vs 0.09, respectively) and an increase for empyema (8.1 vs 11.1, respectively) and nonmalignant pleural effusion (78.1 vs 100.1, respectively). Empyema hospitalizations have high costs per case ($38,591) and length of stay (13.8 days). The mean proportion of readmissions attributed to a pleural cause varied widely: malignant pleural mesothelioma, 49%; malignant pleural effusion, 45%; nonmalignant pleural effusion, 31%; empyema, 27%; primary spontaneous pneumothorax, 27%; secondary spontaneous pneumothorax, 27%; and iatrogenic pneumothorax, 20%. Secondary spontaneous pneumothorax had the shortest time to readmission in 2016 (10.3 days, 95% CI, 8.8-11.8 days).

Interpretation

Significant epidemiologic trends and changes in various pleural diseases were observed. The analysis identifies multiple opportunities for improvement in management of pleural diseases.

Section snippets

Study Design and Data Sources

Data were obtained from a family of US administrative databases published under the Healthcare Utilization Project13 by the Agency for Healthcare Research and Quality (Table 1).14, 15, 16, 17, 18 The baseline to describe demographic features related to pleural disease hospitalizations, ED treat-and-discharge (T&D) visits, and readmission events was 2016. Trends spanning 10 years were described for hospitalization and ED T&D events. Data from 2010 through 2016 were selected for the readmission

Characteristics of Missing Data

Across all pleural diseases and years, data were missing for the following inpatient admission variables: race (10.2%), total admission costs (4.0%), in-hospital death (0.07%), sex (0.03%), and LOS (0.005%). Similarly, data were missing for the following 30-day readmission variables: total readmission costs (2.4%); in-hospital death during readmission visit (0.04%); and for two ED care variables, charges (26%) and sex (0.02%). Finally, data from the Nationwide Ambulatory Surgery Sample are not

Discussion

These analyses describe the contemporary landscape of pleural disease burden across various care delivery venues in US adults, thereby providing a novel and comprehensive perspective. That pleural disease-related hospitalization costs exceed $10 billion shows that pleural disease expenditures exceed those of more widely studied, yet less common, pulmonary conditions (eg, idiopathic pulmonary fibrosis26 [$1.8 billion] and sarcoidosis27 [$1.3-$8.7 billion]). By providing recent national estimates

Interpretation

In summary, these analyses suggest that trends in pleural disease are dynamic and that the clinical and economic burden associated with pleural disease in the United States exceeds that of some better studied pulmonary conditions. Various opportunities for enhanced management of pleural diseases are suggested.

Take-home Points

Study Question: What are the current epidemiologic data on adult pleural disease in the United States?

Results: Sex distribution in primary spontaneous pneumothorax has

Acknowledgments

Author contributions: S. R. M. contributed substantially to the conception, design, analysis, interpretation of data, and drafting of the work; approved the final version; and is the guarantor for the content of the manuscript, answerable for questions related to integrity, data, and analysis. J. K. S. contributed substantially to the design and drafting of the work, approved the final submitted version, and agrees to be accountable for all aspects of the work. R. L. contributed substantially

References (58)

  • C. Fitzmaurice et al.

    The Global Burden of Cancer 2013

    JAMA Oncol

    (2015)
  • G. Savarese et al.

    Global public health burden of heart failure

    Card Fail Rev

    (2017)
  • The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

    Lancet Gastroenterol Hepatol

    (2020)
  • R.J. Hallifax et al.

    Trends in the incidence and recurrence of inpatient-treated spontaneous pneumothorax, 1968-2016

    JAMA

    (2018)
  • A. Bobbio et al.

    Epidemiology of spontaneous pneumothorax: gender-related differences

    Thorax

    (2015)
  • L.J. Melton et al.

    Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974

    Am Rev Respir Dis

    (1979)
  • S.R. Mummadi et al.

    Outcomes of a clinical pathway for pleural disease management: “pleural pathway.”

    Pulm Med

    (2018)
  • Mummadi SR. Trends in US pleural disease hospitalizations. Paper presented at: 5th European Congress for Bronchology...
  • S.L. Bedolla et al.

    Trends in inpatient resource utilization and outcomes for pleural disease with ambulatory management pathways in the U. S. (1993-2011)

    Am J Respir Care Med

    (2015)
  • Healthcare Cost and Utilization Project. HCUP databases. Agency for Healthcare Research and Quality;...
  • Healthcare Cost and Utilization Project. HCUP Nationwide Emergency Department Sample (NEDS). Agency for Healthcare...
  • Healthcare Cost and Utilization Project. HCUP Nationwide Inpatient Sample (NIS). Agency for Healthcare Research and...
  • Healthcare Cost and Utilization Project. HCUP National Inpatient Sample (NIS). Agency for Healthcare Research and...
  • Healthcare Cost and Utilization Project. HCUP Nationwide Readmission Database (NRD). Agency for Healthcare Research and...
  • HCUP Nationwide Ambulatory Surgical Sample (NASS)

    (2016)
  • M. Buckland et al.

    The relationship between recall and precision

    J Am Soc Inf Sci

    (1994)
  • A. Elixhauser et al.

    Comorbidity measures for use with administrative data

    Med Care

    (1998)
  • Healthcare Cost and Utilization Project. HCUP comorbidity software

    (2007-2016)
  • Healthcare Cost and Utilization Project. HCUP cost-to-charge ratio files (CCR)

    (2007-2016)
  • Cited by (36)

    • Burden of all-cause and organism-specific parapneumonic empyema hospitalization rates prior to the SARS-CoV-2 pandemic in the United States

      2023, Respiratory Medicine
      Citation Excerpt :

      The introduction of pneumococcal conjugate vaccines (PCVs) into the US childhood immunization schedule in 2000 (7-valent PCV) was associated with reductions in parapneumonic empyema among children while existing trends in empyema among adults remained less affected [1]. The introduction of the 13-valent PCV (PCV13) in 2010 was also shown to be associated with further rapid initial reductions in empyema among US children [2–5]. However, whether PCV13 introduction was associated with declines in empyema among adults and whether the early changes observed among children were sustained remain unclear.

    • Pleural mesothelioma

      2022, Medicina Clinica
    View all citing articles on Scopus

    FUNDING/SUPPORT: This study was supported by the Cleveland Clinic's Center for Populations Health Research (CPHR) Q3 2019 award (#CPHR-2019-9).

    View full text