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An Analysis of Physician Practice Patterns

John E. Heffner, MD; John McDonald, MD; Celia Barbieri, MS; Jeffrey Klein, MD

Arch Surg. 1995;130(4):433-438.

Abstract
Objective
To evaluate physician practices in managing patients with parapneumonic effusions and the impact of practice patterns on clinical outcome.

Design
Case series.

Setting
Private, tertiary care medical center.

Patients
Thirty-nine hospitalized patients with complicated parapneumonic effusions and a separate group of 191 patients admitted with community-acquired pneumonia.

Interventions
None.

Main Outcome Measures
Evaluation of physician practice patterns in managing complicated parapneumonic effusion and the impact of delaying thoracentesis (2 days after pleural fluid detection) or pleural drainage (2 days after pleural fluid criteria for drainage fulfilled) on duration of hospitalization, cost of hospitalization, and need for thoracotomy.

Results
Thirty-eight of the 39 patients with complicated parapneumonic effusions underwent thoracentesis that was "delayed" (5.7±3.1 days) in 16 patients. Delays in thoracentesis were associated with longer hospitalizations (P=.02). Laboratory tests ordered on nonpurulent pleural fluid were incomplete for 16 of 38 patients. Chest tube or surgical pleural drainage was delayed (4.2±3.5 days) in 10 of 38 patients who underwent thoracentesis. Delays in initiating drainage were associated with prolonged hospitalization (P=.04). Delaying interventions accounted for a mean cost increment per patient of $8462 for delayed thoracentesis and $9332 for delayed drainage. Of the 191 patients with community-acquired pneumonia, 99 (52%) had pleural effusions but only 15 (15%) underwent thoracentesis.

Conclusions
Physicians commonly delay thoracentesis and chest tube drainage to observe parapneumonic effusions for improvement. This practice pattern is associated with longer and more costly hospitalizations.

(Arch Surg. 1995;130:433-438)

Author Affiliations
From the Departments of Medicine (Drs Heffner and McDonald and Ms Barbieri) and Radiology (Dr Klein), St Joseph's Hospital and Medical Center, Phoenix, Ariz.

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