Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score
Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections.
In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0–2), medium risk (3–4), and high-risk (5–7) groups.
Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively).
Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.
KeywordsComplicated parapneumonic effusions Empyema Intrapleural fibrinolytic therapy Cost of care Tube thoracostomy Video assisted thoracoscopic surgery Mortality
We would like to thank Scott E. Kopec, MD for his support in this project.
ST, AFS, and DBK designed the study and contributed to analysis and draft manuscripts. RNS, ST, JH, and SA were involved data extraction. ST performed the analysis and all authors were involved in the write up and final corrections of the manuscript.
Compliance with Ethical Standards
Conflict of interest
The authors have no conflicts of interest with regard to the content of this manuscript.
- 10.Strange C (2017) Parapneumonic effusion and empyema in adults—UpToDate. https://www.uptodate.com/contents/parapneumonic-effusion-and-empyema-in-adults?search=empyema&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H12. Accessed 6 Mar 2018
- 18.Plutinsky J, Taligova Z, Sabova R, Plutinsky M (2016) Why Fibrinolysis Is Recommended in our Local Standards of Empyema Management. In: B36. PLEURAL DISEASE: CLINICAL STUDIES. American Thoracic Society, Washington pp A3244–A3244Google Scholar
- 25.Ramanjaneya R, Zuhaib BMM M (2016) Medical Thoracoscopy in the Treatment of Complicated Parapneumonic Effusions. In: B36. PLEURAL DISEASE: CLINICAL STUDIES. American Thoracic Society, pp A3227–A3227Google Scholar
- 27.Lee H, Park S, Shin H, Kim K (2015) Assessment of the usefulness of video-assisted thoracoscopic surgery in patients with non-tuberculous thoracic empyema. J Thorac Dis 7:394–399. https://doi.org/10.3978/j.issn.2072-1439.2014.12.42 PubMedPubMedCentralGoogle Scholar
- 30.Barad SJ, Howell SM, Tom J (2018) Is a shortened length of stay and increased rate of discharge to home associated with a low readmission rate and cost-effectiveness after primary total knee arthroplasty? Arthroplasty Today 4:107–112. https://doi.org/10.1016/j.artd.2015.08.003 CrossRefPubMedGoogle Scholar
- 31.Tian W (2016) An All-Payer View of Hospital Discharge to Postacute Care, 2013 #205. Agency for Healthcare Research and QualityGoogle Scholar
- 35.Park C-K, Oh H-J, Choi H-Y et al (2016) Microbiological characteristics and predictive factors for mortality in pleural infection: a single-center cohort study in Korea. PLoS ONE 11:. https://doi.org/10.1371/journal.pone.0161280