CHF indicates congestive heart failure; CTD, connective tissue disease; PPPE, parapneumonic pleural effusion.
eAppendix. Supplementary Methods
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Tian P, Qiu R, Wang M, et al. Prevalence, Causes, and Health Care Burden of Pleural Effusions Among Hospitalized Adults in China. JAMA Netw Open. 2021;4(8):e2120306. doi:10.1001/jamanetworkopen.2021.20306
More than 50 causes of pleural effusion (PE) are recognized.1 An estimated 1.5 million patients in the US experience PE each year, with most cases caused by congestive heart failure, pneumonia, and cancer.2,3 In 2012, 126 800 people were hospitalized for PE at a cost of more than $5 billion in the US.3 However, studies on the epidemiology of PE in the Chinese population are scant. We investigated the prevalence, causes, and health care burden of PE in China.
We conducted a multicenter, cross-sectional study including a nationally representative sample of patients at 56 general hospitals from 50 municipalities in mainland China. All tertiary hospitals in each region of China were sampled. The ratio of included hospitals in each region’s capital and noncapital cities was 1:1.
Discharge records of adults who had received a diagnosis of PE and were admitted to the inpatient departments between January 1 and December 31, 2018, were reviewed. Patients with PE confirmed by ultrasonography or computed tomography (CT) were included. A panel of experts confirmed the diagnosis of PE and determined its etiology according to international guidelines (see eAppendix in the Supplement). Race/ethnicity data were not collected. The Ethics Committee of West China Hospital, Sichuan University reviewed and approved this study and provided a waiver of informed consent because of the retrospective nature of this study. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
The χ2 test was used to compare the differences in causes of PE among patients with different smoking statuses. Data were analyzed with SPSS version 21.0 (IBM Corp) from July to September 2020. Statistical significance was defined as 2-sided P < .05.
In total, 24 711 eligible patients were included. Among them, 15 540 (62.9%) were male patients; the mean (SD) age was 61.6 (16.9) years. The estimated prevalence of PE in our sample was 4684 per 1 million Chinese adults (95% CI, 4675-4692 per 1 million Chinese adults). The 3 most common causes were parapneumonic pleural effusion and empyema (6210 patients [25.1%]), malignant neoplasm (5849 patients [23.7%]), and tuberculosis (3035 patients [12.3%]). Tuberculosis was the most common cause in patients aged 18 to 39 years (1063 patients [4.3%]); malignant neoplasm was the most common cause in patients aged 60 to 79 years (3218 patients [13.0%]); and parapneumonic pleural effusion and empyema was the most common cause in patients aged 40 to 59 years (1756 patients [7.1%]) and those aged 80 years and older (1354 patients [5.5%]) (Table). Smokers were more likely than nonsmokers to have malignant PE (33.1% vs 28.3%; P < .001; χ21 = 45.3) and tuberculous PE (15.7% vs 14.9%; P = .03; χ21 = 4.6) (Figure). The median hospitalization cost was ¥15 534.5 (interquartile range, ¥9447.2-¥29 000.0) (US $2401.4 [interquartile range, US $1460.4-$4483.1]).
This study found that the number of patients with PE in China is high. Although causes of PE have also been reported,2,4 we found that the causes differed by age and smoking status. Total hospitalization costs per patient with PE are similar to those per patient with chronic obstructive pulmonary disease (US $1964 to $3449 per patient), representing 33% to 40% of the mean household income in China, increasing the total cost of inpatient care for both individual and social health insurance.5
A limitation of this study was its retrospective design; there was potential selection bias. Patients who were clinically suspected of having PE but with no confirmation by CT or ultrasound were excluded, which led to an underestimation of the disease burden.
To our knowledge, this study provided the largest Chinese data set on the prevalence, causes, and health care burden of PE. Policy makers and health care professionals should address this concern by considering age and smoking factors when developing preventions and treatments for patients with PE.
Accepted for Publication: June 1, 2021.
Published: August 10, 2021. doi:10.1001/jamanetworkopen.2021.20306
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Tian P et al. JAMA Network Open.
Corresponding Author: Weimin Li, MD, PhD, Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, #37 GuoXue Alley, Chengdu Sichuan Province 610041, China (email@example.com).
Author Contributions: Dr Li had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Tian, Qiu, and Wang contributed equally.
Concept and design: Qiu, Wang, Xu, Cao.
Acquisition, analysis, or interpretation of data: Tian, Xu, Yang, Li.
Drafting of the manuscript: Tian, Qiu, Xu.
Critical revision of the manuscript for important intellectual content: Wang, Cao, Yang, Li.
Statistical analysis: Tian, Yang.
Obtained funding: Tian, Li.
Administrative, technical, or material support: Qiu, Wang, Xu, Li.
Supervision: Yang, Li.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grants 82072598, 81871890, and 91859203 from the National Science Foundation of China.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank the participants of China pleural effusion study for their valued support, assistance and cooperation. We thank Ping Wang (Chinese PLA General Hospital, Beijing, China); Luming Dai (First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China); Jie Cao (Tianjin Medical University General Hospital, Tianjing, China); Shaping Deng (First People's Hospital of Zigong City, Zigong, Sichuan Province, China); Jianqing Zhao (The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei Province, China); Yuanrong Dai (The Second Affiliated Hospital and Yuling Children’s Hospital of WMU/The Second School of Medicine, WMU, Wenzhou, Zhejiang Province, China); Guoxiang Lai (The 900th Hospital of the Joint Logistics Team, Fuzhou, Fujian Province, China); Xianwei Ye (Guizhou Provincial People’s Hospital, Guiyang, Guizhou Province, China); Jun Li (First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province); Lei Ni (Ruijin Hospital, Medical School of Shanghai Jiaotong University, Shanghai, China); Xiaoju Liu (The First Hospital of Lanzhou University/The First School of Clinical Medicine, Lanzhou, Gansu Province, China); Wenhua Bao (The First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang Province, China); Chunling Du (Qingpu Branch of Zhongshan Hospital, Fu Dan University, Shanghai, China); Huiqing Zeng (Zhongshan Hospital Xiamen University, Xiamen, Fujian Province, China); Jing Wang (The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China); Xianming Fan (The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China); Qiong Dong (Nanchong Central Hospital, Nanchong, Sichuan Province, China); Hongcheng Wu (Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang Province, China); Yuehong Wang (The First Affiliated Hospital, Zhejiang University/The First Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, China); Weiguo Xu (Mianyang Central Hospital, Mianyang, Sichuan Province, China); Yalun Li, Dan Liu, Deying Kang, Shengmin Zhao, Hao Zeng (West China Hospital, Sichuan University, Chengdu, Sichuan Province, China); Qing Xu (The Affiliated Ningde Municipal Hospital of Fujian Medical University); Jianan Huang (The First Affiliated Hospital of Soochow University); Xiaoju Chen (Affiliated Hospital of North Sichuan Medical College); Zheng Liu (Hebei Petro China Central Hospital); Hong Zhu (Peking University Third Hospital); Damin Xu (Panzhihua Central Hospital); Chen Qiu (Shenzhen People’s Hospital); Hui Ren (The First Affiliated Hospital of Xi’an Jiaotong University); Hailong Wei (Leshan People′s Hospital); Yong Cao (Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology); Jian Gou (The First People’s Hospital of Xianyang); MEI Lang qu cuo (Tibet Autonomous Region People’s Hospital); Jin Zhang (General Hospital of Ningxia Medical University); Qiang Hu (Affiliated Hospital of Panzhihua College); Yunxiang Zeng (The First Affiliated Hospital of Guangzhou Medical University); Yajun Tuo (Qinghai Provincial People’s Hospital); Zanfeng Wang (The First Hospital of China Medical University); Songping Wang (The Affiliated Hospital of Southwest Medical University); Shuanglin Liu (Xinqiao Hospital, Army Medical University); Shuliang Guo (The First Affiliated Hospital of Chongqing Medical University); Zhen Peng (People's Hospital of Xinjiang Uygur Autonomous Region); Ruibin Guo (Yangquan Coalmine Group General Hospital); Hongmei Zhou (Affiliated Zhongshan Hospital of Guangdong Medical University/Chen Xinghai Hospital); Zhougui Ling (The Fourth Affiliated Hospital of Guangxi Medical University); Jian Zhang (Xijing Hospital, Airforce Military Medical University); Mingyan Jiang (Xiangtan City Central Hospital); Suqin Ben (The First People′s Hospital of Shanghai), Yutian Bian (The First People’s Hospital of Baiyin); Guangnan Liu (The second Affiliated Hospital of Guangxi Medical University); Xiaoling Li (Inner Mongolia People’s Hospital); Zhuo Zhang (The Central Hospital of Jilin City); Caiqing Zhang (Shandong Provincial Qianfoshan Hospital) and Zhongmei Li (Fukuang General Hospital of Liaoning Health Industry Group). All of these individuals contributed to the acquisition and interpretation of data, and they were not compensated.