Efficacy and Cost-Effectiveness of VATS Versus Chest Tube Drainage in First-Episode Primary Spontaneous Pneumothorax With Blebs: A Propensity Score-Matched Retrospective Study

Efficacy and Cost-Effectiveness of VATS Versus Chest Tube Drainage in First-Episode Primary Spontaneous Pneumothorax With Blebs: A Propensity Score-Matched Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy and Cost-Effectiveness of VATS Versus Chest Tube Drainage in First-Episode Primary Spontaneous Pneumothorax With Blebs: A Propensity Score-Matched Retrospective Study Qingcai Lin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7363743/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Feb, 2026 Read the published version in BMC Pulmonary Medicine → Version 1 posted 15 You are reading this latest preprint version Abstract Background Optimal management for first-episode primary spontaneous pneumothorax (PSP) with pulmonary blebs remains uncertain, balancing recurrence prevention against procedural costs. This study compared video-assisted thoracoscopic surgery (VATS) and chest tube drainage in terms of recurrence prevention and cost-effectiveness, incorporating sensitivity analyses to evaluate robustness across variable assumptions. Methods In a retrospective cohort (2010–2020), 245 first-episode PSP patients with computed tomography (CT)-confirmed blebs were included. Propensity score matching (1:1, caliper = 0.02) balanced baseline characteristics (age, bleb size, etc.), generating 33 matched pairs. Primary outcomes were recurrence rate and incremental cost-effectiveness ratio (ICER). Results VATS reduced 5-year recurrence rates from 48.5–12.1% (P = 0.004; absolute risk reduction [ARR] = 36.4%, number needed to treat [NNT] = 2.75) and improved recurrence-free survival (hazard ratio [HR] = 0.166, P < 0.001). The base-case ICER was ¥160,300 per quality-adjusted life-year (QALY) gained (¥48,937 per recurrence avoided), with 99.14% probability of cost-effectiveness at China’s World Health Organization (WHO)-recommended willingness-to-pay (WTP) threshold (¥287,247 / QALY). Sensitivity analyses confirmed robustness: ICER remained favorable at ¥156,338 / QALY when pneumothorax utility dropped to 0.5; a 20% cost increase yielded ¥192,200 / QALY. Discount rate variations (3%: ¥159,800 / QALY; 6%: ¥138,029 / QALY) maintained > 98.4% cost-effectiveness probability. Conclusions VATS reduces recurrence by 83.4% in first-episode PSP with blebs and demonstrates robust cost-effectiveness. Early surgical intervention should be considered for patients with blebs across diverse resource settings. Primary spontaneous pneumothorax Video-assisted thoracoscopic surgery Chest tube drainage Cost-effectiveness analysis Propensity score matching Figures Figure 1 Figure 2 Figure 3 Background Primary spontaneous pneumothorax (PSP), defined as the presence of air in the pleural cavity in the absence of traumatic injury, most commonly occurs in young adults.[ 1 ] Its reported incidence varies between 15.5 and 22.7 cases per 100,000 population, with a consistently observed male predominance reflected in a female-to-male ratio of 1:3.3 to 1:5.[ 2 , 3 ] Up to 40% of first-episode patients experience recurrence within 5 years, particularly those with pulmonary blebs visualized on computed tomography (CT) imaging. [ 4 – 7 ] While current international guidelines recommend chest tube drainage as initial management for primary episodes, growing evidence suggests this approach may be suboptimal given high recurrence rates and associated long-term healthcare burdens.[ 8 – 10 ] Video-assisted thoracoscopic surgery (VATS) has demonstrated superior efficacy in recurrent PSP, with randomized trials reporting recurrence rates below 5%.[ 11 – 13 ] However, its role in first-episode PSP remains contentious due to concerns over procedural costs and potential overtreatment. Recent economic analyses reveal that recurrence-related expenses, including emergency visits, repeated hospitalizations, and productivity loss, may increase total costs compared to initial surgical intervention.[ 14 – 17 ] Although the 2025 cost-utility model proposed that VATS could be cost-effective, there was still a significant evidence gap for comparison among patients with the same underlying conditions and bulla characteristics. [ 18 ] Existing studies predominantly focus on recurrent PSP populations, lacking robust data on first-episode cohorts with radiologically confirmed blebs.[ 16 , 17 ] Furthermore, previous comparisons are compromised by selection bias from unadjusted baseline imbalances in critical prognostic factors such as bleb size and age.[ 10 ] Crucially, no real-world studies have employed rigorous propensity score matching (PSM) to evaluate both clinical outcomes and cost-effectiveness in this population. To address these limitations, this retrospective cohort study applies 1:1 PSM methodology to minimize confounding variables while comparing VATS and chest tube drainage in first-episode PSP patients with CT-confirmed blebs. We assess not only recurrence outcomes but also incremental cost-effectiveness ratios (ICERs), utilizing World Health Organization (WHO)-recommended willingness-to-pay (WTP) thresholds tailored for emerging economies.[ 19 , 20 ] Methods Study Design and Data Source This study utilized electronic medical records from the Hospital Information System of Longyan First Affiliated Hospital of Fujian Medical University between January 2010 and May 2020. We identified patients with first-episode PSP and radiologically confirmed ruptured pulmonary blebs (subpleural air cysts with pleural discontinuity on chest CT). The cohort was stratified by initial treatment into two groups: (1) VATS group undergoing video-assisted thoracoscopic bullectomy with pleurodesis, and (2) chest tube group receiving closed-tube thoracostomy as intervention. Ethical approval was obtained from the Institutional Review Board (Approval No.: LYREC2025-K165-01) with waiver of informed consent for anonymized data analysis. Participant Selection Eligibility criteria required: (a) definitive diagnosis of first-episode PSP with blebs rupture necessitating intervention, (b) absence of underlying cardiopulmonary diseases, and (c) complete medical records including operative notes, itemized cost statements, and 60-month follow-up. Exclusion criteria systematically eliminated patients with: (i) secondary pneumothorax (trauma, chronic obstructive pulmonary disease and cystic fibrosis), (ii) prior ipsilateral thoracic surgery, (iii) > 20% missing key variables, or (iv) concurrent major procedures (e.g., lobectomy). Initial screening yielded 486 cases, with 245 meeting inclusion criteria (VATS group = 188, Chest tube group = 57) prior to matching. (Appendix 1) Propensity Score Matching To address baseline imbalances, propensity scores were estimated using logistic regression with the following covariates: age, sex, smoking status, laterality of pneumothorax, maximum bleb diameter (categorized as 5 cm), number of blebs (1–2, 3–5, > 5), and degree of lung collapse. (Appendix 2) One-to-one nearest-neighbor matching was performed with a caliper width of 0.02 standard deviations of the propensity score logit, resulting in 33 well-balanced pairs. Standardized mean differences (SMD) decreased from 0.631 (pre-match) to 0.081 (post-match), confirming adequate balance (SMD < 0.1 considered negligible). Outcome Measures The study evaluated two endpoints through comprehensive follow-up and economic analysis. The first outcome was ipsilateral pneumothorax recurrence within 5 years post-intervention, rigorously defined as radiographically confirmed pneumothorax. For the second outcome, we conducted a formal cost-effectiveness analysis from the healthcare payer perspective, calculating incremental cost per quality-adjusted life-year (QALY) gained. Statistical Analysis Continuous variables were reported as medians with interquartile ranges (IQR) and compared using Mann-Whitney U tests (pre-match), Wilcoxon signed-rank tests (post-match) and paired t-test (post-match). Categorical variables were analyzed with χ² or Fisher's exact tests as appropriate, transitioning to McNemar's test for matched pairs. Time-to-event outcomes were evaluated through Kaplan-Meier survival curves with log-rank testing and Cox proportional hazards regression adjusting for residual confounders. We conducted a cost-effectiveness analysis from the healthcare payer perspective, adopting the WHO-CHOICE framework[ 19 ]. Incremental cost-effectiveness ratios (ICERs) as: ICER = ΔCost/ΔEffect (QALYs gained; recurrence avoided), were evaluated against China's WHO-recommended WTP thresholds (1–3× gross domestic product [GDP] per capita, ¥95,749–¥287,247/QALY).[ 21 ] Probabilistic sensitivity analysis incorporated Monte Carlo simulations (n = 10,000) with parameters calibrated to regional cost databases (Appendix 3). All analyses were conducted using the Social Sciences (SPSS) version 29.0 (International Business Machines [IBM] Corp, Armonk, NY) with P < 0.05 defining statistical significance. Sample Size Considerations The sample size calculation was performed a priori using the two-independent proportions formula, based on preliminary institutional data demonstrating anticipated recurrence rates of 45.6% in the chest tube group versus 11.7% in the VATS group. With α = 0.05 (two-tailed) and β = 0.20 (80% power), the initial estimation yielded a requirement of 26 patients per group. To account for potential limitations inherent to retrospective studies, including approximately 5% anticipated data incompleteness from missing medical records, 10% expected loss to follow-up in longitudinal outcomes assessment, and 5% reduction in matching efficiency during propensity score analysis, we conservatively inflated the sample size by 20%. This adjustment established a minimum target of 32 patients per treatment arm before matching. The final propensity-matched cohort successfully achieved 33 pairs (n = 66), providing enhanced statistical robustness. Post-hoc analysis confirmed this sample size afforded 86.2% power to detect the observed clinically significant hazard ratio (HR) for recurrence, while maintaining adequate precision for cost-effectiveness evaluations. Results The propensity score-matched cohort analysis included 33 patient pairs (n = 66) with well-balanced baseline characteristics after matching (mean SMD = 0.081)(Table 1). The VATS group and chest tube group showed comparable distributions of age (median 50 vs 46 years, P = 0.341), sex (84.8% male in both), smoking status (54.5% vs 66.7%, P = 0.125), and bleb characteristics (large blebs >5 cm: 6.1% in both groups). No significant differences existed in complication rates (36.4% vs 39.4%, P = 1.000) or degree of lung collapse (>50% collapse: 63.6% vs 57.6%, P = 0.754). VATS demonstrated superior efficacy in preventing pneumothorax recurrence. The recurrence rate was significantly lower in the VATS group (12.1%, 4/33) compared to the chest tube group (48.5%, 16/33), with an absolute risk reduction (AAR) of 36.4% ( P < 0.001). This corresponds to a number needed to treat of 2.75, indicating that for every 3 patients treated with VATS instead of chest tube drainage, one additional recurrence would be prevented. Time-to-event analysis revealed markedly prolonged recurrence-free survival in the VATS group (median not reached, 95% confidence interval[CI]:48.99-59.62 months) versus the chest tube group (median 24 months, 95% CI:21.97-41.38 months; log-rank P < 0.001)(Fig. 1). Cox proportional hazards analysis confirmed VATS independently reduced recurrence risk by 83.4% ( HR = 0.166, 95% CI:0.055-0.498, P < 0.001). The economic evaluation demonstrated that while VATS incurred higher initial costs (median ¥26,922, IQR 23,455-33,206 vs ¥6,256, IQR 3,769-9,306; P < 0.001), it showed favorable cost-effectiveness. The ICER was ¥160,300 per QALY gained (or ¥48,937 per recurrence avoided), incorporating utility values of 1.0 for stable health, 0.7 during pneumothorax events, and 0.95 post-recovery, with an assumed 14-day recurrence duration (Table 2).[9,18,22] This resulted in a total QALY gain of 3.67 with VATS. The ICER remained substantially below China's WHO-recommended WTP threshold of ¥287,247 per QALY gained (3×GDP per capita). Sensitivity analyses confirmed the robustness of these findings across varying assumptions (Table 3). When pneumothorax utility values were decreased to 0.5, the ICER remained favorable at ¥156,338 per QALY gained. Even with a 20% increase in procedure costs (¥705,395 total), the ICER of ¥192,200 per QALY gained stayed below the WHO threshold. At a 3% discount rate, the ICER was ¥159,800 per QALY gained with a cost-effectiveness acceptability probability of 98.49%. At a 6% discount rate, the ICER decreased to ¥138,029 per QALY gained while maintaining high cost-effectiveness acceptability (98.47%). The Monte Carlo simulation (n = 10,000 iterations) demonstrated consistent cost-effectiveness outcomes, with 100.0% of iterations in the cost-effectiveness plane (Fig. 2) falling within the northeast quadrant (higher effectiveness at higher cost), centered at an incremental cost of ¥587,829 and 3.67 QALYs gained. The acceptability curve analysis (Fig. 3) revealed a 99.14% probability of VATS being cost-effective at China's WHO-recommended WTP threshold of ¥287,247 / QALY (3×GDP per capita), decreasing to 3.57% probability at the lower 1×GDP threshold of ¥95,749 / QALY. Post-hoc analysis confirmed adequate statistical power (86.2%) for detecting the observed treatment effect. Hospital stay duration showed a clinically meaningful difference between groups (median 8 days, IQR 7-10.5 vs 7 days, IQR 4-10.5; P = 0.042). The comprehensive matching protocol and extensive sensitivity analyses address potential limitations related to the retrospective design while reinforcing the validity of our findings regarding both clinical outcomes and cost-effectiveness. Discussion This propensity score-matched study demonstrates that VATS significantly reduces recurrence risk in first-episode PSP patients with pulmonary blebs while achieving robust cost-effectiveness. Our findings reveal a 36.4% absolute risk reduction (ARR) with VATS compared to chest tube drainage, translating to one recurrence prevented per three patients treated, alongside an 83.4% hazard reduction ( HR = 0.166) over 5 years. These results challenge current guideline recommendations favoring conservative management for initial episodes and provide evidence to support early surgical intervention in selected patients.[ 8 , 9 , 23 ] The clinical superiority of VATS aligns with emerging pathophysiological understanding of PSP. Large (> 5 cm) and numerous blebs, validated as independent recurrence predictors in contemporary studies, create structural vulnerabilities that chest tube drainage fails to address.[ 12 , 24 , 25 ] VATS directly eliminates these substrates through bleb resection while pleural abrasion induces adhesions, reducing recurrence risk more effectively than reactive pleural inflammation from drainage alone.[ 13 , 26 ] Our data confirm that patients with radiologically confirmed blebs constitute a high-risk subgroup warranting aggressive initial management, particularly given the 48.5% recurrence rate observed in conservatively managed patients. From a health economics perspective, VATS demonstrates compelling value despite higher upfront costs. The ICER of ¥160,300 per QALY gained falls substantially below China's WHO-recommended WTP threshold (¥287,247 / QALY), with Monte Carlo simulations (n = 10,000) confirming a 99.14% probability of cost-effectiveness. This economic viability persists even under conservative assumptions, including a 20% cost increase (ICER ¥192,200 / QALY), and addresses critical gaps in guideline development for resource-constrained settings. There exists an inverse relationship between discount rates and ICERs, whereby higher discount rates (6%) yield lower ICERs compared to lower rates (3%). This observation aligns with established principles in health economics. The majority of intervention costs are incurred at the outset (e.g., surgical procedures), making these costs relatively less sensitive to discounting. Health benefits are realized over the course of patients’ lifetimes; consequently, higher discount rates significantly reduce the present value of quality-adjusted life years. It is important to note that the cost-effectiveness acceptability probability remained highly consistent (> 98.4%) across all scenarios involving varying discount rates. This stability underscores the robustness of the intervention’s value proposition under different discount rate assumptions within policy-relevant ranges. Furthermore, the utilization of real-world cost data in this analysis incorporate actual costs associated with disease recurrence across the treatment continuum with 1:1 PSM matching of basic patient information and bulla characteristics, thereby addressing a key limitation of previous model-based studies (individual differences).[ 14 , 18 ] The 36.4% ARR provides particularly valuable information for shared decision-making. While relative risk metrics (83.4%) illustrate biological efficacy, ARR quantifies tangible clinical impact in patient-centric terms: without intervention, approximately half of first-episode patients with blebs will experience recurrence within five years; VATS reduces this risk by over one-third.[ 27 ] This intuitive metric facilitates risk-benefit discussions with young patients weighing immediate recovery against long-term recurrence prevention. Methodologically, this study advances PSP research through rigorous propensity score matching that balanced critical prognostic variables, including bleb size distribution and smoking status, achieving near-perfect covariate balance (mean SMD = 0.081). This design minimizes selection bias inherent in retrospective comparisons and responds to calls for higher-quality real-world evidence in pneumothorax management. Our incorporation of itemized 10-year cost data further strengthens economic conclusions by capturing true resource utilization patterns beyond theoretical models. Several limitations warrant consideration. The single-center retrospective design risks unmeasured confounding despite meticulous matching. Generalizability may be limited to similar healthcare economies. The 5-year follow-up might miss late recurrences beyond this window. Finally, our QALY estimates derived from population utility weights rather than direct patient measures, though extensive sensitivity analyses mitigate this concern. These findings translate to actionable practice recommendations: prioritizing VATS for first-episode PSP patients exhibiting large (> 5 cm) or numerous blebs on CT imaging represents the most immediate clinical application, given their 48.5% baseline recurrence risk with conservative management. Guideline committees should incorporate cost-effectiveness frameworks, particularly WHO-recommended thresholds, when formulating resource-conscious recommendations for diverse healthcare settings. For shared decision-making with patients, utilizing the AAR of 36.4% rather than relative risk metrics provides more intuitive understanding of intervention benefits, as this translates directly to preventing one recurrence per three patients treated. Health systems must concurrently develop clinical pathways enabling timely VATS access presentation, as delays increase recurrence-associated costs.[ 15 ] Future research should prospectively validate these findings across varied healthcare economies while exploring techniques like awake VATS that may enhance cost-effectiveness, alongside integrating patient-reported outcomes to refine utility estimations in this young population. Conclusions VATS significantly reduces recurrence risk (83.4% hazard reduction; ARR = 36.4%) versus chest tube drainage in first-episode PSP with blebs, with a median recurrence-free survival > 48 months versus 24 months. Its ICER (¥160,300 / QALY) falls below China’s WHO-recommended WTP threshold (¥287,247 / QALY), supported by a 99.14% cost-effectiveness probability. These findings challenge current guidelines favoring conservative initial management and advocate for early VATS in high-risk patients with blebs. Guideline committees should integrate cost-effectiveness frameworks and WHO thresholds to promote value-based care. Future research should validate these outcomes prospectively and explore awake VATS to enhance accessibility. Abbreviations ARR Absolute Risk Reduction CI Confidence Interval CT Computed Tomography GDP Gross Domestic Product HR Hazard Ratio IBM International Business Machines ICER Incremental Cost-Effectiveness Ratio IQR Interquartile Range NNT Number Needed to Treat PSM Propensity Score Matching PSP Primary Spontaneous Pneumothorax QALY Quality-Adjusted Life-Year SMD Standardized Mean Difference VATS Video-Assisted Thoracoscopic Surgery WHO World Health Organization WTP Willingness-to-Pay Declarations Correspondence to: Qingcai Lin, MM; email: [email protected] Ethics approval and consent to participate This study was approved by the Institutional Review Board of the Ethics Committee of Longyan First Affiliated Hospital of Fujian Medical University (Approval No.: LYREC2025-K165-01). Patient consent was waived due to the retrospective nature of the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding No external funding was received. Authors' contributions Q.C.Lin 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, including and especially any adverse effects. Q.C.Lin contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript. All authors approved the final version for submission. Acknowledgements The authors thank the Department of Thoracic Surgery at Longyan First Affiliated Hospital of Fujian Medical University for their clinical support. Authors' information Department of Thoracic Surgery (Q.C. Lin.), Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China. 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Tables Table 1 Baseline Characteristics Before and After Propensity Score Matching Variables Before Matching After Matching Statistical Analysis SMD Chest Tube (n=57) VATS (n=188) Chest Tube (n=33) VATS (n=33) Pre-Match Test Pre-Match vs. Post-Match Post-Match Test Categorical Variables Sex Male 46(80.7%) 161(85.6%) 28(84.8%) 28(84.8%) P =0.404 0.131 vs. 0 Female 11(19.3%) 27(14.4%) 5(15.2%) 5(15.2%) P =1.000 Age <45 years old 21(36.8%) 161(85.6%) 16(48.5%) 16(48.5%) P <0.001 0.725 vs. 0 ≥45 years old 36(63.2%) 27(14.4%) 17(51.5%) 17(51.5%) P =1.000 Smoking state No 23(40.4%) 136(72.3%) 11(33.3%) 15(45.5%) P <0.001 0.679 vs. 0.252 Yes 34(59.6%) 52(27.7%) 22(66.7%) 18(54.5%) P =0.125 The laterality of PSP Left 22(38.6%) 83(44.1%) 13(39.4%) 17(51.5%) P =0.542 0.112 vs. 0.245 Right 35(61.4%) 105(55.9%) 20(60.6%) 16(48.5%) P =0.453 Degree of lung collapse volume 30%-50% 26(45.6%) 93(49.5%) 14(42.4%) 12(36.4%) P =0.652 0.078 vs. 0.123 >50% 31(54.4%) 95(50.5%) 19(57.6%) 21(63.6%) P =0.754 Maximum blebs diameter <1 cm 10(17.5%) 127(67.6%) 8(24.2%) 10(30.3%) P 5 cm 11(19.3%) 2(1.1%) 2(6.1%) 2(6.1%) 0.631 vs. 0 Number of blebs 1-2 19(33.3%) 163(86.7%) 16(48.5%) 16(48.5%) P 5 17(29.8%) 5(2.7%) 4(12.1%) 4(12.1%) 0.790 vs. 0 Complications Combined with complications 20(35.1%) 47(25.0%) 13(39.4%) 12(36.4%) P =0.174 - No complications 37(64.9%) 141(75.0%) 20(60.6%) 21(63.6%) P =1.000 Status of recurrence Recurrence 26(45.6%) 22(11.7%) 16(48.5%) 4(12.1%) P <0.001 - No recurrence 31(54.4%) 166(88.3%) 17(51.5%) 29(87.9%) P =0.004 Continuous Variables Age (years) 53(41-62) 28(21-37) 50(28.5-59.5) 46(26-57.5) P <0.001 - P =0.341 Length of hospital stay (days) 7(4.5-10.5) 8(6-10) 7(4-10.5) 8(7-10.5) P =0.022 - P =0.042 Time to recurrence (months) 15(2-60) 60(60-60) 15(2-60) 60(60-60) P <0.001 - P <0.001 Total cost(¥) 6,218(3,791-9,100) 25,247(20,656-28,766) 6,256(3,769-9,306) 26,922(23,455-33,206) P <0.001 - P <0.001 Abbreviations: IQR, Interquartile range; PSP, Primary spontaneous pneumothorax; SMD, Standardized mean difference; VATS, Video-assisted thoracoscopic surgery. Data presented as n (%) for categorical variables and median (IQR) for continuous variables. Propensity score matching (1:1, caliper = 0.02) achieved negligible imbalance (mean SMD: 0.631→0.081). Pre-matching p-values from Chi-square test, Fisher’s exact test and Mann-Whitney U test. Post-matching p-values from McNemar test, Bowker’s test, Paired t-test and Wilcoxon signed-rank test. The PSM algorithm and the baseline characteristics before and after matching are detailed in Appendix 1. Table 2 Cost-Effectiveness Analysis of VATS versus Chest Tube Metric Value Incremental Cost (ΔCost) ¥17,813 per patient Incremental Effect (ΔEffect) 36.4% recurrences avoided ICER ¥160,300 per QALY gained (or ¥48,937 per recurrence avoided) WHO Threshold ¥ 287,247 per QALY gained (3×GDP) Conclusion VATS cost-effective Abbreviations: GDP, Gross domestic product; ICER, Incremental cost-effectiveness ratio; QALY, Quality-adjusted life-year; WHO, World Health Organization. WHO threshold = 3×GDP per capita (¥287,247 / QALY in China). Utilities: Stable: 1.0; Pneumothorax: 0.7; Post-recovery: 0.95; Recurrence duration: 14 days. Table 3 Sensitivity Analysis of Cost-Effectiveness Parameter Varied Scenario ΔCost (¥) ΔQALY ICER (¥ / QALY) CE Probability at WTP Thresholds Base Case Reference 587,829 3.67 160,300 0.9914 Pneumothorax utility Reduced to 0.5 587,829 3.76 156,338 0.9881 Pneumothorax utility Increased to 0.8 587,829 3.62 162,384 0.9807 Recurrence Duration Shortened (7 days) 587,829 3.60 163,286 0.9806 Recurrence Duration Extended (21 days) 587,829 3.74 157,200 0.9856 Cost variation +20% 705,395 3.67 192,200 0.9322 Cost variation -20% 470,263 3.67 128,100 0.9981 Discount Rate 0% 587,091 3.67 159,970 0.9873 Discount Rate 3% 506,565 3.17 159,800 0.9849 Discount Rate 6% 587,076 3.67 138,029 0.9847 Abbreviations: CE, cost-effectiveness; WTP, willingness-to-pay. Additional Declarations No competing interests reported. Supplementary Files Appendix1.Flowchartofstudyprocedures.drawio.pdf Supplementary Material The flow chart of the study procedures is provided in Appendix 1 (Appendix 1. Flow chart of study procedures.drawio.pdf). Appendix2.PSMalgorithmandbaselinecharacteristicsbeforeandaftermatching.xlsx The PSM algorithm and baseline characteristics before and after matching are detailed in Appendix 2 (Appendix 2. PSM algorithm and baseline characteristics before and after matching.xlsx). Appendix3.Costeffectivenessanalysis.xlsx The economic evaluation (cost-effectiveness analysis) is presented in Appendix 3 (Appendix 3. Cost-effectiveness analysis.xlsx), which includes: Monte Carlo simulations, Cost-Effectiveness Plane, Cost-Effectiveness Acceptability Curve (CEAC), and Sensitivity Analysis. Cite Share Download PDF Status: Published Journal Publication published 05 Feb, 2026 Read the published version in BMC Pulmonary Medicine → Version 1 posted Editorial decision: Revision requested 24 Oct, 2025 Reviews received at journal 15 Oct, 2025 Reviewers agreed at journal 03 Oct, 2025 Reviewers agreed at journal 02 Oct, 2025 Reviews received at journal 19 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviewers agreed at journal 01 Sep, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 27 Aug, 2025 Editor invited by journal 25 Aug, 2025 Editor assigned by journal 22 Aug, 2025 Submission checks completed at journal 22 Aug, 2025 First submitted to journal 13 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7363743","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499884562,"identity":"d4d980d8-621e-4888-9ffb-ace531bffc10","order_by":0,"name":"Qingcai Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBACA4n8bxIPDBgY2CBcGyDB3MDAcACflhw2iQSEljQgi5GAFp4zQC0I/mEitLD3ALUU3JHtk26/+OFHwXk5g/uNjQ8+nGGQ5xfDrs+Amf/4jwSDZ8ZtMmeKJXsMbhsbHGNsNpxxg8Fw5uwEHFp4QH45nNgmkZPGwGNwO3HDMcY2aZ4PDAkGt4nQwvjH4BxJWtKPMfMYHIBquUFYizHQFmZpGYNkY8ljiUC/nJHA6Rf7ZqCWD38Oy86fkf7w45s/dnJ8hw8ffPDhmI08vzR2LTAAjAseA2QBCbzKoVrYHxBUNQpGwSgYBSMTAAApgl6BlxFFKgAAAABJRU5ErkJggg==","orcid":"","institution":"Longyan First Hospital","correspondingAuthor":true,"prefix":"","firstName":"Qingcai","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2025-08-13 10:08:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7363743/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7363743/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12890-026-04155-9","type":"published","date":"2026-02-05T15:59:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89284201,"identity":"b96a4691-f977-4990-9180-0b6d4152bb0f","added_by":"auto","created_at":"2025-08-18 11:05:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1574104,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier Curve for Recurrence-Free Survival. Chest tube group: median 24 months (95% CI: 21.97-41.38). VATS group: not reached (95% CI: 48.99-59.62). Log-rank test:\u003cem\u003eχ² \u003c/em\u003e= 13.464, \u003cem\u003eP \u003c/em\u003e\u0026lt; 0.001\u003c/p\u003e","description":"","filename":"Figure1.KaplanMeierCurveforRecurrenceFreeSurvival..png","url":"https://assets-eu.researchsquare.com/files/rs-7363743/v1/c1991568fa66804dbb2fa9a9.png"},{"id":89284204,"identity":"600ea17a-b51d-4b86-9e5e-1fb849787c5c","added_by":"auto","created_at":"2025-08-18 11:05:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1187160,"visible":true,"origin":"","legend":"\u003cp\u003eCost-Effectiveness Plane for VATS versus Chest Tube\u003c/p\u003e","description":"","filename":"Figure2.CostEffectivenessPlaneforVATSversuschesttube.png","url":"https://assets-eu.researchsquare.com/files/rs-7363743/v1/b4e742598e1205fe9728bb05.png"},{"id":89285075,"identity":"dafaf5e9-2966-4339-9f40-f62d2102bfee","added_by":"auto","created_at":"2025-08-18 11:13:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":442159,"visible":true,"origin":"","legend":"\u003cp\u003eCost-Effectiveness Acceptability Curve. Probability of VATS being cost-effective: 99.14% at WHO threshold (3×GDP, ¥287,247 / QALY) vs. 3.57% at lower threshold (1×GDP, ¥95,749 / QALY)\u003c/p\u003e","description":"","filename":"Figure3.CostEffectivenessAcceptabilityCurve.png","url":"https://assets-eu.researchsquare.com/files/rs-7363743/v1/f6f6815143f9d4388f88df57.png"},{"id":102234288,"identity":"890e9478-2da8-4442-bc78-edbf3e905bc8","added_by":"auto","created_at":"2026-02-09 16:09:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4322204,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7363743/v1/f4674cf8-675f-4c7b-997b-28ac27cd668c.pdf"},{"id":89284203,"identity":"319502cb-5d4d-459c-b3b4-3b7e1dd6c7c7","added_by":"auto","created_at":"2025-08-18 11:05:24","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34035,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe flow chart of the study procedures is provided in Appendix 1 (Appendix 1. Flow chart of study procedures.drawio.pdf).\u003c/p\u003e","description":"","filename":"Appendix1.Flowchartofstudyprocedures.drawio.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7363743/v1/13e7db22d869f5ecef3eed14.pdf"},{"id":89285076,"identity":"c5542913-bbe2-431f-aafa-8654d33aad0f","added_by":"auto","created_at":"2025-08-18 11:13:24","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15352,"visible":true,"origin":"","legend":"\u003cp\u003eThe PSM algorithm and baseline characteristics before and after matching are detailed in Appendix 2 (Appendix 2. PSM algorithm and baseline characteristics before and after matching.xlsx).\u003c/p\u003e","description":"","filename":"Appendix2.PSMalgorithmandbaselinecharacteristicsbeforeandaftermatching.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7363743/v1/d211e391a7a17c9bb791bb15.xlsx"},{"id":89284215,"identity":"5edf8e2c-5dbe-4e9e-8acc-eb01f15d63d7","added_by":"auto","created_at":"2025-08-18 11:05:24","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":2614940,"visible":true,"origin":"","legend":"\u003cp\u003eThe economic evaluation (cost-effectiveness analysis) is presented in Appendix 3 (Appendix 3. Cost-effectiveness analysis.xlsx), which includes: Monte Carlo simulations, Cost-Effectiveness Plane, Cost-Effectiveness Acceptability Curve (CEAC), and Sensitivity Analysis.\u003c/p\u003e","description":"","filename":"Appendix3.Costeffectivenessanalysis.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7363743/v1/684efcd161b74045b40eaf39.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy and Cost-Effectiveness of VATS Versus Chest Tube Drainage in First-Episode Primary Spontaneous Pneumothorax With Blebs: A Propensity Score-Matched Retrospective Study","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary spontaneous pneumothorax (PSP), defined as the presence of air in the pleural cavity in the absence of traumatic injury, most commonly occurs in young adults.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Its reported incidence varies between 15.5 and 22.7 cases per 100,000 population, with a consistently observed male predominance reflected in a female-to-male ratio of 1:3.3 to 1:5.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Up to 40% of first-episode patients experience recurrence within 5 years, particularly those with pulmonary blebs visualized on computed tomography (CT) imaging. [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] While current international guidelines recommend chest tube drainage as initial management for primary episodes, growing evidence suggests this approach may be suboptimal given high recurrence rates and associated long-term healthcare burdens.[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eVideo-assisted thoracoscopic surgery (VATS) has demonstrated superior efficacy in recurrent PSP, with randomized trials reporting recurrence rates below 5%.[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] However, its role in first-episode PSP remains contentious due to concerns over procedural costs and potential overtreatment. Recent economic analyses reveal that recurrence-related expenses, including emergency visits, repeated hospitalizations, and productivity loss, may increase total costs compared to initial surgical intervention.[\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Although the 2025 cost-utility model proposed that VATS could be cost-effective, there was still a significant evidence gap for comparison among patients with the same underlying conditions and bulla characteristics. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Existing studies predominantly focus on recurrent PSP populations, lacking robust data on first-episode cohorts with radiologically confirmed blebs.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Furthermore, previous comparisons are compromised by selection bias from unadjusted baseline imbalances in critical prognostic factors such as bleb size and age.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Crucially, no real-world studies have employed rigorous propensity score matching (PSM) to evaluate both clinical outcomes and cost-effectiveness in this population.\u003c/p\u003e\u003cp\u003eTo address these limitations, this retrospective cohort study applies 1:1 PSM methodology to minimize confounding variables while comparing VATS and chest tube drainage in first-episode PSP patients with CT-confirmed blebs. We assess not only recurrence outcomes but also incremental cost-effectiveness ratios (ICERs), utilizing World Health Organization (WHO)-recommended willingness-to-pay (WTP) thresholds tailored for emerging economies.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Data Source\u003c/h2\u003e\u003cp\u003eThis study utilized electronic medical records from the Hospital Information System of Longyan First Affiliated Hospital of Fujian Medical University between January 2010 and May 2020. We identified patients with first-episode PSP and radiologically confirmed ruptured pulmonary blebs (subpleural air cysts with pleural discontinuity on chest CT). The cohort was stratified by initial treatment into two groups: (1) VATS group undergoing video-assisted thoracoscopic bullectomy with pleurodesis, and (2) chest tube group receiving closed-tube thoracostomy as intervention. Ethical approval was obtained from the Institutional Review Board (Approval No.: LYREC2025-K165-01) with waiver of informed consent for anonymized data analysis.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipant Selection\u003c/h3\u003e\n\u003cp\u003eEligibility criteria required: (a) definitive diagnosis of first-episode PSP with blebs rupture necessitating intervention, (b) absence of underlying cardiopulmonary diseases, and (c) complete medical records including operative notes, itemized cost statements, and 60-month follow-up. Exclusion criteria systematically eliminated patients with: (i) secondary pneumothorax (trauma, chronic obstructive pulmonary disease and cystic fibrosis), (ii) prior ipsilateral thoracic surgery, (iii)\u0026thinsp;\u0026gt;\u0026thinsp;20% missing key variables, or (iv) concurrent major procedures (e.g., lobectomy). Initial screening yielded 486 cases, with 245 meeting inclusion criteria (VATS group\u0026thinsp;=\u0026thinsp;188, Chest tube group\u0026thinsp;=\u0026thinsp;57) prior to matching. (Appendix 1)\u003c/p\u003e\n\u003ch3\u003ePropensity Score Matching\u003c/h3\u003e\n\u003cp\u003eTo address baseline imbalances, propensity scores were estimated using logistic regression with the following covariates: age, sex, smoking status, laterality of pneumothorax, maximum bleb diameter (categorized as \u0026lt;\u0026thinsp;1 cm, 1\u0026ndash;5 cm, \u0026gt;\u0026thinsp;5 cm), number of blebs (1\u0026ndash;2, 3\u0026ndash;5, \u0026gt;\u0026thinsp;5), and degree of lung collapse. (Appendix 2) One-to-one nearest-neighbor matching was performed with a caliper width of 0.02 standard deviations of the propensity score logit, resulting in 33 well-balanced pairs. Standardized mean differences (SMD) decreased from 0.631 (pre-match) to 0.081 (post-match), confirming adequate balance (SMD\u0026thinsp;\u0026lt;\u0026thinsp;0.1 considered negligible).\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe study evaluated two endpoints through comprehensive follow-up and economic analysis. The first outcome was ipsilateral pneumothorax recurrence within 5 years post-intervention, rigorously defined as radiographically confirmed pneumothorax. For the second outcome, we conducted a formal cost-effectiveness analysis from the healthcare payer perspective, calculating incremental cost per quality-adjusted life-year (QALY) gained.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eContinuous variables were reported as medians with interquartile ranges (IQR) and compared using Mann-Whitney U tests (pre-match), Wilcoxon signed-rank tests (post-match) and paired t-test (post-match). Categorical variables were analyzed with \u003cem\u003eχ\u0026sup2;\u003c/em\u003e or Fisher's exact tests as appropriate, transitioning to McNemar's test for matched pairs. Time-to-event outcomes were evaluated through Kaplan-Meier survival curves with log-rank testing and Cox proportional hazards regression adjusting for residual confounders.\u003c/p\u003e\u003cp\u003eWe conducted a cost-effectiveness analysis from the healthcare payer perspective, adopting the WHO-CHOICE framework[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Incremental cost-effectiveness ratios (ICERs) as: ICER\u0026thinsp;=\u0026thinsp;ΔCost/ΔEffect (QALYs gained; recurrence avoided), were evaluated against China's WHO-recommended WTP thresholds (1\u0026ndash;3\u0026times; gross domestic product [GDP] per capita, \u0026yen;95,749\u0026ndash;\u0026yen;287,247/QALY).[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Probabilistic sensitivity analysis incorporated Monte Carlo simulations (n\u0026thinsp;=\u0026thinsp;10,000) with parameters calibrated to regional cost databases (Appendix 3). All analyses were conducted using the Social Sciences (SPSS) version 29.0 (International Business Machines [IBM] Corp, Armonk, NY) with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 defining statistical significance.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSample Size Considerations\u003c/h2\u003e\u003cp\u003eThe sample size calculation was performed a priori using the two-independent proportions formula, based on preliminary institutional data demonstrating anticipated recurrence rates of 45.6% in the chest tube group versus 11.7% in the VATS group. With \u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05 (two-tailed) and \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.20 (80% power), the initial estimation yielded a requirement of 26 patients per group. To account for potential limitations inherent to retrospective studies, including approximately 5% anticipated data incompleteness from missing medical records, 10% expected loss to follow-up in longitudinal outcomes assessment, and 5% reduction in matching efficiency during propensity score analysis, we conservatively inflated the sample size by 20%. This adjustment established a minimum target of 32 patients per treatment arm before matching. The final propensity-matched cohort successfully achieved 33 pairs (n\u0026thinsp;=\u0026thinsp;66), providing enhanced statistical robustness. Post-hoc analysis confirmed this sample size afforded 86.2% power to detect the observed clinically significant hazard ratio (HR) for recurrence, while maintaining adequate precision for cost-effectiveness evaluations.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe propensity score-matched cohort analysis included 33 patient pairs (n = 66) with well-balanced baseline characteristics after matching (mean SMD = 0.081)(Table 1). The VATS group and chest tube group showed comparable distributions of age (median 50 vs 46 years, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.341), sex (84.8% male in both), smoking status (54.5% vs 66.7%, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 0.125), and bleb characteristics (large blebs \u0026gt;5 cm: 6.1% in both groups). No significant differences existed in complication rates (36.4% vs 39.4%, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e= 1.000) or degree of lung collapse (\u0026gt;50% collapse: 63.6% vs 57.6%,\u003cem\u003e\u0026nbsp;P\u0026nbsp;\u003c/em\u003e= 0.754).\u003c/p\u003e\n\u003cp\u003eVATS demonstrated superior efficacy in preventing pneumothorax recurrence. The recurrence rate was significantly lower in the VATS group (12.1%, 4/33) compared to the chest tube group (48.5%, 16/33), with an absolute risk reduction (AAR) of 36.4% (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). This corresponds to a number needed to treat of 2.75, indicating that for every 3 patients treated with VATS instead of chest tube drainage, one additional recurrence would be prevented. Time-to-event analysis revealed markedly prolonged recurrence-free survival in the VATS group (median not reached, 95% confidence interval[CI]:48.99-59.62 months) versus the chest tube group (median 24 months, 95% CI:21.97-41.38 months; log-rank \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001)(Fig. 1). Cox proportional hazards analysis confirmed VATS independently reduced recurrence risk by 83.4% (\u003cem\u003eHR\u003c/em\u003e = 0.166, 95% CI:0.055-0.498, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eThe economic evaluation demonstrated that while VATS incurred higher initial costs (median \u0026yen;26,922, IQR 23,455-33,206 vs \u0026yen;6,256, IQR 3,769-9,306; \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001), it showed favorable cost-effectiveness. The ICER was \u0026yen;160,300 per QALY gained (or \u0026yen;48,937 per recurrence avoided), incorporating utility values of 1.0 for stable health, 0.7 during pneumothorax events, and 0.95 post-recovery, with an assumed 14-day recurrence duration (Table 2).[9,18,22] This resulted in a total QALY gain of 3.67 with VATS. The ICER remained substantially below China\u0026apos;s WHO-recommended WTP threshold of \u0026yen;287,247 per QALY gained (3\u0026times;GDP per capita).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSensitivity analyses confirmed the robustness of these findings across varying assumptions (Table 3). When pneumothorax utility values were decreased to 0.5, the ICER remained favorable at \u0026yen;156,338 per QALY gained. Even with a 20% increase in procedure costs (\u0026yen;705,395 total), the ICER of \u0026yen;192,200 per QALY gained stayed below the WHO threshold. At a 3% discount rate, the ICER was \u0026yen;159,800 per QALY gained with a cost-effectiveness acceptability probability of 98.49%. At a 6% discount rate, the ICER decreased to \u0026yen;138,029 per QALY gained while maintaining high cost-effectiveness acceptability (98.47%).\u003c/p\u003e\n\u003cp\u003eThe Monte Carlo simulation (n = 10,000 iterations) demonstrated consistent cost-effectiveness outcomes, with 100.0% of iterations in the cost-effectiveness plane (Fig. 2) falling within the northeast quadrant (higher effectiveness at higher cost), centered at an incremental cost of \u0026yen;587,829 and 3.67 QALYs gained. The acceptability curve analysis (Fig. 3) revealed a 99.14% probability of VATS being cost-effective at China\u0026apos;s WHO-recommended WTP threshold of \u0026yen;287,247 / QALY (3\u0026times;GDP per capita), decreasing to 3.57% probability at the lower 1\u0026times;GDP threshold of \u0026yen;95,749 / QALY.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePost-hoc analysis confirmed adequate statistical power (86.2%) for detecting the observed treatment effect. Hospital stay duration showed a clinically meaningful difference between groups (median 8 days, IQR 7-10.5 vs 7 days, IQR 4-10.5;\u003cem\u003e\u0026nbsp;P\u003c/em\u003e = 0.042). The comprehensive matching protocol and extensive sensitivity analyses address potential limitations related to the retrospective design while reinforcing the validity of our findings regarding both clinical outcomes and cost-effectiveness.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis propensity score-matched study demonstrates that VATS significantly reduces recurrence risk in first-episode PSP patients with pulmonary blebs while achieving robust cost-effectiveness. Our findings reveal a 36.4% absolute risk reduction (ARR) with VATS compared to chest tube drainage, translating to one recurrence prevented per three patients treated, alongside an 83.4% hazard reduction (\u003cem\u003eHR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.166) over 5 years. These results challenge current guideline recommendations favoring conservative management for initial episodes and provide evidence to support early surgical intervention in selected patients.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe clinical superiority of VATS aligns with emerging pathophysiological understanding of PSP. Large (\u0026gt;\u0026thinsp;5 cm) and numerous blebs, validated as independent recurrence predictors in contemporary studies, create structural vulnerabilities that chest tube drainage fails to address.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] VATS directly eliminates these substrates through bleb resection while pleural abrasion induces adhesions, reducing recurrence risk more effectively than reactive pleural inflammation from drainage alone.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Our data confirm that patients with radiologically confirmed blebs constitute a high-risk subgroup warranting aggressive initial management, particularly given the 48.5% recurrence rate observed in conservatively managed patients.\u003c/p\u003e\u003cp\u003eFrom a health economics perspective, VATS demonstrates compelling value despite higher upfront costs. The ICER of \u0026yen;160,300 per QALY gained falls substantially below China's WHO-recommended WTP threshold (\u0026yen;287,247 / QALY), with Monte Carlo simulations (n\u0026thinsp;=\u0026thinsp;10,000) confirming a 99.14% probability of cost-effectiveness. This economic viability persists even under conservative assumptions, including a 20% cost increase (ICER \u0026yen;192,200 / QALY), and addresses critical gaps in guideline development for resource-constrained settings.\u003c/p\u003e\u003cp\u003eThere exists an inverse relationship between discount rates and ICERs, whereby higher discount rates (6%) yield lower ICERs compared to lower rates (3%). This observation aligns with established principles in health economics. The majority of intervention costs are incurred at the outset (e.g., surgical procedures), making these costs relatively less sensitive to discounting. Health benefits are realized over the course of patients\u0026rsquo; lifetimes; consequently, higher discount rates significantly reduce the present value of quality-adjusted life years. It is important to note that the cost-effectiveness acceptability probability remained highly consistent (\u0026gt;\u0026thinsp;98.4%) across all scenarios involving varying discount rates. This stability underscores the robustness of the intervention\u0026rsquo;s value proposition under different discount rate assumptions within policy-relevant ranges. Furthermore, the utilization of real-world cost data in this analysis incorporate actual costs associated with disease recurrence across the treatment continuum with 1:1 PSM matching of basic patient information and bulla characteristics, thereby addressing a key limitation of previous model-based studies (individual differences).[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe 36.4% ARR provides particularly valuable information for shared decision-making. While relative risk metrics (83.4%) illustrate biological efficacy, ARR quantifies tangible clinical impact in patient-centric terms: without intervention, approximately half of first-episode patients with blebs will experience recurrence within five years; VATS reduces this risk by over one-third.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] This intuitive metric facilitates risk-benefit discussions with young patients weighing immediate recovery against long-term recurrence prevention.\u003c/p\u003e\u003cp\u003eMethodologically, this study advances PSP research through rigorous propensity score matching that balanced critical prognostic variables, including bleb size distribution and smoking status, achieving near-perfect covariate balance (mean SMD\u0026thinsp;=\u0026thinsp;0.081). This design minimizes selection bias inherent in retrospective comparisons and responds to calls for higher-quality real-world evidence in pneumothorax management. Our incorporation of itemized 10-year cost data further strengthens economic conclusions by capturing true resource utilization patterns beyond theoretical models.\u003c/p\u003e\u003cp\u003eSeveral limitations warrant consideration. The single-center retrospective design risks unmeasured confounding despite meticulous matching. Generalizability may be limited to similar healthcare economies. The 5-year follow-up might miss late recurrences beyond this window. Finally, our QALY estimates derived from population utility weights rather than direct patient measures, though extensive sensitivity analyses mitigate this concern.\u003c/p\u003e\u003cp\u003eThese findings translate to actionable practice recommendations: prioritizing VATS for first-episode PSP patients exhibiting large (\u0026gt;\u0026thinsp;5 cm) or numerous blebs on CT imaging represents the most immediate clinical application, given their 48.5% baseline recurrence risk with conservative management. Guideline committees should incorporate cost-effectiveness frameworks, particularly WHO-recommended thresholds, when formulating resource-conscious recommendations for diverse healthcare settings. For shared decision-making with patients, utilizing the AAR of 36.4% rather than relative risk metrics provides more intuitive understanding of intervention benefits, as this translates directly to preventing one recurrence per three patients treated. Health systems must concurrently develop clinical pathways enabling timely VATS access presentation, as delays increase recurrence-associated costs.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Future research should prospectively validate these findings across varied healthcare economies while exploring techniques like awake VATS that may enhance cost-effectiveness, alongside integrating patient-reported outcomes to refine utility estimations in this young population.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eVATS significantly reduces recurrence risk (83.4% hazard reduction; ARR\u0026thinsp;=\u0026thinsp;36.4%) versus chest tube drainage in first-episode PSP with blebs, with a median recurrence-free survival\u0026thinsp;\u0026gt;\u0026thinsp;48 months versus 24 months. Its ICER (\u0026yen;160,300 / QALY) falls below China\u0026rsquo;s WHO-recommended WTP threshold (\u0026yen;287,247 / QALY), supported by a 99.14% cost-effectiveness probability. These findings challenge current guidelines favoring conservative initial management and advocate for early VATS in high-risk patients with blebs. Guideline committees should integrate cost-effectiveness frameworks and WHO thresholds to promote value-based care. Future research should validate these outcomes prospectively and explore awake VATS to enhance accessibility.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eARR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eAbsolute Risk Reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eComputed Tomography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eGDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eGross Domestic Product\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eHazard Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eIBM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eInternational Business Machines\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eICER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eIncremental Cost-Effectiveness Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eInterquartile Range\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eNNT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eNumber Needed to Treat\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003ePSM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003ePropensity Score Matching\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003ePSP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003ePrimary Spontaneous Pneumothorax\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eQALY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eQuality-Adjusted Life-Year\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eSMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eStandardized Mean Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eVATS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eVideo-Assisted Thoracoscopic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eWTP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 506px;\"\u003e\n \u003cp\u003eWillingness-to-Pay\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCorrespondence to:\u0026nbsp;\u003c/strong\u003eQingcai Lin, MM; email: [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Ethics Committee of Longyan First Affiliated Hospital of Fujian Medical University (Approval No.: LYREC2025-K165-01). Patient consent was waived due to the retrospective nature of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQ.C.Lin 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, including and especially any adverse effects. Q.C.Lin contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript. All authors approved the final version for submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Department of Thoracic Surgery at Longyan First Affiliated Hospital of Fujian Medical University for their clinical support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Thoracic Surgery (Q.C. Lin.), Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBintcliffe OJ, Hallifax RJ, Edey A, Feller-Kopman D, Lee YCG, Marquette CH, et al. Spontaneous pneumothorax: time to rethink management? 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Pulmonology. 2022;28(4) :276\u0026ndash;83. https://doi.org/10.1016/j.pulmoe.2020.06.003.\u003c/li\u003e\n\u003cli\u003eWalker S, Hallifax R, Ricciardi S, Fitzgerald D, Keijzers M, Lauk O, et al. Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax. Eur Respir J. 2024;63(5) :2300797. https://doi.org/10.1183/13993003.00797-2023.\u003c/li\u003e\n\u003cli\u003eRoberts ME, Rahman NM, Maskell NA, Bibby AC, Blyth KG, Corcoran JP, et al. British Thoracic Society Guideline for pleural disease. Thorax. 2023;78(11) :1143\u0026ndash;56. https://doi.org/10.1136/thorax-2023-220304.\u003c/li\u003e\n\u003cli\u003eEamer G, Povolo CA, Petropoulos JA, Ohinmaa A, Vanhouwelingen L. Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis. Chest. 2023;164(4) :1007\u0026ndash;18. https://doi.org/10.1016/j.chest.2023.05.017.\u003c/li\u003e\n\u003cli\u003eMithiran H, Leow L, Ong K, Liew T, Siva D, Liang S, et al. Video-Assisted Thoracic Surgery (VATS) Talc Pleurodesis Versus Pleurectomy for Primary Spontaneous Pneumothorax: A Large Single-Centre Study with No Conversion. World J Surg. 2019;43(8) :2099\u0026ndash;105. https://doi.org/10.1007/s00268-019-05001-2.\u003c/li\u003e\n\u003cli\u003eJeong JY, Shin AY, Ha JH, Suh JH, Choi SY, Kim JS, et al. Natural History of Contralateral Bullae/Blebs After Ipsilateral Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax: A Retrospective Cohort Study. Chest. 2022;162(5) :1213\u0026ndash;22. https://doi.org/10.1016/j.chest.2022.05.001.\u003c/li\u003e\n\u003cli\u003eCzerny M, Salat A, Fleck T, Hofmann W, Zimpfer D, Eckersberger F, et al. Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax. Ann Thorac Surg. 2004;77(5) :1802\u0026ndash;5. https://doi.org/10.1016/j.athoracsur.2003.10.057.\u003c/li\u003e\n\u003cli\u003eTschopp JM, Boutin C, Astoul P, Janssen JP, Grandin S, Bolliger CT, et al. Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur Respir J. 2002;20(4) :1003\u0026ndash;9. https://doi.org/10.1183/09031936.02.00278202.\u003c/li\u003e\n\u003cli\u003eQureshi FG, Sandulache VC, Richardson W, Ergun O, Ford HR, Hackam DJ. Primary vs delayed surgery for spontaneous pneumothorax in children: which is better? J Pediatr Surg. 2005;40(1) :166\u0026ndash;9. https://doi.org/10.1016/j.jpedsurg.2004.09.042.\u003c/li\u003e\n\u003cli\u003eFalcoz PE, Binquet C, Clement F, Kaili D, Quantin C, Chocron S, et al. Management of the second episode of spontaneous pneumothorax: a decision analysis. Ann Thorac Surg. 2003;76(6) :1843\u0026ndash;8. https://doi.org/10.1016/s0003-4975(03)01324-9.\u003c/li\u003e\n\u003cli\u003eDivisi D, Di Leonardo G, Crisci R. Vats Versus Axillary Minithoracotomy in the Management of the Second Episode of Spontaneous Pneumothorax: Cost-Benefit Analysis. World J Surg. 2016;40(9) :2171\u0026ndash;7. https://doi.org/10.1007/s00268-016-3558-2.\u003c/li\u003e\n\u003cli\u003eDavis ML, Hall J, Taylor RA, Klemisch R, Farjah F, Hall MK. Management of Primary Spontaneous Pneumothorax in the Emergency Department: A Cost-Effectiveness Analysis. J Am Coll Emerg Physicians Open. 2025;6(4) :100209. https://doi.org/10.1016/j.acepjo.2025.100209.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. New cost-effectiveness updates from WHO-CHOICE [Internet]. Geneva: World Health Organization; [cited 2025 Aug 7]. Available from: https://www.who.int/news-room/feature-stories/detail/new-cost-effectiveness-updates-from-who-choice. \u003c/li\u003e\n\u003cli\u003eIino H, Hashiguchi M, Hori S. Estimating the range of incremental cost-effectiveness thresholds for healthcare based on willingness to pay and GDP per capita: A systematic review. PLoS One. 2022;17(4) :e0266934. https://doi.org/10.1371/journal.pone.0266934.\u003c/li\u003e\n\u003cli\u003e国家统计局. 2025年7月份国民经济运行情况 [Internet]. 2025 Jul 16 [cited 2025 Aug 7]. Available from: https://www.stats.gov.cn/sj/zxfb/202507/t20250716_1960426.html. \u003c/li\u003e\n\u003cli\u003eHoffman LA, Guttendorf J. Preparation and Evolving Role of the Acute Care Nurse Practitioner. CHEST. 2017;152(6) :1339\u0026ndash;45. https://doi.org/10.1016/j.chest.2017.08.007.\u003c/li\u003e\n\u003cli\u003eJouneau S, Ricard JD, Seguin-Givelet A, Big\u0026eacute; N, Contou D, Desmettre T, et al. SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax. Ann Intensive Care. 2023;13(1) :88. https://doi.org/10.1186/s13613-023-01181-2.\u003c/li\u003e\n\u003cli\u003eHuang N, He S, Chen S, Zhang G, Ruan L, Huang J. Incidence and risk factors for recurrent primary spontaneous pneumothorax after video-assisted thoracoscopic surgery: a systematic review and meta-analysis. J Thorac Dis. 2024;16(6) :3696\u0026ndash;710. https://doi.org/10.21037/jtd-24-175.\u003c/li\u003e\n\u003cli\u003eNonomura R, Yabe R, Oshima Y, Sasaki T, Ishibashi N, Sugawara T. Post-surgery spontaneous pneumothorax: Long-term recurrence rates and follow-up challenges revealed by a written survey. PLoS One. 2024;19(10) :e0307910. https://doi.org/10.1371/journal.pone.0307910.\u003c/li\u003e\n\u003cli\u003eOwen GS, Sullivan GA, Skertich NJ, Pillai S, Madonna MB, Shah AN, et al. Long-Term Recurrence Risk Following Pleurectomy or Pleurodesis for Primary Spontaneous Pneumothorax. J Surg Res. 2022;278 :132\u0026ndash;9. https://doi.org/10.1016/j.jss.2022.03.028.\u003c/li\u003e\n\u003cli\u003eSaad AB, Migaou A, Ammar M, Mhamed SC, Fahem N, Rouatbi N, et al. [Recurrence score to predict the risk of recurrence after first episode of primary spontaneous pneumothorax]. Pan Afr Med J. 2020;36 :107. https://doi.org/10.11604/pamj.2020.36.107.23432.\u003c/li\u003e\n\u003cli\u003eNg GYH, Nah SA, Teoh OH, Ong LY. Primary spontaneous pneumothorax in children: factors predicting recurrence and contralateral occurrence. Pediatr Surg Int. 2020;36(3) :383\u0026ndash;9. https://doi.org/10.1007/s00383-020-04619-x.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Baseline Characteristics Before and After Propensity Score Matching\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"554\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 99px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 152px;\"\u003e\n \u003cp\u003eBefore Matching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 152px;\"\u003e\n \u003cp\u003eAfter Matching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003eStatistical Analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eSMD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003eChest Tube (n=57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 81px;\"\u003e\n \u003cp\u003eVATS (n=188)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 70px;\"\u003e\n \u003cp\u003eChest Tube (n=33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 81px;\"\u003e\n \u003cp\u003eVATS (n=33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003ePre-Match Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003ePre-Match vs. Post-Match\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003ePost-Match Test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eCategorical Variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e46(80.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e161(85.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e28(84.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e28(84.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.404\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.131 vs. 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e11(19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e27(14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e5(15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e5(15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026lt;45 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e21(36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e161(85.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e16(48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e16(48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.725 vs. 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026ge;45 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e36(63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e27(14.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e17(51.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e17(51.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=1.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eSmoking state\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e23(40.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e136(72.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e11(33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e15(45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.679 vs. 0.252\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e34(59.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e52(27.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e22(66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e18(54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.125\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eThe laterality of PSP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e22(38.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e83(44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e13(39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e17(51.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.112 vs. 0.245\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e35(61.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e105(55.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e20(60.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e16(48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eDegree of lung collapse volume\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;30%-50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e26(45.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e93(49.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e14(42.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e12(36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.652\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.078 vs. 0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026gt;50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e31(54.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e95(50.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e19(57.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e21(63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.754\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eMaximum blebs diameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026lt;1 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e10(17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e127(67.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e8(24.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e10(30.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e1.175 vs. 0.137\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; 1-5 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e36(63.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e59(31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e23(69.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e21(63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.672 vs. 0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt;5 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e11(19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e2(1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e2(6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e2(6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.631 vs. 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNumber of blebs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e19(33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e163(86.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e16(48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e16(48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e1.300 vs. 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e21(36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e20(10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e13(39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e13(39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.648 vs. 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026gt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e17(29.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e5(2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e4(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e4(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.790 vs. 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eCombined with complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e20(35.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e47(25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e13(39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e12(36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eNo complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e37(64.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e141(75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e20(60.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e21(63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eStatus of recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e26(45.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e22(11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e16(48.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e4(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eNo recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e31(54.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e166(88.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e17(51.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e29(87.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.004\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003eContinuous Variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e53(41-62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e28(21-37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e50(28.5-59.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e46(26-57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e7(4.5-10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e8(6-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e7(4-10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e8(7-10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e=0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eTime to recurrence (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e15(2-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e60(60-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e15(2-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e60(60-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eTotal cost(\u0026yen;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e6,218(3,791-9,100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e25,247(20,656-28,766)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e6,256(3,769-9,306)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e26,922(23,455-33,206)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: IQR, Interquartile range; PSP, Primary spontaneous pneumothorax; SMD, Standardized mean difference; VATS, Video-assisted thoracoscopic surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData presented as n (%) for categorical variables and median (IQR) for continuous variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePropensity score matching (1:1, caliper = 0.02) achieved negligible imbalance (mean SMD: 0.631\u0026rarr;0.081). Pre-matching p-values from Chi-square test, Fisher\u0026rsquo;s exact test and Mann-Whitney U test. Post-matching p-values from McNemar test, Bowker\u0026rsquo;s test, Paired t-test and Wilcoxon signed-rank test. The PSM algorithm and the baseline characteristics before and after matching are detailed in Appendix 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eCost-Effectiveness Analysis of VATS versus Chest Tube\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"553\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eMetric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 372px;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eIncremental Cost (\u0026Delta;Cost)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 372px;\"\u003e\n \u003cp\u003e\u0026yen;17,813 per patient\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eIncremental Effect (\u0026Delta;Effect)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 372px;\"\u003e\n \u003cp\u003e36.4% recurrences avoided\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eICER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 372px;\"\u003e\n \u003cp\u003e\u0026yen;160,300 per QALY gained (or \u0026yen;48,937 per recurrence avoided)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eWHO Threshold\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 372px;\"\u003e\n \u003cp\u003e\u0026yen; 287,247 per QALY gained (3\u0026times;GDP)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003eConclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 372px;\"\u003e\n \u003cp\u003eVATS cost-effective\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: GDP, Gross domestic product; ICER, Incremental cost-effectiveness ratio; QALY, Quality-adjusted life-year; WHO, World Health Organization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO threshold = 3\u0026times;GDP per capita (\u0026yen;287,247 / QALY in China). Utilities: Stable: 1.0; Pneumothorax: 0.7; Post-recovery: 0.95; Recurrence duration: 14 days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eSensitivity Analysis of Cost-Effectiveness\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eParameter Varied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eScenario\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026Delta;Cost (\u0026yen;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026Delta;QALY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003eICER (\u0026yen; / QALY)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCE Probability at WTP Thresholds\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eBase Case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e587,829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e160,300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9914\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003ePneumothorax utility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eReduced to 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e587,829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e156,338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9881\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003ePneumothorax utility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eIncreased to 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e587,829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e162,384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9807\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eRecurrence Duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eShortened (7 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e587,829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e163,286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9806\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eRecurrence Duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003eExtended (21 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e587,829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e157,200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9856\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eCost variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e+20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e705,395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e192,200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9322\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eCost variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e-20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e470,263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e128,100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eDiscount Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e587,091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e159,970\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9873\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eDiscount Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e506,565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e159,800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9849\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 131px;\"\u003e\n \u003cp\u003eDiscount Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e587,076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003e138,029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.9847\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: CE, cost-effectiveness; WTP, willingness-to-pay.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary spontaneous pneumothorax, Video-assisted thoracoscopic surgery, Chest tube drainage, Cost-effectiveness analysis, Propensity score matching","lastPublishedDoi":"10.21203/rs.3.rs-7363743/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7363743/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOptimal management for first-episode primary spontaneous pneumothorax (PSP) with pulmonary blebs remains uncertain, balancing recurrence prevention against procedural costs. This study compared video-assisted thoracoscopic surgery (VATS) and chest tube drainage in terms of recurrence prevention and cost-effectiveness, incorporating sensitivity analyses to evaluate robustness across variable assumptions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn a retrospective cohort (2010\u0026ndash;2020), 245 first-episode PSP patients with computed tomography (CT)-confirmed blebs were included. Propensity score matching (1:1, caliper\u0026thinsp;=\u0026thinsp;0.02) balanced baseline characteristics (age, bleb size, etc.), generating 33 matched pairs. Primary outcomes were recurrence rate and incremental cost-effectiveness ratio (ICER).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eVATS reduced 5-year recurrence rates from 48.5\u0026ndash;12.1% \u003cem\u003e(P\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004; absolute risk reduction [ARR]\u0026thinsp;=\u0026thinsp;36.4%, number needed to treat [NNT]\u0026thinsp;=\u0026thinsp;2.75) and improved recurrence-free survival (hazard ratio [HR]\u0026thinsp;=\u0026thinsp;0.166, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The base-case ICER was \u0026yen;160,300 per quality-adjusted life-year (QALY) gained (\u0026yen;48,937 per recurrence avoided), with 99.14% probability of cost-effectiveness at China\u0026rsquo;s World Health Organization (WHO)-recommended willingness-to-pay (WTP) threshold (\u0026yen;287,247 / QALY). Sensitivity analyses confirmed robustness: ICER remained favorable at \u0026yen;156,338 / QALY when pneumothorax utility dropped to 0.5; a 20% cost increase yielded \u0026yen;192,200 / QALY. Discount rate variations (3%: \u0026yen;159,800 / QALY; 6%: \u0026yen;138,029 / QALY) maintained\u0026thinsp;\u0026gt;\u0026thinsp;98.4% cost-effectiveness probability.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eVATS reduces recurrence by 83.4% in first-episode PSP with blebs and demonstrates robust cost-effectiveness. Early surgical intervention should be considered for patients with blebs across diverse resource settings.\u003c/p\u003e","manuscriptTitle":"Efficacy and Cost-Effectiveness of VATS Versus Chest Tube Drainage in First-Episode Primary Spontaneous Pneumothorax With Blebs: A Propensity Score-Matched Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 11:05:19","doi":"10.21203/rs.3.rs-7363743/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-24T07:44:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-15T17:39:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197664831216736520175122969755730824590","date":"2025-10-03T08:49:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333053926767249036798997670021673578509","date":"2025-10-02T06:33:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T13:02:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T02:44:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4928621608664221930736550457148909216","date":"2025-09-01T11:34:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211313866373854110230450743226712247567","date":"2025-08-27T21:36:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244900160843617100882721219054949847820","date":"2025-08-27T12:47:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211562279588827706495579722464143845147","date":"2025-08-27T10:41:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-27T10:38:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-25T21:50:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-22T09:04:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T09:03:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-08-13T10:03:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91ed54e2-fae0-4bc5-ae48-3a5d230395be","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:04:39+00:00","versionOfRecord":{"articleIdentity":"rs-7363743","link":"https://doi.org/10.1186/s12890-026-04155-9","journal":{"identity":"bmc-pulmonary-medicine","isVorOnly":false,"title":"BMC Pulmonary Medicine"},"publishedOn":"2026-02-05 15:59:41","publishedOnDateReadable":"February 5th, 2026"},"versionCreatedAt":"2025-08-18 11:05:19","video":"","vorDoi":"10.1186/s12890-026-04155-9","vorDoiUrl":"https://doi.org/10.1186/s12890-026-04155-9","workflowStages":[]},"version":"v1","identity":"rs-7363743","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7363743","identity":"rs-7363743","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}