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

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.