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Surgical decortication is recommended by national guidelines for management of early empyema, but intrapleural fibrinolysis is frequently used as a first-line therapy in clinical practice. This study compared the cost effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema. A decision analysis model was developed. The base clinical case was a 65-year-old male with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator (tPA) and de