The Role of Health Insurance in Patient Reported Satisfaction with Bladder Management in Neurogenic Lower Urinary Tract Dysfunction Due to Spinal Cord Injury.

PURPOSE: Neurogenic lower urinary tract dysfunction is a significant source of morbidity for individuals with spinal cord injury and is managed with a range of treatment options that differ in efficacy, tolerability and cost. The effect of insurance coverage on bladder management, symptoms and quality of life is not known. We hypothesized that private insurance is associated with fewer bladder symptoms and better quality of life. MATERIALS AND METHODS: This is a cross-sectional, retrospective analysis of 1,226 surveys collected as part of the prospective Neurogenic Bladder Research Group SCI Registry. We included patients with complete insurance information, which was classified as private or public insurance. The relationship between insurance and bladder management, bladder symptoms and quality of life was modeled using multinomial logistic regression analysis. Spinal cord injury quality of life was measured by the Neurogenic Bladder Symptom Score. RESULTS: We identified 654 privately insured and 572 publicly insured individuals. The demographics of these groups differed by race, education, prevalence of chronic pain and bladder management. Publicly insured patients were more likely to be treated with indwelling catheters or spontaneous voiding and less likely to take bladder medication compared to those with private insurance. On multivariate analysis insurance type was not associated with differences in bladder symptoms (total Neurogenic Bladder Symptom Score) or in urinary quality of life. CONCLUSIONS: There is an association between insurance coverage and the type of bladder management used following spinal cord injury, as publicly insured patients are more likely to be treated with indwelling catheters. However, insurance status, controlling for bladder management, did not impact bladder symptoms or quality of life.

The validity of validation: A practical assessment.

OBJECTIVE: To assess the time to achieve reliable reporting of electronic health record data compared with manual reporting during validation. DESIGN: Secondary analysis of aggregate data for number of patients present, number of patients with a central venous catheter, and number of patients with an indwelling urinary catheter during validation of an electronic health record reporting tool. SETTING: Mayo Clinic Health System in Wisconsin. PARTICIPANTS: Mayo Clinic infection prevention and control staff, unit champions, and all inpatients. METHODS: We simultaneously collected electronic and manual counts of device data and compared discrepancies to determine their source. If manual data entry was incorrect, manual counts were coded as inaccurate. If electronically abstracted data did not reflect an accurate count, errors were attributed to the system. Data were compared using standard statistical methods. RESULTS: Within 30 days after beginning validation of electronic reporting for central venous catheter days and urinary catheter days, electronic counts were durably more reliable than manual counts. CONCLUSIONS: Manual validation for capturing and reporting electronic data and reporting can be shorter than the 90 days currently mandated by National Healthcare Safety Network criteria. Compared with a longer validation period, a shorter validation period may yield substantial savings while achieving the same validity.

Cost analysis comparison between peripherally inserted central catheters and implanted chest ports in patients with cancer-A health economic evaluation of the PICCPORT trial.

BACKGROUND: A reliable central venous access device is a cornerstone in the treatment of cancer. Both peripherally inserted central catheters (PICC) and totally implanted chest ports (PORT) are commonly used for the delivery of chemotherapy. Both types of catheter can cause adverse events such as catheter-related deep venous thrombosis (CR-DVT), infection and mechanical complications. METHOD: We conducted a randomized controlled trial including 399 patients with cancer and performed a health economic evaluation investigating the cost related to PICCs and PORTs using several clinically relevant dimensions from a healthcare perspective. The cost was determined using process and cost estimate models. RESULT: PICCs are associated with a higher total cost when compared with PORTs. Combining the costs of all categories, the prize per inserted device was 824.58 EUR for PICC and 662.34 EUR for PORT. When adjusting for total catheter dwell time the price was 6.58 EUR/day for PICC and 3.01 EUR/day for PORT. The difference in CR-DVT was the main contributor to the difference in cost. The daily cost of PICC is approximately twice to that of PORT. CONCLUSION: We have demonstrated that the cost from a healthcare perspective is higher in cancer patients receiving a PICC than to those with a PORT. The difference is driven mainly by the cost related to the management of adverse events. Our findings are relevant to anaesthetists, oncologists and vascular access clinicians and should be considered when choosing vascular access device prior to chemotherapy.

A Randomized Trial Comparing Outcomes of 3 Types of Peripheral Intravenous Catheters.

BACKGROUND: There was an increase in peripheral intravenous catheter (PIVC) complications and adverse patient events after product conversion during the merger between a rural hospital and a larger hospital system. A review of the existing literature identified a gap in evidence evaluating 2 closed PIVC systems compared with an open PIVC system. PURPOSE: The purpose of the current project was to ascertain whether open or closed PIVCs are best for patients, staff, and the health care system in terms of 3 main criteria: quality, safety, and cost. METHODS: A prospective, 2-site randomized controlled trial was used to compare outcomes. RESULTS: There were no differences in the complication rates between catheter types. There was a statistically significant increase in blood leakage and a decrease in clinician satisfaction with the open-system catheter. CONCLUSIONS: Our project supports current clinical recommendation that a closed PIVC system, regardless of type, is not only safer and cost-effective but also preferred by patients and clinicians.

Low rate of intraperitoneal port placement in ovarian cancer patients, a population-based assessment.

INTRODUCTION: The National Comprehensive Cancer Network (NCCN) guidelines recommend intraperitoneal chemotherapy in optimally debulked stage III ovarian cancer patients. The objective of this investigation was to determine the rate of intraperitoneal port placement in patients undergoing surgery for ovarian cancer in a national database maintained by the American College of Surgeons. METHOD: We identified ovarian cancer patients in the National Surgical Quality Improvement Program database from 2006 to 2012. Demographics, comorbidities, operative outcomes, and postoperative complications were abstracted. Descriptive analyses were conducted using Wilcoxon rank-sum and Chi square tests, and multivariate regression models were used to analyze pre-operative and post-operative variables associated with intraperitoneal port placement. RESULTS: We identified 2659 ovarian cancer patients who underwent primary surgical management. Of these patients, only 128 (4.8%) had an intraperitoneal port placed at the time of surgery. In multivariable analyses, intraperitoneal ports were associated with body mass index ≤25, disseminated cancer, later portion of the study period (2009-2012), and operative time >200 min. Intraperitoneal port placement was not associated with any difference in surgical site infection, wound disruption, major postoperative complication, readmission within 30 days, or death within 30 days. DISCUSSION: Recent investigation of practice at NCCN institutions between 2003 and 2012 found only 35% of eligible ovarian cancer patients received intraperitoneal chemotherapy. Using intraperitoneal port placement as a surrogate for intraperitoneal chemotherapy administration, our investigation suggests an even lower rate (4.8%) nationally.

Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters.

PURPOSE: The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS: A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS: Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION: Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making.

Urinary tract infection after acute stroke: Impact of indwelling urinary catheterization and assessment of catheter-use practices in French stroke centers.

INTRODUCTION: Urinary catheterization and acute urinary retention increase the risk of urinary tract infection (UTI). Our study aimed to investigate the incidence of UTI following acute stroke at our stroke center (SC) and to assess urinary catheter-care practices among French SCs. METHODS: Stroke patients hospitalized within 24h of stroke onset were prospectively enrolled between May and September 2013. Neurological deficit level was assessed on admission using the US National Institutes of Health Stroke Scale (NIHSS). Patients were followed-up until discharge. Indwelling urinary catheterization (IUC) was the only technique authorized during the study. An electronic survey was also conducted among French SCs to assess their practices regarding urinary catheterization in acute stroke patients. RESULTS: A total of 212 patients were included, with 45 (21.2%) receiving indwelling urinary catheters. The overall estimated incidence of UTI was 14.2%, and 18% among patients receiving IUC. On univariate analysis, IUC was significantly associated with older age, longer hospital stays and higher NIHSS scores. Of the 30 SCs that responded to our survey, 19 (63.3%) declared using IUC when urinary catheterization was needed. The main argument given to justify its use was that it was departmental policy to adopt this technique. Also, 27 participants (90%) stated that conducting a study to assess the impact of urinary catheterization techniques on UTI rates in acute stroke patients would be relevant. DISCUSSION: Our results are in accord with previously reported data and confirm the high burden of UTI among acute stroke subjects. However, no association was found between IUC and UTI on univariate analysis due to a lack of statistical power. Also, our survey showed high heterogeneity in catheter-use practices among French SCs, but offered no data to help determine the best urinary catheterization technique. CONCLUSION: Urinary catheterization is common after acute stroke and a well-known risk factor of UTI. However, as high heterogeneity in catheter-use practices is found among French SCs, randomized studies comparing the efficacy of urinary catheterization techniques in terms of UTI prevention in acute stroke patients are now warranted.

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study.

BACKGROUND: Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy. METHODS: In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated. DISCUSSION: This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications. TRIAL REGISTRATION: Dutch trial registry: NTR6015 . Registered 9 August 2016.

Investigation into the causes of indwelling urethral catheter implementation and its effects on clinical outcomes and health care resources among dementia patients with pneumonia: A retrospective cohort study.

There is a possibility that unnecessary treatments and low-quality medical care, such as inappropriate indwelling urethral catheter use, are being provided to older Japanese individuals.The aim of this study was to investigate contextual effects relating to indwelling urethral catheters in older people with dementia and to clarify the effects of indwelling urethral catheter use on patients' mortality, length of stay (LOS), and health care spending. This retrospective cohort study involved 4501 male and female Japanese participants. Those who were aged 75 or older with dementia and had a primary diagnosis of acute lower respiratory disease with antibiotics administered during hospitalization were eligible for inclusion. Patient mortality, LOS, and total charge during hospitalization were the main study outcomes. This study showed that indwelling urethral catheter use was significantly associated with higher mortality, longer LOS, and higher total charge for hospitalization. The pattern of indwelling urethral catheter use was clustered by care facility level. Physician density was significantly associated with indwelling urethral catheter use; the relationship was not linear but U-shaped, such that the approximate median had the lowest rate of urethral catheter use and this increased gradually toward both lower and higher physician densities. Our study found considerable variation in indwelling urethral catheter use between care facilities in older people with dementia. Additionally, indwelling urethral catheter use was related to poor outcomes. Based on these findings, we consider there to be an urgent need for constructing a framework to measure, report on, and promote the improvement of care quality for older individuals in Japan.

Barriers to reducing urinary catheter use: a qualitative assessment of a statewide initiative.

IMPORTANCE: Preventing catheter-associated urinary tract infection (CAUTI), a common health care-associated infection, is important for improving the care of hospitalized patients and in meeting the goals for reduction of health care-associated infections set by the US Department of Health and Human Services. OBJECTIVE: To identify ways to enhance CAUTI prevention efforts based on the experiences of hospitals participating in the Michigan Health and Hospital Association Keystone Center for Patient Safety statewide program to reduce unnecessary use of urinary catheters (the Bladder Bundle). DESIGN: Qualitative assessment of data collected through semistructured telephone interviews with key informants at 12 hospitals and in-person interviews and site visits at 3 of the 12 hospitals. The analysis focused on perceptions and key issues identified by hospitals as influencing implementation of CAUTI prevention practices as recommended by the Bladder Bundle initiative. SETTING: Twelve purposefully sampled hospitals in Michigan. PARTICIPANTS: Key informants including infection preventionists, clinical personnel, and senior executives. RESULTS: Common barriers to Bladder Bundle implementation and appropriate urinary catheter use included (1) difficulty with nurse and physician engagement, (2) patient and family request for indwelling catheters, and (3) catheter insertion practices and customs in the emergency department. Strategies to address these barriers were also identified by several of the participating hospitals, including (1) incorporating urinary management (eg, planned toileting) as part of other patient safety programs, such as a fall reduction program, (2) explicitly discussing the risks of indwelling urinary catheters with patients and families, and (3) engaging with emergency department nurses and physicians to implement a process that ensures that appropriate indications for catheter use are followed. CONCLUSIONS AND RELEVANCE: The Bladder Bundle program provides a model for implementing strategies to reduce CAUTI. These findings provide actionable information to inform CAUTI prevention-related activities in hospitals throughout the country.

Pediatric visits to United States Emergency Departments for alcohol-related disorders.

BACKGROUND: The use of alcohol by pediatric patients has not been thoroughly examined in the United States (US). Patients with complaints related to alcohol use frequently present to the Emergency Department initially. OBJECTIVE: Our aim was to determine the number of pediatric patients (ages 17 years and younger) presenting to Emergency Departments (EDs) in the US from 2006 to 2008 for alcohol-related disorders and examine selected clinical and demographic features of this population. METHODS: This was a retrospective cohort study using 3 years (2006-2008) of data from the Nationwide Emergency Department Sample. This database was used to identify patients younger than 18 years of age with an alcohol-related ED visit, and clinical and demographic features were examined. RESULTS: From 2006 to 2008, a total of 218,514 pediatric patients presented to US EDs and received a subsequent diagnosis of an alcohol-related disorder. Mean age of patients was 15.61 years. Most patients were male and tended to be from higher-income communities. CONCLUSIONS: There were 218,514 visits to US EDs by patients younger than 18 years of age for alcohol-related disorders, accounting for >$850 million dollars in charges. ED-based brief alcohol interventions shown to work in adult populations should be explored for use in pediatric patients.

A vascular access coordinator improves the prevalent fistula rate.

The Centers for Medicare and Medicaid Services set the prevalent arteriovenous fistula (AVF) rate of 66% as a national standard. To test the hypothesis that the use of a clinical vascular access coordinator could increase the rate of AVF in a large Nephrology group practice, we implemented an aggressive, multidisciplinary vascular access improvement program led by a trained vascular access coordinator (VAC). In early 2009, we established protocols, approved by all physicians, for the care of vascular access and implemented by a nurse VAC. We retrospectively reviewed Network vascular access data reports from January 2008 through December 2010. The data show that after the implementation of a comprehensive access program led by a VAC, the prevalent AVF rate increased from 50% to 65%. The number of grafts decreased while the percentage of dialysis catheters used for more than 90 days was cut in half. These data suggest that despite an unchanged catheter rate at dialysis initiation, the use of a VAC implementing an aggressive, multidisciplinary access program can significantly increase the AVF rate while decreasing grafts and prevalent catheter use.

Care and cost-utility indicators for high-flow PICC catheters: a study.

Intravenous therapy teams (IVTT) provide care, education and supervision of the patient with a central line, and his/her family. This article discusses the creation of an IVTT in the Hospital Clínico San Carlos of Madrid, Spain, demonstrating its effectiveness using cost-utility analysis and outcomes indicators. In 2009 the IVTT began using a high-flow peripherally inserted central catheter (PICC) with its target population of chronic patients dependent on central venous catheters or prolonged IV treatment. The team designed activity, welfare, educational and economic indicators. Of the 98 catheters placed, 80% of patients achieved a positive response; 42% of catheters were removed after death and 30% by the end of treatment. Four percent were removed due to infection. The average implantation duration was 45 days. The economic study showed an increasing cost saving compared to peripheral catheters after 90 days of implantation, and after 77 days compared to central venous catheters. This translated into an immediate saving of 161 euros (£133.70) and 303.83 euros (£252.31) per catheter over Hickman lines and ports, as well as reduced risks, length of hospital stays and costs. The study shows PICC to be cost-effective with reported benefits to patients, professionals and organizations. The creation of the IVTT has resulted in improvements to care and the management of resources.

Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value.

BACKGROUND AND OBJECTIVE: Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs. RESEARCH DESIGN: CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV. RESULTS: ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs. CONCLUSIONS: The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.

A rehabilitation hospital's experience with ionic silver Foley catheters.

A small rehabilitation hospital in northern Arkansas had a problem with catheter-associated urinary tract infections (CAUTI). A review of practices and policies provided no reason for the trend. The facility trialed an ionic silver Foley catheter finding that it dramatically reduced the incidence of CAUTI in their patient population.

Catheter outcomes in home infusion.

Intravenous catheter outcomes are a prominent topic for healthcare providers whose patients receive intravenous medications. There are thousands of products being marketed today claiming to improve catheter outcomes, thus improving overall patient outcomes and reducing provider costs associated with catheter infections and replacement. Catheter-related bloodstream infections (CR-BSIs) cost hospitals between $5000 and $34,000 per infection, and 12% to 25% of bloodstream infections are attributable to patient mortality. Products that claim to prevent CR-BSIs and subsequently reduce the number of bloodstream infections are a multimillion-dollar industry.

Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis.

AIM: This paper is a report of a systematic review and meta-analysis of strategies, other than antimicrobial coated catheters, hypothesized to reduce risk of catheter-related bloodstream infections and catheter colonization in the intensive care unit setting. BACKGROUND: Catheter-related bloodstream infections occur at a rate of 5 per 1000 catheter days in the intensive care unit setting and cause substantial mortality and excess cost. Reducing risk of catheter-related bloodstream infections among intensive care unit patients will save costs, reduce length of stay, and improve outcomes. METHODS: A systematic review of studies published between January 1985 and February 2007 was carried out using the keywords 'catheterization - central venous' with combinations of infection*, prevention* and bloodstream*. All included studies were screened by two reviewers, a validated data extraction instrument was used and data collection was completed by two blinded independent reviewers. Risk ratios for catheter-related bloodstream infections and catheter colonization were estimated with 95% confidence intervals for each study. Results from studies of similar interventions were pooled using meta-analyses. RESULTS: Twenty-three studies were included in the review. The strategies that reduced catheter colonization included insertion of central venous catheters in the subclavian vein rather than other sites, use of alternate skin disinfection solutions before catheter insertion and use of Vitacuff in combination with polymyxin, neomycin and bacitracin ointment. Strategies to reduce catheter-related bloodstream infection included staff education multifaceted infection control programmes and performance feedback. CONCLUSION: A range of interventions may reduce risks of catheter-related bloodstream infection, in addition to antimicrobial catheters.

Effectiveness of multifaceted hospitalwide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand.

OBJECTIVE: To evaluate the efficacy of a multifaceted hospitalwide quality improvement program that featured an intervention to remind physicians to remove unnecessary urinary catheters. METHODS: A hospitalwide preintervention-postintervention study was conducted over 2 years (July 1, 2004, through June 30, 2006). The intervention consisted of nurse-generated daily reminders that were used by an intervention team to remind physicians to remove unnecessary urinary catheters, beginning 3 days after insertion. Clinical, microbiological, pharmaceutical, and cost data were collected. RESULTS: A total of 2,412 patients were enrolled in the study. No differences were found in the demographic and/or clinical characteristics of patients between the preintervention and postintervention periods. After the intervention, reductions were found in the rate of inappropriate urinary catheterization (mean rate, preintervention vs postintervention, 20.4% vs 11% [P=.04]), the rate of catheter-associated urinary tract infection (CA-UTI) (mean rate, 21.5 vs 5.2 infections per 1,000 catheter-days [P<.001]), the duration of urinary catheterization (mean, 11 vs 3 days [P<.001]), and the total length of hospitalization (mean, 16 vs 5 days [P<.001]). A linear relationship was seen between the monthly average duration of catheterization and the rate of CA-UTI (r=0.89; P<.001). The intervention had the greatest impact on the rate of CA-UTI in the intensive care units (mean rate, preintervention vs postintervention, 23.4 vs 3.5 infections per 1,000 catheter-days [P=.01]). The monthly hospital costs for antibiotics to treat CA-UTI were reduced by 63% (mean, $3,739 vs $1,378 [P<.001]), and the hospitalization cost for each patient during the intervention was reduced by 58% (mean, $366 vs $154 [P<.001]). CONCLUSIONS: This study suggests that a multifaceted intervention to remind physicians to remove unnecessary urinary catheters can significantly reduced the duration of urinary catheterization and the CA-UTI rate in a hospital in a developing country.