RESUMO
Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.
Assuntos
Cateteres de Demora , Falha de Equipamento , Diálise Renal , Humanos , Diálise Renal/economia , Diálise Renal/instrumentação , Cateteres de Demora/efeitos adversos , Cateteres de Demora/economia , Masculino , Falência Renal Crônica/terapia , Pessoa de Meia-Idade , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/economia , Cateterismo Venoso Central/instrumentação , Análise Custo-Benefício , Feminino , Remoção de Dispositivo/métodos , Remoção de Dispositivo/economia , Desenho de EquipamentoRESUMO
BACKGROUND: The optimal duration of infusion set use to prevent life-threatening catheter-related bloodstream infection (CRBSI) is unclear. We aimed to compare the effectiveness and costs of 7-day (intervention) versus 4-day (control) infusion set replacement to prevent CRBSI in patients with central venous access devices (tunnelled cuffed, non-tunnelled, peripherally inserted, and totally implanted) and peripheral arterial catheters. METHODS: We did a randomised, controlled, assessor-masked trial at ten Australian hospitals. Our hypothesis was CRBSI equivalence for central venous access devices and non-inferiority for peripheral arterial catheters (both 2% margin). Adults and children with expected greater than 24 h central venous access device-peripheral arterial catheter use were randomly assigned (1:1; stratified by hospital, catheter type, and intensive care unit or ward) by a centralised, web-based service (concealed before allocation) to infusion set replacement every 7 days, or 4 days. This included crystalloids, non-lipid parenteral nutrition, and medication infusions. Patients and clinicians were not masked, but the primary outcome (CRBSI) was adjudicated by masked infectious diseases physicians. The analysis was modified intention to treat (mITT). This study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12610000505000 and is complete. FINDINGS: Between May 30, 2011, and Dec, 9, 2016, from 6007 patients assessed, we assigned 2944 patients to 7-day (n=1463) or 4-day (n=1481) infusion set replacement, with 2941 in the mITT analysis. For central venous access devices, 20 (1·78%) of 1124 patients (7-day group) and 16 (1·46%) of 1097 patients (4-day group) had CRBSI (absolute risk difference [ARD] 0·32%, 95% CI -0·73 to 1·37). For peripheral arterial catheters, one (0·28%) of 357 patients in the 7-day group and none of 363 patients in the 4-day group had CRBSI (ARD 0·28%, -0·27% to 0·83%). There were no treatment-related adverse events. INTERPRETATION: Infusion set use can be safely extended to 7 days with resultant cost and workload reductions. FUNDING: Australian National Health and Medical Research Council.
Assuntos
Infecções Relacionadas a Cateter/etiologia , Cateterismo Venoso Central/instrumentação , Cateterismo Periférico/instrumentação , Idoso , Austrália , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/economia , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/economia , Criança , Pré-Escolar , Remoção de Dispositivo/economia , Contaminação de Equipamentos/estatística & dados numéricos , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-IdadeRESUMO
Background: Antimicrobial lock solutions are a low-cost strategy that can reduce the incidence of central line-associated bloodstream infection (CLABSI). The aim of this study was to evaluate the cost-effectiveness of antimicrobial locks for the prevention of CLABSI. Methods: We constructed a decision-analytic model comparing antimicrobial lock solutions to heparin locks for the prevention of CLABSI in 3 settings: hemodialysis, cancer treatment, and home parenteral nutrition. Cost-effectiveness was determined by calculating CLABSIs prevented and incremental cost-effectiveness ratios. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. Results: In probabilistic analysis, at a willingness to pay of $50000, antimicrobial lock solutions had a 96.24% chance of being cost-effective, compared with heparin locks in the hemodialysis setting, an 88.00% chance in the cancer treatment setting, and a 92.73% chance in the home parenteral nutrition setting. In base-case analysis, antimicrobial lock solutions resulted in savings of $68721.03 for the hemodialysis setting, $85061.41 for the cancer setting, and $78513.83 for the home parenteral nutrition setting per CLABSI episode prevented. Conclusions: In 3 distinct and clinically important settings (hemodialysis, cancer treatment, and home parenteral nutrition), antimicrobial lock solutions are an effective strategy for the prevention of CLABSI, and their use can result in significant healthcare savings.
Assuntos
Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/métodos , Análise Custo-Benefício , Desinfetantes/administração & dosagem , Desinfecção/métodos , Sepse/prevenção & controle , Infecções Relacionadas a Cateter/economia , Cateterismo Venoso Central/economia , Desinfecção/economia , Humanos , Incidência , Sepse/economiaRESUMO
BACKGROUND: Ultrasound guidance for central venous catheterization is a commonly used alternative to the conventional landmark method. Because from the German perspective, the cost-effectiveness of ultrasound guidance is unclear, this study examined the cost-effectiveness of ultrasound guidance versus the landmark method for adults undergoing a central venous catheterization. METHODS: A decision-tree based model was built to estimate the costs of averted catheter-related complications. Clinical data (e.g. arterial puncture, failed attempts) were obtained from a Cochrane review and a randomized controlled trial, whilst information about cost parameters were taken from a German hospital of maximum care. The analysis was conducted from the perspective of the German Statutory Health Insurance. Results were presented as incremental cost-effectiveness ratios. To assess the parameter uncertainty, several sensitivity analyses were performed (deterministic, probabilistic and with regard to the model structure). RESULTS: Our analysis revealed that ultrasound guidance resulted in fewer complications per person (0.04 versus 0.17 for the landmark method) and was less expensive (51 versus 230 for the landmark method). Results were robust to changes in the model parameters and in the model structure. Whilst our model population reflected approximately 49% of adults undergoing a central venous catheterization cannulation per year, structural sensitivity analyses (e.g. extending the study cohort to patients at higher baseline risk of complications, pediatric patients, or using real-time/indirect catheterization) indicated the cost-effectiveness of ultrasound guidance for a broader spectrum of patients. The results should be interpreted by considering the assumptions (e.g. target population) and approximations (e.g. cost parameters) underpinning the model. CONCLUSIONS: Ultrasound guidance for central venous catheterization averts more catheter-related complications and may save the resources of the German Statutory Health Insurance compared with landmark method.
Assuntos
Cateterismo Venoso Central/economia , Análise Custo-Benefício/métodos , Técnicas de Apoio para a Decisão , Ultrassonografia de Intervenção/economia , Cateterismo Venoso Central/métodos , Árvores de Decisões , Humanos , Ultrassonografia de Intervenção/métodosRESUMO
This article reports the results of three prospective clinical studies conducted in a university hospital regarding the efficacy, safety and cost effectiveness of a subcutaneously anchored sutureless system for securing central venous catheters. The results were favourable to the adoption of such a device, and the analysis of the data allowed the authors to define those categories of patients where the device should have the most benefit: neonates, children, non-compliant older patients with cognitive difficulties, patients with skin abnormalities that may reduce the effectiveness of a skin-adhesive sutureless securement system, patients who are candidates for having a peripherally inserted central catheter (PICC) in place for more than 8 weeks, and any other category of patients with a recognised high risk of catheter dislodgement.
Assuntos
Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/métodos , Cateteres Venosos Centrais , Idoso , Idoso de 80 Anos ou mais , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/economia , Cateterismo Periférico/instrumentação , Criança , Pré-Escolar , Análise Custo-Benefício , Hospitais Universitários , Humanos , Lactente , Recém-Nascido , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Reino UnidoRESUMO
Catheter-related infections and dysfunction are the main catheter complications causing morbidity and mortality in hemodialysis patients. However, there are no consistent data for the choice of catheter lock solutions for tunneled hemodialysis lines. In this prospective, multicenter, randomized, controlled trial, two lock regimens using three commercial catheter lock solutions were compared in 106 hemodialysis patients with a newly inserted tunneled central catheter. In the taurolidine group, TauroLock™-Hep500 was used twice per week and TauroLock™-U25,000 once a week. In the citrate group, a four percent citrate solution was used after each dialysis. Both groups were compared regarding catheter-related infections, catheter dysfunction, and costs. Over a period of 15,690 catheter days, six catheter-related infections occurred in six of 52 patients in the taurolidine group, but 18 occurred in 13 of 54 patients in the citrate group, corresponding to 0.67 and 2.7 episodes of catheter-related infections per 1000 catheter days, respectively (Incidence Rate Ratio 0.25, 95% confidence interval, 0.09 to 0.63). Catheter dysfunction rates were significantly lower in the taurolidine group (18.7 vs. 44.3/1000 catheter days) and alteplase rescue significantly more frequent in the citrate group (9.8 vs. 3.8/1000 catheter days). These differences provided significant catheter-related cost savings of 43% in the taurolidine group vs. citrate group when overall expenses per patient and year were compared. Thus, use of taurolidine-based catheter lock solutions containing heparin and urokinase significantly reduced complications related to tunneled hemodialysis catheters when compared to four percent citrate solution and was overall more cost-efficient.
Assuntos
Anti-Infecciosos/uso terapêutico , Obstrução do Cateter , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/instrumentação , Cateteres de Demora , Cateteres Venosos Centrais , Diálise Renal , Taurina/análogos & derivados , Tiadiazinas/uso terapêutico , Adulto , Idoso , Anti-Infecciosos/efeitos adversos , Anti-Infecciosos/economia , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Áustria , Obstrução do Cateter/economia , Obstrução do Cateter/etiologia , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/economia , Infecções Relacionadas a Cateter/microbiologia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/economia , Cateteres de Demora/efeitos adversos , Cateteres de Demora/economia , Cateteres Venosos Centrais/efeitos adversos , Cateteres Venosos Centrais/economia , Redução de Custos , Análise Custo-Benefício , Custos de Medicamentos , Desenho de Equipamento , Falha de Equipamento , Feminino , Fibrinolíticos/economia , Fibrinolíticos/uso terapêutico , Heparina/economia , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Diálise Renal/economia , Fatores de Risco , Taurina/efeitos adversos , Taurina/economia , Taurina/uso terapêutico , Tiadiazinas/efeitos adversos , Tiadiazinas/economia , Fatores de Tempo , Resultado do Tratamento , Ativador de Plasminogênio Tipo Uroquinase/economia , Ativador de Plasminogênio Tipo Uroquinase/uso terapêuticoRESUMO
AIM: Commencement of haemodialysis with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is associated with improved survival compared with commencement with a central venous catheter. In 2011-2012, Queensland Health made incentive payments to renal units for early referred patients who commenced peritoneal dialysis (PD), or haemodialysis with an AVF/AVG. The aim of this study was to determine if pay for performance improved clinical care. METHODS: All patients who commenced dialysis in Australia between 2009 and 2014 and were registered with the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were included. A multivariable regression model was used to compare rates of commencing dialysis with a PD catheter or permanent AVF/AVG during the pay-for-performance period (2011-2012) with periods prior (2009-2010) and after (2013-2014). RESULTS: A total of 10 858 early referred patients commenced dialysis during the study period, including 2058 in Queensland. In Queensland, PD as first modality increased with time (P < 0.001) but there was no change in AVF/AVG rate at first haemodialysis (P = 0.5). In a multivariate model using the pay-for-performance period as reference, the odds ratio for commencement with PD or haemodialysis with an AVF/AVG in Queensland was 1.02 (95% CI 0.81-1.29) in 2009-2010 and 1.28 (95% CI 1.01-1.61) in 2013-2014. There was no change for the rest of Australia (0.97 95% CI 0.87-1.09 in 2009-2010 and 1.00 95% CI 0.90-1.11 in 2013-14). CONCLUSION: Pay for performance did not improve rates of commencement of dialysis with PD or an AVF/AVG during the payment period. A lag effect on clinical care may explain the improvement in later years.
Assuntos
Derivação Arteriovenosa Cirúrgica/economia , Implante de Prótese Vascular/economia , Cateterismo Venoso Central/economia , Diálise Peritoneal/economia , Avaliação de Processos em Cuidados de Saúde/economia , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Reembolso de Incentivo/economia , Diálise Renal/economia , Adolescente , Adulto , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/tendências , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/tendências , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/tendências , Distribuição de Qui-Quadrado , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal/tendências , Padrões de Prática Médica/economia , Avaliação de Processos em Cuidados de Saúde/tendências , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Queensland , Encaminhamento e Consulta/economia , Reembolso de Incentivo/tendências , Diálise Renal/efeitos adversos , Diálise Renal/tendências , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Patients in the United States frequently initiate hemodialysis with a central venous catheter (CVC) and subsequently undergo placement of a new arteriovenous fistula (AVF) or arteriovenous graft (AVG). Little is known about the clinical and economic effects of initial vascular access choice. We identified 479 patients starting hemodialysis with a CVC at a large medical center (during 2004-2012) who subsequently had an AVF (n=295) or AVG (n=105) placed or no arteriovenous access (CVC group, n=71). Compared with patients receiving an AVG, those receiving an AVF had more frequent surgical access procedures per year (1.01 [95% confidence interval, 0.95 to 1.08] versus 0.62 [95% confidence interval, 0.55 to 0.70]; P<0.001) but a similar frequency of percutaneous access procedures per year. Patients receiving an AVF had a higher median annual cost (interquartile range) of surgical access procedures than those receiving an AVG ($4857 [$2523-$8835] versus $2819 [$1411-$4274]; P<0.001), whereas the annual cost of percutaneous access procedures was similar in both groups. The AVF group had a higher median overall annual access-related cost than the AVG group ($10,642 [$5406-$19,878] versus $6810 [$3718-$13,651]; P=0.001) after controlling for patient age, sex, race, and diabetes. The CVC group had the highest median annual overall access-related cost ($28,709 [$11,793-$66,917]; P<0.001), largely attributable to the high frequency of hospitalizations due to catheter-related bacteremia. In conclusion, among patients initiating hemodialysis with a CVC, the annual cost of access-related procedures and complications is higher in patients who initially receive an AVF versus an AVG.
Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Cateterismo Venoso Central/efeitos adversos , Cateteres de Demora/efeitos adversos , Falência Renal Crônica/etiologia , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Adulto , Idoso , Fístula Arteriovenosa , Vasos Sanguíneos/transplante , Cateterismo Venoso Central/economia , Comorbidade , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/economia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Peripheral inserted central catheters (PICCs) have increasingly become the mainstay of patients requiring prolonged treatment with antibiotics, transfusions, oncologic IV therapy and total parental nutrition. They may also be used in delivering a number of other medications to patients. In recent years, bed occupancy rates have become hugely pressurized in many hospitals and any potential solutions to free up beds is welcome. Recent introductions of doctor or nurse led intravenous (IV) outpatient based treatment teams has been having a direct effect on early discharge of patients and in some cases avoiding admission completely. The ability to deliver outpatient intravenous treatment is facilitated by the placement of PICCs allowing safe and targeted treatment of patients over a prolonged period of time. We carried out a retrospective study of 2,404 patients referred for PICCs from 2009 to 2015 in a university teaching hospital. There was an exponential increase in the number of PICCs requested from 2011 to 2015 with a 64% increase from 2012 to 2013. The clear increase in demand for PICCs in our institution is directly linked to the advent of outpatient intravenous antibiotic services. In this paper, we assess the impact that the use of PICCs combined with intravenous outpatient treatment may have on cost and hospital bed demand. We advocate that a more widespread implementation of this service throughout Ireland may result in significant cost savings as well as decreasing the number of patients on hospital trollies.
Assuntos
Assistência Ambulatorial/economia , Ocupação de Leitos/economia , Cateterismo Venoso Central/economia , Redução de Custos , Tempo de Internação/economia , Assistência Ambulatorial/estatística & dados numéricos , Ocupação de Leitos/estatística & dados numéricos , Cateterismo Periférico , Cateteres de Demora , Hospitais Universitários , Humanos , Irlanda , Tempo de Internação/estatística & dados numéricos , Estudos RetrospectivosRESUMO
OBJECTIVE: Early cannulation arteriovenous grafts (ecAVGs) are proposed as an alternative to tunneled central venous catheters (TCVCs) in patients requiring immediate vascular access for hemodialysis (HD). We compared bacteremia rates in patients treated with ecAVG and TCVC. METHODS: The study randomized 121 adult patients requiring urgent vascular access for HD in a 1:1 fashion to receive an ecAVG with or without (+/-) an arteriovenous fistula (AVF; n = 60) or TCVC+/-AVF (n = 61). Patients were excluded if they had active systemic sepsis, no anatomically suitable vessels, or an anticipated life expectancy <3 months. The primary end point was the culture-proven bacteremia rate at 6 months, with the trial powered to detect a reduction in bacteremia from 24% to 5% (α = .05, ß = .8). Secondary end points included thrombosis, reintervention, and mortality. A cost-effectiveness analysis was also performed. RESULTS: Culture-proven bacteremia developed in 10 patients (16.4%) in the TCVC arm ≤6 months compared with two (3.3%) in the ecAVG+/-AVF arm (risk ratio, 0.2; 95% confidence interval, 0.12-0.56; P = .02). Mortality was also higher in the TCVC+/-AVF cohort (16% [n = 10] vs 5% [n = 3]; risk ratio, 0.3; 95% CI, 0.08-0.45; P = .04). The difference in treatment cost between the two arms was not significant (£11,393 vs £9692; P = .24). CONCLUSIONS: Compared with TCVC+/-AVF, a strategy of ecAVG+/-AVF reduced the rate of culture-proven bacteremia and mortality in patients requiring urgent vascular access for HD. The strategy also proved to be cost-neutral.
Assuntos
Implante de Prótese Vascular/economia , Prótese Vascular/economia , Cateterismo Venoso Central/economia , Cateterismo/economia , Cateteres de Demora/economia , Cateteres Venosos Centrais/economia , Custos de Cuidados de Saúde , Diálise Renal/economia , Adulto , Idoso , Bacteriemia/diagnóstico , Bacteriemia/economia , Bacteriemia/microbiologia , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/economia , Infecções Relacionadas a Cateter/microbiologia , Cateterismo/efeitos adversos , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/mortalidade , Cateteres de Demora/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/economia , Infecções Relacionadas à Prótese/microbiologia , Fatores de Risco , Escócia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Simulation is quickly becoming vital to resident education, but commercially available central line models are costly and little information exists to evaluate their realism. This study compared an inexpensive homemade simulator to three commercially available simulators and rated model characteristics. MATERIALS AND METHODS: Seventeen physicians, all having placed >50 lines in their lifetime, completed blinded central line insertions on three commercial and one homemade model (made of silicone, tubing, and a pressurized pump system). Participants rated each model on the realism of its ultrasound image, cannulation feel, manometry, and overall. They then ranked the models based on the same variables. Rankings were assessed with Friedman's and post hoc Conover's tests, using alphas 0.05 and 0.008 (Bonferroni corrected), respectively. RESULTS: The models significantly differed (P < 0.0004) in rankings across all dimensions. The homemade model was ranked best on ultrasound image, manometry measurement, cannulation feel, and overall quality by 71%, 67%, 53%, and 77% of raters, respectively. It was found to be statistically superior to the second rated model in all (P < 0.003) except cannulation feel (P = 0.134). Ultrasound image and manometry measurement received the lowest ratings across all models, indicating less realistic simulation. The cost of the homemade model was $400 compared to $1000-$8000 for commercial models. CONCLUSIONS: Our data suggest that an inexpensive, homemade central line model is as good or better than commercially available models. Areas for potential improvement within models include the ultrasound image and ability to appropriately measure manometry of accessed vessels.
Assuntos
Cateterismo Venoso Central , Internato e Residência/métodos , Modelos Anatômicos , Treinamento por Simulação/métodos , Cateterismo Venoso Central/economia , Cateterismo Venoso Central/métodos , Humanos , Internato e Residência/economia , Treinamento por Simulação/economia , Método Simples-Cego , Ultrassonografia de Intervenção , Estados UnidosRESUMO
Background Placement of central venous port catheters (CVPS) and peripherally inserted central catheters (PICC) is an integral component of state-of-the-art patient care. In the era of increasing cost awareness, it is desirable to have more information to comprehensively assess both procedures. Purpose To perform a retrospective analysis of interventional radiologic implantation of CVPS and PICC lines in a large patient population including a cost analysis of both methods as well as an investigation the learning curve in terms of the interventions' durations. Material and Methods All CVPS and PICC line related interventions performed in an interventional radiology department during a three-year period from January 2011 to December 2013 were examined. Documented patient data included sex, venous access site, and indication for CVPS or PICC placement. A cost analysis including intervention times was performed based on the prorated costs of equipment use, staff costs, and expenditures for disposables. The decrease in intervention duration in the course of time conformed to the learning curve. Results In total, 2987 interventions were performed by 16 radiologists: 1777 CVPS and 791 PICC lines. An average implantation took 22.5 ± 0.6 min (CVPS) and 10.1 ± 0.9 min (PICC lines). For CVPS, this average time was achieved by seven radiologists newly learning the procedures after performing 20 CVPS implantations. Total costs per implantation were 242 (CVPS) and 201 (PICC lines). Conclusion Interventional radiologic implantations of CVPS and PICC lines are well-established procedures, easy to learn by residents, and can be implanted at low costs.
Assuntos
Cateterismo Venoso Central/economia , Cateterismo Venoso Central/métodos , Análise Custo-Benefício/economia , Curva de Aprendizado , Serviço Hospitalar de Radiologia/economia , Radiologia/educação , Cateterismo Venoso Central/instrumentação , Cateteres Venosos Centrais/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia Intervencionista/economia , Estudos Retrospectivos , Fatores de TempoRESUMO
Peripherally inserted central catheter (PICC) and umbilical venous catheter (UVC) in terms of success rate, complications, cost and time of insertion in neonatal intensive care were compared. Neonates requiring vascular access for minimum 7 days were included. Sample size of 72 per group was determined. Trial was registered at Clinical Trials Registry of India (CTRI/2015/02/005529). Success rates of the UVC and PICC were 68.1% and 65.3%, respectively (p = 0.724). Mean (SD) time needed for PICC and UVC insertion was 34.13 (34.69) and 28.31 (17.19) min, respectively (p = 0.205). Mean (SD) cost of PICC insertion vs. UVC insertion was 60.9 (8.6) vs. 11.9 (8.7) US dollars (p < 0.0001). Commonest cause for failure of UVC was displacement [6 (8.3%)] and that for PICC was blockage [9 (12.5%)]. CONCLUSIONS: UVC is a cheaper alternative to PICC, with similar success rate, short-term complications and time needed for insertion.
Assuntos
Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/economia , Cateterismo Periférico/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Índia , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Risco , Fatores de Tempo , Veias UmbilicaisRESUMO
BACKGROUND: In the United Kingdom, totally implantable venous access systems (TIVAS) are not routinely used. Compared with Hickman catheters, these devices are more expensive and complex to insert. However, it is unclear whether the higher costs may be offset by perceived greater health benefits. This pilot trial aimed to generate relevant data to inform the design of a larger definitive randomised controlled trial. METHODS: This was a phase II prospective, randomised, open trial from two UK oncology centres. The primary end point was overall complication rate. Secondary end points included individual complication rates, time to first complication and quality of life. Analysis was by intention to treat. An economic evaluation was also carried out. RESULTS: A total of 100 patients were randomised in a 3 : 1 ratio to receive a Hickman or a TIVAS. Overall, 54% of patients in the Hickman arm suffered one or more complications compared with 38% in the TIVAS arm (one-sided P=0.068). In the Hickman arm, 28% of the devices were removed prematurely due to a complication compared with 4% in the TIVAS arm. Quality of life based on the device-specific questionnaire was greater in the TIVAS arm for 13 of the 16 questions. The economic evaluation showed that Hickman arm was associated with greater mean cost per patient £1803 (95% CI 462, 3215), but similar quality-adjusted life years -0.01 (95% CI -0.15, 0.15) than the TIVAS arm. However, there is much uncertainty associated with the results. CONCLUSIONS: Compared with Hickman catheters, TIVAS may be the cost-effective option. A larger multicentre trial is needed to confirm these preliminary findings.
Assuntos
Cateterismo Venoso Central/métodos , Sistemas de Liberação de Medicamentos/métodos , Tratamento Farmacológico/métodos , Cateterismo Venoso Central/economia , Análise Custo-Benefício , Sistemas de Liberação de Medicamentos/economia , Tratamento Farmacológico/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: In end-stage renal disease patients with central venous obstruction, who have limited vascular access options, the Hemodialysis Reliable Outflow (HeRO) Graft is a new alternative with a lower incidence of complications and longer effective device life compared to tunneled dialysis catheters (TDCs). We undertook an economic analysis of introducing the HeRO Graft in the UK. METHODS: A 1-year cost-consequence decision analytic model was developed comparing management with the HeRO Graft to TDCs from the perspective of the National Health Service in England. The model comprises four 3-month cycles during which the vascular access option either remains functional for hemodialysis or fails, patients can experience access-related infection and device thrombosis, and they can also accrue associated costs. Clinical input data were sourced from published studies and unit cost data from National Health Service 2014-15 Reference Costs. RESULTS: In the base case, a 100-patient cohort managed with the HeRO Graft experienced 6 fewer failed devices, 53 fewer access-related infections, and 67 fewer device thromboses compared to patients managed with TDCs. Although the initial device and placement costs for the HeRO Graft are greater than those for TDCs, savings from the lower incidence of device complications and longer effective device patency reduces these costs. Overall net annual costs are £2600 for each HeRO Graft-managed patient compared to TDC-managed patients. If the National Health Service were to reimburse hemodialysis at a uniform rate regardless of the type of vascular access, net 1-year savings of £1200 per patient are estimated for individuals managed with the HeRO Graft. CONCLUSIONS: The base case results showed a marginal net positive cost associated with vascular access with the HeRO Graft compared with TDCs for the incremental clinical benefit of reductions in patency failures, device-related thrombosis, and access-related infection events in a patient population with limited options for dialysis vascular access.
Assuntos
Implante de Prótese Vascular/economia , Prótese Vascular/economia , Cateterismo Venoso Central/economia , Cateteres de Demora/economia , Cateteres Venosos Centrais , Custos de Cuidados de Saúde , Falência Renal Crônica/economia , Falência Renal Crônica/terapia , Diálise Renal/economia , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Obstrução do Cateter/economia , Obstrução do Cateter/etiologia , Infecções Relacionadas a Cateter/economia , Infecções Relacionadas a Cateter/microbiologia , Infecções Relacionadas a Cateter/terapia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/instrumentação , Cateteres de Demora/efeitos adversos , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Inglaterra , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/terapia , Humanos , Falência Renal Crônica/diagnóstico , Modelos Econômicos , Desenho de Prótese , Falha de Prótese , Infecções Relacionadas à Prótese/economia , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/terapia , Medicina Estatal/economia , Trombose/economia , Trombose/etiologia , Trombose/terapia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Comparison of two kinds of cannulation (double-lumen cannula [DLC, Avalon Elite Bicaval Dual Lumen Catheter] and conventional cannulation with two cannulas) for venovenous extracorporeal membrane oxygenation (ECMO) therapy in terms of effectiveness, usage complexity, and costs. METHODS: Retrospective case series of 17 patients who received venovenous ECMO therapy due to acute respiratory distress syndrome (ARDS) between January 2010 and March 2012. Nine patients were treated with the DLC and eight patients with conventional cannulation. We analyzed the outcome data, ECMO values, respirator settings, blood gas values, realized prone positioning, and costs, and compared both methods. RESULTS: Both kinds of cannulation are efficient regarding oxygenation and decarboxylation. There is no significant difference in mortality, hospitalization time (intensive care unit [ICU] and hospital) and complications during ECMO therapy between both groups. Cannula implantation is much more complex in the DLC group and requires more experience in TEE (transesophageal echocardiography) diagnostics and cannulation technique. In addition, the costs for the Avalon (MAQUET Cardiopulmonary AG, Germany) cannula are significantly higher than for conventional cannulation. Furthermore, prone positioning could be easier achieved in the DLC group. CONCLUSION: In summary, double-lumen cannulation allows sufficient gas exchange with more effort (material, technical, and physicians' experience) and higher costs but better mobilization possibilities (particularly prone position) and potential avoidance of deep sedation and mechanical ventilation. From the current point of view, the DLC should be reserved for special cases.
Assuntos
Cateterismo Venoso Central/instrumentação , Cateterismo Periférico/instrumentação , Oxigenação por Membrana Extracorpórea/instrumentação , Síndrome do Desconforto Respiratório/terapia , Dispositivos de Acesso Vascular , Adulto , Idoso , Gasometria , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/economia , Cateterismo Venoso Central/métodos , Cateterismo Venoso Central/mortalidade , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/economia , Cateterismo Periférico/métodos , Cateterismo Periférico/mortalidade , Competência Clínica , Ecocardiografia Transesofagiana , Desenho de Equipamento , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/economia , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Custos de Cuidados de Saúde , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente , Seleção de Pacientes , Decúbito Ventral , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/economia , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Peripherally Inserted Central Catheter or PICC Line and implanted subcutaneous ports are two types of central catheters allowing drug administration and blood samplings. These two devices are very controversial (because of infectious and thrombotic complications), it seemed interesting to estimate their cost of implantation and to correlate them with the reimbursement by the Health Insurance. MATERIALS AND METHODS: Direct (material and drugs) and indirect (use of the room and staff) costs were prospectively evaluated for PICC Lines and implanted subcutaneous ports. RESULTS: The global costs of the implantation of a PICC Line and of an implanted subcutaneous port in the interventional radiology room and in the operating room were respectively evaluated at 220.2 , 286.6 and 666.3 . DISCUSSION-CONCLUSION: Only a PICC Line in outpatients can be reimbursed by the health insurance; which amounts to 110.4 . The establishment therefore loses money with every implantation. However, PICC Lines offer to the patients a fast access to a central venous way and thus an optimal therapeutic care, fulfilling one of the main missions of the public health institutions. Implanted subcutaneous ports are economically worth being implanted only in ambulatory inpatients. Its implantation in radiology seemed more profitable because the indirect costs were much more moderate.
Assuntos
Cateterismo Venoso Central/economia , Injeções Subcutâneas/economia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/economia , Custos e Análise de Custo , Humanos , Injeções Subcutâneas/efeitos adversos , Injeções Subcutâneas/instrumentação , Pessoa de Meia-IdadeRESUMO
BACKGROUND: No randomized trials have so far investigated the cost effectiveness of different methods for implantation and use of central venous ports in oncology patients. PATIENTS AND METHODS: Overall, 403 patients eligible for receiving intravenous chemotherapy for solid tumours were randomly assigned to implantation of a single type of port, either through a percutaneous landmark access to the internal jugular vein, an ultrasound (US)-guided access to the subclavian vein, or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Insertion and maintenance costs were estimated by obtaining the charges for an average implant and use, while the costs of the management of complications were analytically assessed. The total cost was defined as the purchase cost plus the insertion cost plus the maintenance cost plus the cost of treatment of the complications, if any. RESULTS: A total of 401 patients were evaluable-132 with the internal jugular vein, 136 with the subclavian vein and 133 with the cephalic vein access. No differences were found for the rate of early complications. The US-guided subclavian insertion site had significantly lower failures. Infections occurred in 1, 3, and 3 patients (internal jugular, subclavian, and cephalic access, respectively; p = 0.464), whereas venous thrombosis was observed in 15, 8, and 11 patients, respectively (p = 0.272). Mean cost for purchase, implantation, diagnosis and treatment of complications in each patient was
Assuntos
Antineoplásicos/administração & dosagem , Cateterismo Venoso Central/economia , Cateteres de Demora/economia , Análise Custo-Benefício , Bombas de Infusão Implantáveis/economia , Neoplasias/tratamento farmacológico , Neoplasias/economia , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Humanos , Veias Jugulares , Masculino , Pessoa de Meia-Idade , Neoplasias/patologia , Prognóstico , Adulto JovemRESUMO
BACKGROUND: The early removal of central intravenous (IV) catheters, as a means of reducing the incidence of central line-associated blood stream infections (CLABSI), remains a major health care initiative. However, attaining IV access in the surgical intensive care unit (SICU) can be quite difficult. We report the success of a novel, resident-driven program for the placement of ultrasound-guided midline catheters in critically ill patients. MATERIALS AND METHODS: A prospective pilot study of 31 subjects admitted to the SICU from June to December 2011 was performed. Intermediate-length (20 cm) midline catheters were placed by trained housestaff, under ultrasound guidance, into the basilic or cephalic veins. Procedural details including time to cannulation, complications, and costs were recorded. RESULTS: Successful placement was achieved in 96.8% (n = 30), with a mean follow-up of 9.8 ± 5.6 (range 2-21) days. An average of 1.3 ± 0.7 (range 1-4) attempts with a median of 13.0 ± 14.5 (range 0.5-68) minutes was required for successful venous cannulation. The most common site was the basilic vein (n = 23). Only minor complications were encountered; three catheters leaked at the insertion site and one patient developed phlebitis. No CLABSI occurred. The total procedure cost was $87 per catheter for the SICU team compared with $1500 per catheter when performed by an interventional radiologist. During the study period, a total of 283 central line days were avoided with an estimated cost savings of $13,614. CONCLUSIONS: Ultrasound-guided midline catheters placed by the housestaff are a cost-effective alternative for patients in the SICU with difficult IV access. Successful placement can help facilitate early central line removal and thus may reduce CLABSI rates.
Assuntos
Cateterismo Venoso Central/métodos , Cuidados Críticos/métodos , Remoção de Dispositivo/métodos , Custos Hospitalares , Ultrassonografia de Intervenção/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Venoso Central/economia , Análise Custo-Benefício , Cuidados Críticos/economia , Estado Terminal/terapia , Remoção de Dispositivo/economia , Feminino , Seguimentos , Humanos , Internato e Residência , Masculino , Corpo Clínico Hospitalar , Pessoa de Meia-Idade , Projetos Piloto , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Ultrassonografia de Intervenção/economiaRESUMO
PURPOSE: Indwelling central venous catheters (CVCs) have been increasingly used to enable delivery of intravenous chemotherapy. We aimed to compare the safety and cost of two commonly used CVCs, peripherally inserted central venous catheter (PICCs) and ports, in the delivery of chemotherapy in patients with non-haematological malignancies. METHODS: Seventy patients were randomly assigned to receive either a PICC or a port. The primary endpoint was occurrence of major complications, which required removal of the CVC and secondary endpoints included occurrence of any complications. RESULTS: Port devices were associated with fewer complications compared with PICC lines (hazard ratio of 0.25, CI, 0.09-0.86, P = 0.038). Major complication rate was lower in the port arm compared to the PICC arm (0.047 versus 0.193 major complications/100 catheter days, P = 0.034) with 6 versus 20 % of patients experiencing major complications, respectively. Thrombosis, the most common complication, was significantly higher in the PICC arm compared to the port arm (25 versus 0 %, P = 0.013). Quality of life and cost estimates did not differ significantly between the two arms. CONCLUSIONS: Port devices are associated with a lower risk of complications, with no difference in cost, compared to PICC lines in patients with non-haematological malignancies receiving intravenous chemotherapy.