Peripherally Inserted Central Catheter Versus Centrally Inserted Central Catheter for In-Hospital Infusion Therapy: A Cost-Effectiveness Analysis.

OBJECTIVES: To evaluate the comparative effectiveness and cost-effectiveness of peripherally inserted central catheters (PICCs) compared with centrally inserted central catheters (CICCs). METHODS: Prospective cohort study was followed by an economic analysis over a 30-day time horizon. Propensity score matching was used to select hospitalized adults with similar indications for PICC or CICC. The composite outcome was device removal or replacement because of complications before the end of treatment. The economic evaluation was based on a decision tree model for cost-effectiveness analysis, with calculation of the incremental cost-effectiveness ratio (ICER) per catheter removal avoided. All costs are presented in Brazilian reais (BRL) (1 BRL = 0.1870 US dollar). RESULTS: A total of 217 patients were followed in each group; 172 (79.3%) of those receiving a PICC and 135 (62.2%) of those receiving a CICC had no device-related complication, respectively. When comparing the events leading to device removal, the risk of composite endpoint was significantly higher in the CICC group (hazard ratio 0.20; 95% CI 0.11-0.35). The cost of PICC placement was BRL 1290.98 versus BRL 467.16 for a CICC. In the base case, the ICER for placing a PICC instead of a CICC was BRL 3349.91 per removal or replacement avoided. On univariate sensitivity analyses, the model proved to be robust within an ICER range of 2500.00 to 4800.00 BRL. CONCLUSIONS: PICC placement was associated with a lower risk of complications than CICC placement. Although the cost of a PICC is higher, its use avoided complications and need for catheter replacement before the end of treatment.

[Ultrasound-guided umbilical venous catheterisation: A cost-effectiveness analysis]. / Cateterización venosa umbilical guiada por ultrasonografía: un análisis de coste-efectividad.

INTRODUCTION: Although the use of ultrasound for the insertion of central catheters has proven to be cost-effective in adults, it is not known if this is the case in the neonatal population. This study compared the cost-effectiveness of ultrasound-guided umbilical venous catheterisation with conventional catheterisation in a neonatal intensive care unit of a Public University Hospital. PATIENTS AND METHODS: A retrospective observational study was conducted on newborns that required an umbilical venous catheter before completing their first 24hours of extra-uterine life. Two retrospective cohorts were formed, including one with ultrasound-guided catheterisation and the other with conventional catheterisation. The effectiveness was measured using 2 variables: placement of ideal position and insertion without complications. The cost of human and material resources (consumable and non-consumable), the cost-effectiveness ratio, and the incremental cost-effectiveness ratio were estimated, as well as carrying out a sensitivity analysis. RESULTS: Catheter obstruction was more frequent in guided catheterisation than in conventional catheterisation (7.7% vs. 0%, p=.04) and catheter dysfunction was higher in the latter (79% vs. 3.8%, p<.0001). The cost-effectiveness ratio of the guided catheterisation was €153.9, and €484.6 for the conventional one. The incremental cost-effectiveness ratio was €45.5. The sensitivity analysis showed a €2.6 increase in the cost-effectiveness ratio of the guided catheterisation and €47 in the conventional one. CONCLUSIONS: The use of ultrasound to guide umbilical catheterisation is more efficient than conventional catheterisation since, despite using more economic resources, it offers greater effectiveness.

Direct cost of maintenance of totally implanted central venous catheter patency.

OBJECTIVE: to identify the average direct cost of maintaining the patency of totally implanted central venous catheter with heparin at a Day Hospital of a public hospital of high complexity specialized in the treatment of cancer patients, and estimate the average direct cost of replacing heparin with sodium chloride 0.9%. METHOD: quantitative, exploratory-descriptive study, with a sample of 200 non-participant observations of the maintenance of totally implanted central venous catheters with heparin. The average direct cost was calculated by multiplying the (clocked) time spent by professionals to complete the procedure by the direct unit cost of workforce, added to the cost of materials and solutions. RESULTS: the estimated total direct cost of catheter maintenance with heparin was US$ 9.71 (SD=1.35) on average, ranging from US$ 7.98 to US$ 23.28. The estimated total direct cost of maintenance with 0.9% sodium chloride in the place of heparin was US$ 8.81 (SD=1.29) on average, resulting in a reduction of US$ 0.90 per procedure. CONCLUSION: the results contributed to propose strategies to assist in cost containment/minimization in this procedure. The replacement of heparin by 0.9% sodium chloride proved to be an option to reduce the total average direct cost.

Thromboelastometry versus standard coagulation tests versus restrictive protocol to guide blood transfusion prior to central venous catheterization in cirrhosis: study protocol for a randomized controlled trial.

BACKGROUND: Liver failure patients have traditionally been empirically transfused prior to invasive procedures. Blood transfusion is associated with immunologic and nonimmunologic reactions, increased risk of adverse outcomes and high costs. Scientific evidence supporting empirical transfusion is lacking, and the best approach for blood transfusion prior to invasive procedures in cirrhotic patients has not been established so far. The aim of this study is to compare three transfusion strategies (routine coagulation test-guided - ordinary or restrictive, or thromboelastometry-guided) prior to central venous catheterization in critically ill patients with cirrhosis. METHODS/DESIGN: Design and setting: a double-blinded, parallel-group, single-center, randomized controlled clinical trial in a tertiary private hospital in São Paulo, Brazil. INCLUSION CRITERIA: adults (aged 18 years or older) admitted to the intensive care unit with cirrhosis and an indication for central venous line insertion. Patients will be randomly assigned to three groups for blood transfusion strategy prior to central venous catheterization: standard coagulation tests-based, thromboelastometry-based, or restrictive. The primary efficacy endpoint will be the proportion of patients transfused with any blood product prior to central venous catheterization. The primary safety endpoint will be the incidence of major bleeding. Secondary endpoints will be the proportion of transfusion of fresh frozen plasma, platelets and cryoprecipitate; infused volume of blood products; hemoglobin and hematocrit before and after the procedure; intensive care unit and hospital length of stay; 28-day and hospital mortality; incidence of minor bleeding; transfusion-related adverse reactions; and cost analysis. DISCUSSION: This study will evaluate three strategies to guide blood transfusion prior to central venous line placement in severely ill patients with cirrhosis. We hypothesized that thromboelastometry-based and/or restrictive protocols are safe and would significantly reduce transfusion of blood products in this population, leading to a reduction in costs and transfusion-related adverse reactions. In this manner, this trial will add evidence in favor of reducing empirical transfusion in severely ill patients with coagulopathy. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02311985 . Retrospectively registered on 3 December 2014.

Evaluation of cost-effectiveness from the funding body's point of view of ultrasound-guided central venous catheter insertion compared with the conventional technique.

OBJECTIVE: To evaluate the cost-effectiveness, from the funding body's point of view, of real-time ultrasound-guided central venous catheter insertion compared to the traditional method, which is based on the external anatomical landmark technique. METHODS: A theoretical simulation based on international literature data was applied to the Brazilian context, i.e., the Unified Health System (Sistema Único de Saúde - SUS). A decision tree was constructed that showed the two central venous catheter insertion techniques: real-time ultrasonography versus external anatomical landmarks. The probabilities of failure and complications were extracted from a search on the PubMed and Embase databases, and values associated with the procedure and with complications were taken from market research and the Department of Information Technology of the Unified Health System (DATASUS). Each central venous catheter insertion alternative had a cost that could be calculated by following each of the possible paths on the decision tree. The incremental cost-effectiveness ratio was calculated by dividing the mean incremental cost of real-time ultrasound compared to the external anatomical landmark technique by the mean incremental benefit, in terms of avoided complications. RESULTS: When considering the incorporation of real-time ultrasound and the concomitant lower cost due to the reduced number of complications, the decision tree revealed a final mean cost for the external anatomical landmark technique of 262.27 Brazilian reals (R$) and for real-time ultrasound of R$187.94. The final incremental cost of the real-time ultrasound-guided technique was -R$74.33 per central venous catheter. The incremental cost-effectiveness ratio was -R$2,494.34 due to the pneumothorax avoided. CONCLUSION: Real-time ultrasound-guided central venous catheter insertion was associated with decreased failure and complication rates and hypothetically reduced costs from the view of the funding body, which in this case was the SUS.

Avaliação de custo-efetividade da passagem de cateter venoso central guiada por ultrassonografia comparada com a técnica convencional sob perspectiva da fonte pagadora / Evaluation of cost-effectiveness from the funding body's point of view of ultrasound-guided central venous catheter insertion compared with the conventional technique

RESUMO Objetivo: Avaliar o custo-efetividade da inserção de cateter venoso central guiada por ultrassonografia em tempo real, em comparação com a técnica tradicional, que é baseada na técnica de reparos anatômicos externos, sob a perspectiva da fonte pagadora. Métodos: Uma simulação teórica, baseada em dados de literatura internacional foi aplicada ao contexto brasileiro, ou seja, ao Sistema Único de Saúde (SUS). Foi estruturada uma árvore de decisão, que apresentava as duas técnicas para inserção de cateter venoso central: ultrassonografia em tempo real versus reparos anatômicos externos. As probabilidades de falha e complicações foram extraídas de uma busca nas bases PubMed e Embase, e os valores associados ao procedimento e às complicações foram extraídos de pesquisa de mercado e do Departamento de Informática do Sistema Único de Saúde (DATASUS). Cada alternativa de passagem do cateter venoso central teve um custo calculado por meio do seguimento de cada um dos possíveis caminhos da árvore de decisão. A razão de custo-efetividade incremental foi calculada considerando-se a divisão do custo incremental médio da técnica de ultrassonografia em tempo real comparada à técnica de reparos anatômicos externos pelo benefício incremental médio, em termos de complicações evitadas. Resultados: O custo final médio avaliado pela árvore de decisão, considerando a incorporação da ultrassonografia em tempo real e a redução de custo por diminuição de complicações, para a técnica de reparos anatômicos externos foi de R$262,27 e, para ultrassonografia em tempo real, de R$187,94. O custo incremental final foi de -R$74,33 por cateter venoso central. A razão de custo-efetividade incremental foi -R$2.494,34 por pneumotórax evitado. Conclusão: A inserção de cateter venoso central com auxílio de ultrassonografia em tempo real esteve associada à diminuição da taxa de falhas e complicações, além de hipoteticamente reduzir custos na perspectiva da fonte pagadora, no caso o SUS.

ABSTRACT Objective: To evaluate the cost-effectiveness, from the funding body's point of view, of real-time ultrasound-guided central venous catheter insertion compared to the traditional method, which is based on the external anatomical landmark technique. Methods: A theoretical simulation based on international literature data was applied to the Brazilian context, i.e., the Unified Health System (Sistema Único de Saúde - SUS). A decision tree was constructed that showed the two central venous catheter insertion techniques: real-time ultrasonography versus external anatomical landmarks. The probabilities of failure and complications were extracted from a search on the PubMed and Embase databases, and values associated with the procedure and with complications were taken from market research and the Department of Information Technology of the Unified Health System (DATASUS). Each central venous catheter insertion alternative had a cost that could be calculated by following each of the possible paths on the decision tree. The incremental cost-effectiveness ratio was calculated by dividing the mean incremental cost of real-time ultrasound compared to the external anatomical landmark technique by the mean incremental benefit, in terms of avoided complications. Results: When considering the incorporation of real-time ultrasound and the concomitant lower cost due to the reduced number of complications, the decision tree revealed a final mean cost for the external anatomical landmark technique of 262.27 Brazilian reals (R$) and for real-time ultrasound of R$187.94. The final incremental cost of the real-time ultrasound-guided technique was -R$74.33 per central venous catheter. The incremental cost-effectiveness ratio was -R$2,494.34 due to the pneumothorax avoided. Conclusion: Real-time ultrasound-guided central venous catheter insertion was associated with decreased failure and complication rates and hypothetically reduced costs from the view of the funding body, which in this case was the SUS.

Robot-assisted needle insertion for venous catheterization / Injeção-robô para cateterismo venoso

Vein access can be challenging for a variety of patients. The development of robots-assisted central or peripheral veins puncture would facilitate life of health professionals and patients. New robots are under development for this purpose and probably they will become available for practical use in the near future. These techniques may decrease significantly the cost of medicine, which currently uses less informatics resources than other industries.

O acesso venoso pode ser difícil em muitos pacientes. O desenvolvimento de robôs com capacidade de puncionar veias centrais ou periféricas pode facilitar a vida dos profissionais de saúde e dos pacientes. Novos robôs estão sendo desenvolvidos para essa finalidade e, provavelmente, entrarão em uso na prática clínica em um futuro próximo. Técnicas como estas poderão baixar progressivamente o custo em medicina, que, atualmente, tem usado menos recursos de informática que outras áreas.

Robot-assisted needle insertion for venous catheterization.

Vein access can be challenging for a variety of patients. The development of robots-assisted central or peripheral veins puncture would facilitate life of health professionals and patients. New robots are under development for this purpose and probably they will become available for practical use in the near future. These techniques may decrease significantly the cost of medicine, which currently uses less informatics resources than other industries.

Avaliação das coberturas para sítio de inserção do cateter venoso central no TMO: análise de custos / Evaluacion de las coberturas para sitio de insercion del cateter venoso central en TMO: analisis de costos / Cost analysis and evaluation of covers for a central venous catheter insertion site in BMT

A utilização de um cateter venoso central (CVC) torna-se necessária para manter um acesso venoso prolongado, sendo amplamente utilizado nos transplantes de medula óssea. A implantação de um CVC torna-se necessária para manter umacesso venoso seguro, por período prolongado, para que se receba periodicamente manuseios para aspiração sanguínea e administração de medicamentos e hemocomponentes. Contudo, a utilização das diferentes coberturas para o curativo do sítio de inserção do cateter é controversa quanto ao custo e à prevenção de infecção. Objetivou-se, com este estudo, analisar a utilização e o custo de diferentes tipos de coberturas de CVC em relação à periodicidade de sua troca e, também, a frequência de infecções relacionadas ao dispositivo em um serviço de transplante de medula óssea. Foi realizada uma pesquisa retrospectiva com caráter exploratório e descritivo, mediante coleta de dados de prontuários de 68 pacientes. Foi possível observar que o período de permanência do filme transparente como cobertura variou de quatro a sete dias, enquanto para o de gaze estéril foi de uma dois dias. A utilização da gaze estéril para cobertura apresentou custo mais elevado em comparação como uso de filme, dada a necessidade de trocas repetidas durante a semana. Não foi encontrada diferença estatística entre as diferentes coberturas utilizadas e a ocorrência de infecção. Conclui-se que há necessidade de constante avaliação do processo do cuidado em enfermagem, associada à assistência, à pesquisa e à gerência, uma vez que estudos sobre o impacto de procedimentos padronizados podem levar ao aprimoramento do serviço da enfermagem e da instituição.

A central venous catheter is indispensable to maintain a prolonged venous access, and is widely used in bone marrow transplants. The implementation of a central venous catheter (CVC) is necessary to keep a safer venous access for long periods of time. It is necessary as well to maintain blood aspiration, administration of medication and blood products. However, the choosing of different dressing covers for the catheter insertion site is controversial given the difference in its costandabilityt o prevent infections. This study aimed to analyze the use and cost of different types of Central Venous Catheter covers, how often it is changed, and the appearance of infections related to that device in a Bone Marrow Transplantation Unit. A retrospective research with an exploratory and descriptive approach was carried out. Data was collected from 68 patients’medical records. It was observed that a transparent film dressing lasted from 4 to 7 days, whilst sterile gauze pads were inplace from24 hours to 48 hours. The use of sterile gauze pads had a higher cost when compared to transparent film as the former needed to be changed more frequently during the week. There was no connection between the use of the different dressing covers and the appearance of infection. In conclusion a constant evaluation of the nursing care procedure is needed, along with an appropriate care, research and sensible management. Further studies on the importance of standardized procedures could lead to the improvement of the nursing care service and of the hospital in general.

Para mantener un acceso venoso prolongado y seguro se necesita el Catéter Venoso Central (CVC), ampliamente utilizado en los trasplantes de médula ósea, debiendo ser manipulado periódicamente para aspirar la sangre e inyectar medicamentos y hemocomponentes. No obstante, la utilización de las diferentes coberturas para el sitio de inserción del catéter es discutible, tomando en cuenta los costos y la prevención de infecciones. El presente estudio tuvo como objetivo analizar la situación yel costo de diferentes tipos de coberturas del Catéter Venoso Central en relación a los reemplazos rutinarios y a la frecuenciade casos de infección vinculados al dispositivo en un Servicio deTrasplante de Médula Ósea. Fue realizada una investigación retrospectiva con carácter descriptivo exploratorio y recogida de datos de historias clínicas de 68 pacientes. Fue posible observar que el período de permanencia del apósito transparente como cobertura varió de 4 a 7 días, mientras que para gasa IV fue de 1 a 2 días. El uso de gasa estéril para cobertura presentó un costo mas elevado en comparación conel uso de los apósitos transparentes, debido a la necesidad de efectuar cambios repetidos durante la semana. No se encontró ninguna diferencia estadística entre las dos coberturas utilizadas ni tampoco que haya habido infección. En conclusión, es necesaria la evaluación constante en el proceso de cuidados en enfermería asociada a la atención, investigación y gerencia, una vez que estudios sobre el impacto de procedimientos estandarizados pueden llevar a la excelencia del servicio de enfermería y de la institución.

The attributable cost, length of hospital stay, and mortality of central line-associated bloodstream infection in intensive care departments in Argentina: A prospective, matched analysis.

BACKGROUND: Limited information is available on the financial impact of central venous catheter-associated bloodstream infection (BSI) in Argentina. To calculate the cost of BSIs in the intensive care department (ICU), a 5-year prospective nested case-control study was undertaken at 3 hospitals in Argentina. METHODS: We studied 6 adult ICUs from 3 hospitals. In all, 142 patients with BSI and 142 control patients without BSI were matched for hospital, type of ICU, year of admission, length of stay, sex, age, and average severity of illness score. Patients' length of stay in the ICU was obtained prospectively on daily rounds. The hospitals' finance departments provided the cost of each ICU day. The hospitals' pharmacies provided the cost of antibiotics prescribed for BSIs. RESULTS: The mean extra length of stay for patients with BSI compared with control patients was 11.9 days, the mean extra antibiotic defined daily dose was 22.6, the mean extra antibiotic cost was $1913, the mean extra cost was $4888.42, and the excess mortality was 24.6%. CONCLUSIONS: In this study, patients with central venous catheter-associated BSI experienced significant prolongation of hospitalization, increased use of health care costs, and a higher attributable mortality. These findings support the need to implement preventative interventions for patients hospitalized with central venous catheters in Argentina.

[Analysis of the costs and complications of different procedures for the administration of intravenous liquids]. / Análisis de costos y complicaciones de diferentes procedimientos para administración de líquidos intravenosos.

With the purpose of finding the most economical method to administer intravenous fluids, we studied 3 groups of children with different pathologies: 50 cases with peripheral intravenous lines (PIL), 50 with venesection (VD) and 50 with percutaneous silastic catheter (PC). To facilitate the cost-expense analysis, each procedure was standardized to a "PIL unit". We found that PIL is the less expensive when IV fluids are administered for over periods of less than 5 days; even though we had an index failure of 24%. The PC has a low cost easy to place and with the advantage that can be established centrally for the measurement of central venous pressure, administration of hypertonic solutions or total parenteral nutrition. Preserving the vascular lumen when it is withdrawn, and resulting as an ideal method when administering fluids for for more than 5 days. VD must be left as a last resource, given its cost and because generally this ruins permanently the vein employed. Complications observed in the 3 procedures were similar to those reported by other authors and there were no mayor complications observed in this study.