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An economic evaluation of rt-PA locking solution in dialysis catheters.

ABSTRACT: In a recent randomized trial, weekly recombinant tissue plasminogen activator (rt-PA), 1 mg per lumen, once per week, and twice-weekly heparin as a locking solution (rt-PA/heparin) resulted in lower risks of hemodialysis catheter malfunction and catheter-related bacteremia compared with thrice-weekly heparin (heparin alone). We collected detailed costs within this trial to determine how choice of locking solution would affect overall health care costs, including the cost of locking solutions and all other relevant medical costs over the course of the 6-month trial. Nonparametric bootstrap estimates were used to derive 95% confidence intervals (CIs) and mean cost differences between the treatment groups. The cost of the locking solution was higher in patients receiving rt-PA/heparin, but this was partially offset by lower costs for managing complications. Overall, the difference in unadjusted mean cost for managing patients with rt-PA/heparin versus heparin alone was Can$323 (95% CI, -$935 to $1581; P=0.62). When the costs were extrapolated over a 1-year time horizon using decision analysis, assuming ongoing rt-PA effectiveness, the overall costs of the strategies were similar. This finding was sensitive to plausible variation in the frequency and cost of managing patients with catheter-related bacteremia, and whether the benefit of rt-PA on catheter-related bacteremia was maintained in the long term. In summary, we noted no significant difference in the mean overall cost of an rt-PA/heparin strategy as a locking solution for catheters compared with thrice-weekly heparin. Cost savings due to a lower risk of hospitalization for catheter-related bacteremia partially offset the increased cost of rt-PA.

SUBMITTER: Manns BJ

PROVIDER: S-EPMC4243340 | biostudies-literature | 2014 Dec

REPOSITORIES: biostudies-literature

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An economic evaluation of rt-PA locking solution in dialysis catheters.

Manns Braden J BJ Scott-Douglas Nairne N Tonelli Marcello M Ravani Pietro P LeBlanc Martine M Dorval Marc M Holden Rachel R Moist Louise L Lok Charmaine C Zimmerman Deborah D Au Flora F Hemmelgarn Brenda R BR

Journal of the American Society of Nephrology : JASN 20140710 12

In a recent randomized trial, weekly recombinant tissue plasminogen activator (rt-PA), 1 mg per lumen, once per week, and twice-weekly heparin as a locking solution (rt-PA/heparin) resulted in lower risks of hemodialysis catheter malfunction and catheter-related bacteremia compared with thrice-weekly heparin (heparin alone). We collected detailed costs within this trial to determine how choice of locking solution would affect overall health care costs, including the cost of locking solutions and ...[more]

PMID: 25012176

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Project description:Importance:Although quality improvement (QI) interventions can reduce central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI), their economic value is uncertain. Objective:To systematically review economic evaluations of QI interventions designed to prevent CLABSI and/or CRBSI in acute care hospitals. Evidence Review:A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, Worldcat, prior systematic reviews (January 2004 to July 2016), and IDWeek conference abstracts (2013-2016), was conducted from 2013 to 2016. We included English-language studies of any design that evaluated organizational or structural changes to prevent CLABSI or CRBSI, and reported program and infection-related costs. Dual reviewers assessed study design, effectiveness, costs, and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net savings. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter-days per study per year. Findings:Of 505 articles, 15 unique studies were eligible, together representing data from 113 hospitals. Thirteen studies compared Agency for Healthcare Research and Quality-recommended practices with usual care, including 7 testing insertion checklists. Eleven studies were based on uncontrolled before-after designs, 1 on a randomized controlled trial, 1 on a time-series analysis, and 2 on modeled estimates. Overall, the weighted mean IRR was 0.43 (95% CI, 0.35-0.51) and incremental net savings were $1.85 million (95% CI, $1.30 million to $2.40 million) per hospital over 3 years (2015 US dollars). Each $100?000-increase in program cost was associated with $315?000 greater savings (95% CI, $166?000-$464?000; P?<?.001). Infections and net costs declined when hospitals already used checklists or had baseline infection rates of 1.7 to 3.7 per 1000 catheter-days. Study quality was not associated with effectiveness or costs. Conclusions and Relevance:Interventions related to central venous catheters were, on average, associated with 57% fewer bloodstream infections and substantial savings to hospitals. Larger initial investments may be associated with greater savings. Although checklists are now widely used and infections have started to decline, additional improvements and savings can occur at hospitals that have not yet attained very low infection rates.

Project description:BackgroundSodium bicarbonate (NaHCO3) is one of the promising solutions that has good safety profile and theoretical advantages regarding antimicrobial and antithrombotic properties but there are still limited reports.ObjectiveTo compare the efficacy in lowering rate of catheter loss due to catheter-related thrombosis (CRT) or catheter-related blood stream infection (CRBSI) between sodium bicarbonate and heparin lock in prevalent chronic hemodialysis (HD) patients.DesignA multicenter, randomized, open-label study.SettingIn a developing country, Thailand.PatientsChronic HD patients with tunneled central venous catheter.MeasurementsCatheter loss rate, rate of catheter-related blood stream infection, catheter-related thrombosis, and exit site or tunnel infection.MethodsThe prospective multicenter randomized controlled trial was conducted, we randomly assigned 118 patients undergoing HD with tunneled central venous catheter to receive a catheter locking solution of sodium bicarbonate or heparin. The primary outcome was a catheter loss rate due to CRT or CRBSI, while the secondary outcome was a composite outcome of CRT, CRBSI, or exit site/tunnel infection (ESI/TI).ResultsThe present study was stopped early due to an excess of catheter-related thrombosis in the sodium bicarbonate group. From the first 6 weeks of follow-up, there were no catheter losses due to CRT or CRBSI in both groups. The sodium bicarbonate group had a significantly higher rate of the secondary composite outcomes and this was entirely caused by CRT with the median time to thrombosis of 23.6 days. Every CRT event could be successfully rescued by using a single dose of recombinant tissue plasminogen activator (rt-PA).LimitationsShort follow-up period.ConclusionsIn prevalent HD patients with tunneled CVCs, use of a sodium bicarbonate locking solution for prevention of CRT is inferior to heparin and is associated with a high rate of catheter-related thrombosis.Trial registrationThe study was registered with the Thai Clinical Trials Registry TCTR 20200610003.

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An economic evaluation of rt-PA locking solution in dialysis catheters.

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An economic evaluation of rt-PA locking solution in dialysis catheters.

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