title: Fluoroscopically guided vs modified traditional placement of tunneled hemodialysis catheters: clinical outcomes and cost analysis.
abstract: Tunneled cuffed internal jugular vein catheters are widely used to provide short to medium-term vascular access for hemodialysis. The NKF-K/DOQI guidelines state that fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The KDOQI recommendation makes it difficult for Nephrologists to perform this procedure without access to fluoroscopy. This results in unnecessary waiting times and the inappropriate use of acute, non-tunneled catheters. The purpose of this study is: 1) to compare the outcomes of fluoroscopically guided vs modified traditional catheter placement technique, and 2) to perform a cost analysis of the two techniques. We performed a retrospective investigation of 202 tunneled hemodialysis catheters performed at our tertiary care hospital. Procedural data were obtained from the University of Wisconsin Department of Medicine, Nephrology Section Interventional Nephrology procedural database. Patient demographics, laboratory tests were obtained from the University of Wisconsin Hospital electronic medical record (EMR). Logistic regression was used to evaluate the effect of blind vs fluoro-guided placement on clinical outcomes, corrected for side of procedure, age, gender, previous history of catheter placement, diabetes mellitus (DM), and pre-procedural coagulation parameters. Baseline characteristics of 'blind' vs fluoro-guided groups differed with respect to side of procedure and DM (91.0% vs 79.6%, p = 0.02 and 43.30% vs 58.40%, p = 0.02, respectively). Non-fluoroscopic placement of catheters was associated with a decreased odds ratio of immediate success (OR = 0.1298, CI = 0.02 - 0.71). No difference in major or minor bleeding complications was discovered between the blind vs fluoro-guided group. Cost analysis revealed that performing the non-fluoroscopic technique as the preferred initial procedure would represent a substantial reduction in total bills submitted to third-party payers, including Medicare.
authors.affiliation: Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison 53713, USA. asy@medicine.wisc.edu
authors.forename: A S
authors.initials: AS
authors.lastname: Yevzlin
authors.forename: G U
authors.initials: GU
authors.lastname: Song
authors.forename: R J
authors.initials: RJ
authors.lastname: Sanchez
authors.forename: Y T
authors.initials: YT
authors.lastname: Becker
mesh_terms: D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D002408:Catheters, Indwelling / Q000191:economics; D003362:Cost-Benefit Analysis; D005260:Female; D005471:Fluoroscopy / Q000191:economics; D017048:Health Care Costs; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D007349:Insurance, Health, Reimbursement; D016015:Logistic Models; D008297:Male; D006278:Medicare; D008875:Middle Aged; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D006435:Renal Dialysis / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014922:Wisconsin