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New Choices for Central Venous Catheters^*

Potential Financial Implications

^* From the Pulmonary and Critical Care Medicine Service, Department of Medicine, Walter Reed Army Medical Center, Washington, DC.

Correspondence to: Andrew F. Shorr, MD, MPH, FCCP, Pulmonary and Critical Care Medicine, 6900 Georgia Ave, NW, Washington, DC 20307; e-mail: afshorr{at}dnamail.com

Objective: To determine the cost-effectiveness of the newer antiseptic and antibiotic-impregnated central venous catheters (CVCs) relative to uncoated CVCs and to each other.

Design: Decision model analysis of the cost and efficacy of CVCs coated with either chlorhexidine silver sulfadiazine (CSS) or rifampin-minocycline (RM) at preventing catheter-related bloodstream infections (CRBSIs). The primary outcome is the incremental cost (or savings) to prevent one additional CRBSI. Model estimates are derived from prospective trials of the CSS and RM CVCs and from other studies describing the costs of CRBSIs.

Setting and patients: Hypothetical cohort of 1,000 patients requiring placement of a CVC.

Interventions: In the model, patients were managed with either an uncoated CVC, CSS CVC, or RM CVC.

Measurements and main results: The incremental cost-effectiveness of the treated CVCs was calculated as the savings resulting from CRBSIs averted less the additional costs of the newer devices. Sensitivity analysis of the effect of the major clinical inputs was performed. For the base case analysis, we assumed the incidence of CRBSIs was 3.3% with traditional catheters and that the CSS and RM CVC conferred a relative risk reduction for the development of CRBSIs of 60% and 85%, respectively. Despite their significantly higher cost than older catheters, both novel CVCs yield significant savings. Employing either of the treated CVCs saves approximately $10,000 per CRBSI prevented (relative to standard catheters). Comparing the RM CVC to the CSS CVC revealed the RM product to be economically superior, saving nearly $9,600 per CRBSI averted and $81 per patient in the cohort. For sensitivity analysis, we adjusted all model variables by 50% individually and then simultaneously. This demonstrated the model to be most sensitive to the cost of a CRBSI; however, with all inputs skewed by 50% against both the CSS CVC and the RM CVC, these devices remained economically attractive. Under this scenario, use of either treated device was less costly.

Conclusions: Utilization of antiseptic and antibiotic-impregnated CVCs represent an attractive alternative for the prevention of CRBSIs and may lead to significant savings. Of the two newer, coated devices, the RM CVC performs better financially. These observations hold over a range of estimates for our model inputs.

Key Words: bacteremia • catheter-related bloodstream infection • central venous catheter • cost • cost-effectiveness • infection • nosocomial • prevention

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