Umbilical venous catheter and peripherally inserted central catheter malposition and tip migration in neonates: A mixed methods cost analysis

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What is already known • Venous catheters are essential for neonates requiring vascular access. • Typical methods for determining catheter positioning often result in complications. • The costs of managing catheters in neonatal care is poorly quantified. What this paper adds • In neonates, we find the average per-patient cost of a peripherally inserted central catheter and umbilical venous catheter to be $1,518 and $390 respectively. • In neonates, migration and malposition make up 55% of total peripherally inserted central catheter costs, and 33% of umbilical venous catheter costs. • Migration and malposition are identified as areas of high cost in the usage of peripherally inserted central and umbilical venous catheters in neonates, interventions which target migration and malposition would be likely to significantly reduce complications and costs. Hospitalized neonates require reliable vascular access for life-saving care. The costs associated with their clinical management, and which aspects of care these costs are attributable to, is not well-known. To estimate the economic burden of vascular access care in neonates in the United States and to break down the attribution of costs therein by establishing an economic model of standard care. A four step, mixed-methods study was used to determine and analyse an appropriate economic model for neonatal umbilical venous catheter and peripherally inserted central catheter insertion from the payer’s perspective in the US. An initial model was developed based on a purposive literature search. Secondly, initial face validity of the model was assessed with input from North American clinical experts identified to have appropriate expertise (n=13 for the care of peripherally inserted central catheters and n=12 for the care of umbilical venous catheters).Thirdly, a face-to-face meeting with the same clinical experts was undertaken to ensure the model structure and inputs accurately reflected clinical practice. Lastly, the finalised model was analysed. Feedback from the survey and focus group on model structure, resource usage and costings were incorporated to create decision-tree models for both umbilical venous catheter and peripherally inserted central catheter care. High variability between the opinions of clinicians was noted, which was incorporated into the sensitivity analyses. The umbilical venous catheter base-case expected cost was $390.24 per patient, with an average of 0.04 complications expected per-patient. The peripherally inserted central catheter model base-case expected cost was $1,517.83 per patient, with an average of 0.1 complications per-patient. In the umbilical venous catheter model $82.73 of cost was attributable to malposition and $46.36 to migration. In the peripherally inserted central catheter model, $75.58 was attributable to malposition and $755.14 to migration. Deterministic sensitivity analysis indicated that the strongest driver of costs was catheter dwell time (umbilical venous catheter lower: $245.55, umbilical venous catheter upper: $578.77, peripherally inserted central catheter lower: $1,263.40, peripherally inserted central catheter upper: $1,771.74), followed by probability of migration (umbilical venous catheter lower: $343.91, umbilical venous catheter upper: $439.14, peripherally inserted central catheter lower: $1,329.04, peripherally inserted central catheter upper: $1,733.58) in both models. The migration and malposition of peripherally inserted central catheters and umbilical venous catheters has significant costs and consequences. These should be targeted for evidence-based and innovative solutions to improve neonatal vascular access care.

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