A COST ANALYSIS OF PERIPHERALLY INSERTED
CENTRAL CATHETER IN PAEDIATRICS
by
Zhaoxin Dong
A thesis submitted in conformity with the requirements
for the degree of Master of Science in Health Services Research
Graduate Department Health Policy, Management, and Evaluation
University of Toronto
© Copyright by Zhaoxin Dong 2011
ii
A cost analysis of peripherally inserted central catheter in paediatrics
Zhaoxin Dong
Master of Science in Health Services Research
Graduate Department of Health Policy, Management and Evaluation
University of Toronto
2011
Abstract
Introduction: Peripherally Inserted Central Catheters (PICCs) are commonly used in medium or
long-term infusion therapy. This study aims to assess the costs associated with PICCs and its
determinants.
Methods: A retrospective cohort of patients with PICCs inserted at the Hospital for Sick
Children between Jan.1, 2008 and Dec.31, 2008, were reviewed and followed until their PICCs
were removed. Cost analysis, theoretical cost comparison with peripheral intravenous therapy
(PIV), and multiple linear regressions were applied from the societal perspective.
Findings: The average total cost is $2763.75/catheter/day, including inpatient ward cost. Age,
male, ward, home care, catheter dwell days, and complications were found to be significant
factors influencing the total cost. PICCs can become a cost saving device, compared to PIV, but
is affected by several factors.
Conclusion: Information gleaned from this study will inform decision makers maximizing the
benefits of better resource allocation.
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Acknowledgments
Firstly I would like to give my thanks to my supervisor professor Peter Coyte for his tremendous
help during my master study period. At this moment, thanks are not enough. It is he who guides
me step by step to swim in the broad academic sea; it is he who teaches me how to find my
research interest, how to select a meaningful research topic and how to use the current resources
to figure out that problem efficiently; also it is he who helps me revise this thesis again and again
in order to make it better. In his eyes, science is a serious thing that you need to put all your
efforts into it. His spirits and enthusiasm on research always drives me to pursue my research
dream.
Secondly, thanks to Dr. Bairbre Connolly and Dr. Wendy Ungar as my committee members for
their brilliant guidance on my thesis. Dr. Connolly helped me choose the thesis topic and settle
down in the student room of SickKids to finish my thesis. Every time when I need any help, she
always tries her best to help me. In addition, she is really conscientious to revise my thesis, even
for spelling mistakes. Dr. Ungar also gave me a lot of helpful suggestions to make sure the
research topic and to improve the thesis. She is a nice, patient lady to teach students doing an
economic evaluation better.
Third, I want to thank Nicole Brown for her contributions to my thesis. She is not only a
beautiful lady, but also warmhearted mentor. When I meet some problem, she is always the first
one to help me. She taught me how to use the hospital’s database and helped to me change the
language problem. I am indebted to other staff in the hospital, such as Doina Filipescu, May
Seto, Mari Acebes-Carcao Melissa Oortwyn, Barbara Bruinse, Mina Komal, Sanjay Mahant,
Leonardo Brandao, Ziv Shnitzer, for their good suggestions on data collection.
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Then I want to thank all my friends at the department and elsewhere for your friendship and
endless help. I really appreciate all your support and help when I was in trouble.
Last, but certainly not the least, special thanks to my parents, for their love, encourage, and
understanding. Thank you for their support. They shaped me persistent and diligent qualities and
be positive to everyday. Without their support, I cannot finish the research without disturb.
This research reported herein is partially supported by a CHSRF/CIHR Genesis Fellowship
Award.
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Table of Contents
Contents
Acknowledgments ................................................................................................................... iii
Table of Contents ...................................................................................................................... v
List of Tables ......................................................................................................................... viii
List of Figures ............................................................................................................................ x
List of Appendices ....................................................................................................................xi
List of Abbreviations .............................................................................................................. xii
Chapter 1 Introduction................................................................................................................. 1
1.1 Intravenous therapy ............................................................................................................... 1
1.2 Rationale ............................................................................................................................... 3
1.3 Research questions ............................................................................................................... 6
1.4 Research Goals ...................................................................................................................... 6
1.5 Background ........................................................................................................................... 6
1.5.1 Insertion and application of peripherally inserted central catheter ............................ 7
1.5.2 Comparison between peripherally inserted central catheter and peripheral intravenous lines ................................................................................................ 10
1.5.3 Peripherally inserted central catheter in pediatric patients...................................... 11
1.5.4 Complications related to peripherally inserted central catheters ............................. 12
1.5.5 Costs related to peripherally inserted central catheters ........................................... 22
Chapter 2 Methods .................................................................................................................... 25
2.1 A systematic review of peripherally inserted central catheters ............................................. 25
2.2 Overview of the cost analysis .............................................................................................. 28
2.2.1 Study population and the inclusion and exclusion criteria ...................................... 28
2.2.2 Data Collection ..................................................................................................... 30
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2.2.3 Perspective of this study ........................................................................................ 32
2.2.4 Potential factors associated with peripheral inserted central catheters’ cost ........... 33
2.3 Measurement of cost components ........................................................................................ 34
2.3.1 Costs components associated with peripheral inserted central catheters ................. 35
2.3.2 Cost measurement and valuation ........................................................................... 38
2.4 Cost components associated with PIVs ................................................................................ 50
2.5.1 Statistical analysis software ................................................................................... 52
2.5.2 Descriptive analysis .............................................................................................. 52
2.5.3 Multivariate linear regression model ..................................................................... 52
2.5.4 Cost comparison between peripheral intravenous therapy and peripherally inserted central catheter ...................................................................................... 54
2.5.5 Regression diagnosis of the multivariate linear regression models ......................... 56
2.6 Sensitivity analysis .............................................................................................................. 58
2.7 Ethics .................................................................................................................................. 59
Chapter 3 Results ...................................................................................................................... 60
3.1 Systematic review results of peripherally inserted central catheter costs .............................. 60
3.2 Descriptive analysis of peripherally inserted central catheter ............................................... 63
3.3 Descriptive analysis of a theoretical peripheral intravenous therapy (PIV) ........................... 74
3.4 Multiple linear regression model of peripherally inserted central catheter (PICC) ................ 76
3.5 Multiple linear regression model for peripheral intravenous therapy (PIV) .......................... 78
3.7 Regression diagnosis ........................................................................................................... 82
3.8 Sensitivity analysis of peripherally inserted central catheter costs ........................................ 84
Chapter 4 Discussion ................................................................................................................. 88
4.1 Quality assessment of the papers retrieved for the systematic review .................................. 88
4.2 Comparison between the literature reviews and this study ................................................... 89
4.3 Factors influencing the results ............................................................................................. 90
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4.4 Limitations .......................................................................................................................... 94
4.5 Generalization ..................................................................................................................... 96
4.6 Further study direction......................................................................................................... 97
4.7 Policy implication ............................................................................................................... 97
4.8 Conclusion .......................................................................................................................... 99
References .............................................................................................................................. 101
Appendices ............................................................................................................................. 115
Copyright Acknowledgements ................................................................................................ 121
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List of Tables
Table 1 Classification of Vascular Access Device by the catheter’s dwell time ...........................2
Table 2 Common treatments for catheter-related complications ................................................ 20
Table 3 Cost information listed in the papers ............................................................................ 24
Table 4 Inclusion and exclusion of systematic review ................................................................ 27
Table 5 Chart of included and excluded papers .......................................................................... 27
Table 6 Variables used in this study and their classification ....................................................... 34
Table 7 Cost components associated with PICCs ....................................................................... 37
Table 8 Nurse complication assessment time and their cost on average ..................................... 41
Table 9 Complications and their treatment cost details .............................................................. 43
Table 10 Examples of procedure costs included ........................................................................ 46
Table 11 Examples of materials and tool’s costs ........................................................................ 46
Table 12 Travel approaches and their cost estimation ................................................................ 48
Table 13 Systematic review for PICC cost results ...................................................................... 62
Table 14 Descriptive analysis of demographic characteristics and line information of PICCs .... 68
Table 15 Descriptive analysis of insertion related variables of PICCs ........................................ 69
Table 16 Descriptive analysis of removal and complication related variables of PICCs ............. 70
Table 17 Descriptive analysis of demographic variables and time variables of PICC ................ 71
Table 18 Descriptive analysis of cost variables of PICC ............................................................ 72
Table 19 Descriptive analysis of cumulative cost and cost per day of PICC ............................... 73
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Table 20 Descriptive analysis of PIV ......................................................................................... 75
Table 21 Determinants of total cost associated with a PICC ...................................................... 77
Table 22 Determinants of total cost associated with a PIV ........................................................ 79
Table 23 Determinants of total cost associated with a PICC without inpatient cost ................... 85
Table 24 New descriptive analysis results of the significant factors ........................................... 93
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List of Figures
Figure 1 PICC insertion simulation (Jonathan Rosenfeld, 2008) ..................................................7
Figure 2 Flow diagram of Inclusion and Exclusion Criteria: ...................................................... 29
Figure 3 Flow chart of data collection process, encryption, analysis, and storage ...................... 32
Figure 4 Theoretical model of capturing the breakeven dwell days when PIV and PICC have the
same total costs ......................................................................................................................... 55
Figure 5 Normal Q-Q plot of the total cost and normal Q-Q plot of Log10PICCcost ................... 82
Figure 6 Scatter plot of PICCs ................................................................................................... 83
Figure 7 Normal Q-Q plot of total PIV cost and Normal Q-Q plot of Log10PIVcost ................... 83
Figure 8 Tornado diagram for sensitivity analysis..................................................................... 87
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List of Appendices
Appendix 1 Picture of a PICC and a PIV ................................................................................. 115
Appendix 2 Copyright permission of Jonathan Rosenfeld by email ......................................... 115
Appendix 3 Esh Database ........................................................................................................ 116
Appendix 4 ICD-10 Illness and Injuries Tabular Index ............................................................ 117
Appendix 5 The first page and last page of the Ethical approval. ............................................. 118
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List of Abbreviations
CA$
CBC
Canadian dollar
Complete blood cell
CR-BSI Catheter-Related Blood Stream Infection
CVC Central Venous Catheter
CVD Central Venous Device
DVT Deep Venous Thrombosis
ER Emergency Room
EPC Electronic Patient Chart System
ICD-10 The International Classification of Illness 10th revision
IGT Imaging Guided Therapy Centre
IR Interventional Radiologist
IV Intravenous Therapy
GA General Anesthesia
LMWH low molecular weight heparin
MRN Medical Record Number
NICU Neonatal Intensive Care Unit
OHIP Ontario Health Insurance Plan
PICC Peripherally Inserted Central Catheter
PIV Peripheral Intravenous Therapy
PACS The Picture Archiving and Communication Systems
PICU Pediatric Intensive Care Unit
RNAO Registered Nurses' Association of Ontario
SoB Schedule of Benifits
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SVT Superficial Venous Thrombosis
SickKids The Hospital for Sick Children
TPN Total Parenteral Nutrition
tPA tissue plasminogen activator
TTC Toronto Transit Commision
VAD Venous Access Devices
VAN Vascular Access Nurse
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Chapter 1 Introduction
This chapter provides a brief discussion about different kinds of intravenous therapy (IV)
approaches and a comprehensive introduction to Peripherally Inserted Central Catheters (PICC).
It is divided into five sections as follows: The first section provides a brief introduction of
intravenous therapy. The second section presents the rationale of this study. The third section
describes the research questions of this study followed with the fourth section of research goals.
In the final section, background of PICCs and their applications are presented.
1.1 Intravenous therapy
Successful access to veins is a great medical advance (Samadi et al., 1983), an achievement that
saves and prolongs many patients’ lives. The term ‘Intravenous (IV) Therapy’ relates to the
administration of different therapeutic solutions directly into a vein. Compared with other
approaches such as intramuscular injection, IV therapy is the fastest and most reliable way to
deliver fluids or medications (Samadi et al., 1983). With more than 90% of hospitalized patients
requiring IV therapy (Registered Nurses' Association of Ontario, 2006), the proportion of
patients requiring infusion devices has increased significantly over the past 30 years (Maki et al.,
2006). IV therapy, which has multiple indications, can maintain the fluid and electrolyte balance
of the body, infuse medications, transfuse blood or blood components and provide some
nutritional support such as total parenteral nutrition (TPN) (Nentwich, 1990).
Since the introduction of IV therapy, different venous access devices (VADs) have been
developed and used increasingly for IV therapy (Cheung et al., 2009). IV therapies can be
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broadly divided into two groups based on the treatment duration and purpose: short term and
long term therapies. Short term therapies, with a line dwell time of less than 4 days are usually
given through peripheral veins: while the long term therapies, generally use the central veins
(Edward & Mark et al., 2009). A peripheral IV (PIV) line is one of the most common devices
used for short term purpose IV therapy, while peripherally inserted central catheter (PICC) is one
of the typical devices used for medium and/or long term IV therapy (Appendix 1).
Given the variety of delivery devices available, choosing the most suitable device for patients is
important. Not only does it depend on each patient’s circumstance, but also depends on the
anticipated catheter’s dwell time (Table 1) (Edward & Mark et al., 2009). To determine the most
appropriate VAD, a medical team would consider the following factors (RNAO 2008): 1)
Prescribed therapy; 2) Duration of therapy; 3) Physical assessment; 4) Patient health history; 5)
Support system/resources; 6) Device availability; and 7) Client preference.
Table 1 Classification of Vascular Access Device by the catheter’s dwell time (Edward & Mark
et al., 2009; O’Grady, 2002)
Type of device Entry sites Appropriate duration
Peripheral Devices
PIV Usually inserted in veins of forearm or
hand
Short term less than 96
hours
Midline catheter Usually inserted into the proximal
basilic or cephalic veins
Rarely used when
insertion is longer than 1
month, already replaced
by PICC
Central Devices
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PICC Usually inserted into the peripheral veins
such as basilic veins or brachial veins
but the tip rested in the central veins
such as superior vena cava
Usually for medium term
use between 96 hours and
1 month, but not usually
appropriate if long term
access required
Non-tunneled
central catheter
Inserted percutaneously into central
veins such as subclavian,
external/internal jugular or femoral vein
Short term use if PIV is
not available
Tunneled central
catheter
Implanted into subclavian, internal
jugular, or femoral veins through a
subcutaneous tunnel
For frequent long term
access
Implantable port Tunneled beneath skin and have
subcutaneous port accessed with a
needle; implanted in subclavian or
internal jugular vein
For intermittent long term
access
1.2 Rationale
To evaluate a health care program, four cost sectors are required to consider for an economic
evaluation in health care area: the cost to the health sector, the cost to other sector, the cost borne
by patient/family and cost of productivity losses (Drummond et al, 2005). Therefore, having a
catheter inserted is associated with various cost components, including the insertion costs, the
costs to treat potential complications, outpatient management costs related to the line,
consultation costs, and travel costs as well as indirect costs such as the market value for parental
productivity time losses. However, there is a paucity of studies which have identified and
calculated costs related to PICCs in pediatrics, let alone these detailed cost components. The
current cost studies that can be found on a literature review in pediatrics only mention insertion
costs or management costs, not detailed costs as outlined above. And these studies’ perspectives
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are often not described well. It is also difficult to know whether the study is evaluated from the
social perspective or health care system perspective. Most of these studies focus on the insertion
costs. An economic evaluation restricted to the health care system perspective only, may
maximize health care system’s welfare but may not maximize the welfare of society (Byford &
Raftery, 1998). Therefore, a comprehensive study is necessary to identify the detailed costs of
PICCs from a societal perspective, which should contain all costs related to the whole society,
not just the individuals or organizations involved (Byford & Raftery, 1998). This can provide an
economic evaluation for the clinicians to correctly assess the costs of the clinical devices which
they currently use in order to make an informed choice of device.
With the ever-increasing cost of inpatient care and in the face of fiscal restraint, a general
tendency is to transfer care from the hospital settings to less costly home based services
(National evaluation of the cost-effectiveness of home care, 2002). PICCs can be regarded as a
good option as it allows patients to be discharged earlier with the provision of home care support
which is thought to be less expensive than hospitalization. A study by Schwengel et al. suggested
clinicians should choose a PICC as the venous access device of first choice if patients required
more than four inpatient days, especially when frequent blood samplings and/or other IV access
was anticipated (Schwengel et al., 2004). Other studies commented that a PICC was a cost-
effective catheter for establishing central venous access when hospitalized patients required five
days or more of IV therapy (Haider, et al., 2009; Periard et al., 2008). Another study revealed
that the total complications associated with PICCs were significantly fewer compared to central
venous access devices (CVCs), but considered a PICC was cost-effective when the catheter
dwell days were more than 2 weeks (Smith, et al., 1998). In Thiagarajan’s study, if the catheter
dwell time was longer than 2 weeks, a PICC might be a safe alternative compared to other
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catheters (Thiagarajan, et al., 1998). The Registered Nurses’ Association of Ontario’s (RNAO)
guideline reported that patients who received vascular access therapy longer than six days should
be assessed for the provision of an intermediate to long-term dwelling device such as a PICC
(RNAO 2008).
Based on the literature presented above, a PICC appears to be a preferable option if the expected
dwell time exceeds a specific number of days in adults. However, the literature remains uncertain
as to exactly when a PICC becomes cost saving in pediatrics. Studies about pediatric patients’
cost issues were few (Moore,et al, 2006; Schwengel, et al, 2004; Van Winkle, et al, 2008). In
order to address this question, a cost comparison between PICCs and peripheral intravenous lines
(PIVs) in pediatrics will be described in this study.
All patients referred to IGT who require venous access have a PICC placed rather than a PIV.
Therefore, an actual control group is hard to find. In the absence of a control group, a
theoretically based comparison group of PIV subjects was created. We created a hypothetical
group, which all patients who received a PICC insertion, had PIVs inserted instead. As both
PICCs and PIVs are infusion devices for intravenous therapy and can infuse the medications,
they could be in theory substituted with each other. Furthermore, in Schwengel’s study, they
compared PICCs with PIVs using PIVs as a randomized control group (Schwengel, et al, 2004),
which further supports that they can sometimes be substituted with each other. As these two
infusion devices can be substituted and cost details in SickKids can also be estimated for PIVs,
therefore, a theoretic comparison model was reasonable. The two groups therefore would have
the same demographic characteristics but different lines with distinct cost components, inpatient
days as well as complication rates.
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1.3 Research questions
Primary question
1. What is the average/median cost of the different cost components of a PICC in pediatric
patients from a societal perspective?
2. What are the factors that account for variation in the total cost of a PICC?
Secondary question
3. Under what circumstance would IV therapy that uses PICC yield cost-savings compared
to the use of PIV?
1.4 Research Goals
1. To systematically review the literature in terms of the costs of PICC in pediatrics.
2. To identify and calculate the breakdown costs associated with having a PICC from a
societal perspective.
3. To find the determinants of the total PICC costs.
4. To assess whether PICCs may yield cost-savings when compared to PIV.
1.5 Background
Peripherally Inserted Central Catheter (PICC), introduced in 1975, is a long thin tube or catheter
inserted into a vein (Chait et al, 2002). It is considered as a hybrid device because its tip is rested
in the central veins such as the superior vena cava or inferior vena cava but is inserted firstly
from the peripheral veins such as the basilic vein, cephalic vein or brachial vein (Hoshal, 1975).
When a PICC is to be inserted, the interventional radiologist (IR) will use ultrasound or
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venography to select a suitable peripheral vein to access, such as a basilic or brachial vein
centrally. The tip of the line will be positioned in the superior vena cava or other central veins.
The insertion technique is described in Figure 1 (Jonathan Rosenfeld, 2008). In Figure 1, the
PICC is represented by a dash curve. It is inserted from a vein in the arm, and lies within a vein
which reaches the central chest. The PICC may have one or two separate lumens, each with its
own hub or bung.
Figure 1 PICC insertion simulation (Jonathan Rosenfeld, 2008)
Taken from Nursing Home Abuse Blog, Posted by Jonathan Rosenfeld on October 12, 2008
http://www.nursinghomesabuseblog.com/medication-errors/never-event-2-infection-in-central-venous-
catheters/
Copyright permission was obtained from Jonathan Rosenfeld by email (Appendix 2)
1.5.1 Insertion and application of peripherally inserted central catheter
(1). Peripherally inserted central catheter insertion
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A PICC can be inserted at the bedside with a nurse-lead PICC team, or in an interventional
radiology (IR) suite with the interventional radiology team, consisting of an interventional
radiologist (IR), nurses (RN), technologists, and sometimes an anesthesiologist. The most
commonly used veins for access for a PICC are the basilic, brachial or cephalic veins, especially
the basilic vein which is considered as the access of first choice (Paulson & Miller, 2008). The
basilic vein has a lower incidence of phlebitis compared with other insertion sites (Mazzola et
al., 1999). Factors affecting successful insertion include patient’s age, vein size and condition,
patient edema, hypotension or dehydration as well as impaired skin integrity, all of which can
lead to an unsuccessful insertion. Level of experience of the nurses or interventional radiologists
is another factor that may affect a successful insertion. The success rate can improve from 55%
to 85% as the operator becomes more experienced (Evans & Lentsch, 1999). A PICC requires
careful maintenance in order to prevent complications after insertion, including dressing changes
and securement, daily flushing, and heparinization of the line (Gamulka, et al, 2005).
(2). Insertion procedure in the Hospital for Sick Children1
At the Hospital for Sick Children (SickKids), if a PICC is chosen for a patient, an IR will insert
the PICC in the interventional radiology department called the Image Guided Therapy (IGT).
SickKids is a paediatric, teaching and research hospital affiliated with the University of Toronto.
Before the insertion, informed consent is required. The duration of the procedure depends upon
many factors, including vein accessibility, size of veins, need for sedation. At SickKids most
PICCs (outside of the neonatal intensive care unit) are inserted by IRs. Different sizes of single
or double lumen PICCs, cuffed or uncuffed, are selected for individuals and inserted under a
1 An interventional radiologist provided this information
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combination of sonographic and fluoroscopic guidance. A cuffed catheter is described as “a
catheter with a very short sleeve of dacron attached/adherent to its outer wall, which is
positioned close to the skin exit site in a short tunnel under the skin” while an uncuffed catheter
is “one that has no sleeve of Dacron, is usually not tunneled but placed directly into the vein”2.
A cuffed catheter is a commonly used access device to provide long term access for children
(Goldstein et al., 1997). The entire procedure requires a sterile environment. The use of a guide
wire facilitates the accurate location of the tip of the PICC under fluoroscopy and can direct the
PICC into the correct position. A fluoroscopic image (X-ray) is always taken at the end of the
procedure to document that the line tip is in the proper position. The children can be awake,
sedated, or under general anesthetic during the procedure, based on their procedure duration, age
and the nature of their illness. Most children have a PICC inserted under local anesthetic only.
After insertion, dressings are applied to cover the exposed catheter up to the hub. The site is
dressed and wrapped with a transparent dressing and the extension tube is used as the access to
the line for infusion of medication. The PICCs are later removed when no longer required. If the
PICC is cuffed and present longer than four weeks, the cuff becomes adherent to the skin and
requires local anesthetic and dissection of the cuff which is performed by IRs. If the PICC is
uncuffed or in situ for less than 4 weeks and not adherent to the skin, the PICC can be removed
by an RN.
(3). Peripherally inserted central catheter application
A PICC is most commonly indicated for patients who require IV therapy for a medium or long
term use such as chemotherapy, hyper-alimentation, repeated administration of blood or blood
2 An interventional radiologist gave this definition
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products and venous blood sampling (Amesur et al., 2009). Patients, who require IV therapy but
have exhausted peripheral venous accesses because of frequent IVs, or have sclerotic and/or
thrombosed veins, may still benefit from PICC insertion (Islam et al., 2008). PICCs are also
suitable for patients who require home IV therapy or long term IV access (Weeks-Lozano H,
1991).
1.5.2 Comparison between peripherally inserted central catheter and peripheral intravenous lines
A peripheral intravenous line (PIV), also known as a peripheral cannula, is the most common
intravenous access method for short-term infusion (Lundgren et al., 1996). The cannula is
usually inserted through a peripheral vein, e.g. vein in the hand or arm. It is easy to insert but
requires frequent replacements every 48 to 72 hours in order to minimize the complications such
as extravasation and phlebitis (MOH nursing clinical practice guidelines, 2002). The risk of PIV
therapy includes infection, phlebitis, infiltration, and extravasation with possible issues such as
skin or tissue necrosis (Tully, et al., 1981).
Obtaining PIV access can be challenging in infants with tiny veins and poor cooperation, making
it difficult to provide IV therapies. Compared with a PIV which infuses directly in to a smaller
caliber vein, the central tip of a PICC is positioned in a central vein with larger diameter which
decreases the irritation from medications. Thus it is regarded as a safer approach to IV therapy
from vesicant drugs (Sol et al., 2007). It has been shown that patients have higher satisfactions
with PICCs as compared to PIVs (Polak et al., 1998; Schwengel et al., 2004). A recent study in a
tertiary hospital estimated that 96.8% of patients (mean age±SD, 67.0 ± 16.5) were satisfied with
a PICC as compared to 79.3% of patients with a PIV (Periard et al., 2008). The average number
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of skin punctures was 1.36 per person in the PICC group for treatment compared to 8.25 per
person in PIV group (Periard et al., 2008). In the early 1990s, PICCs became a popular catheter
choice in both adult and pediatric settings because of higher rates of insertion success, better
satisfaction and smaller risk of catheter related complications than other catheters at that time.
PICCs had higher efficacy as an intravenous device because it only required 1.16 punctures on
average for a successful insertion, compared to 1.79 in PIV group in Periard’s study (Periard et
al., 2008). Moreover, a PICC enables an earlier hospital discharge with continuous treatment on
an outpatient basis with the assistance of a home care team. It was estimated that the cost saving
of a PICC with home care was $1,070 per day, compared to the cost of inpatient stay with
peripheral antibiotic therapy (Van Winkle et al., 2008). However, a PICC may not be ideal for
those patients with end-stage renal illness (Allen et al., 2000), serum creatinine level higher than
160 umol L -1 (Periard et al., 2008). Although the PICC may not be a suitable option for all
patients, it has become a viable alternative to subclavian lines, internal jugular lines or femoral
lines (Smith et al., 1998).
1.5.3 Peripherally inserted central catheter in pediatric patients
The increasing survival and better care of hospitalized children with complex medical conditions
means more patients requiring IV therapies (Pettit, 2009). PIVs are difficult to insert due to the
patient’s inability to cooperate, the small size of the veins, the pain from repeated IV punctures,
requirement of frequent changes, and the potential for infection from skin organisms (Stolfi et
al., 2009). Repeated IV punctures are accompanied with patients’ pain and labor cost (Stolfi et
al., 2009; Lago et al., 2008). PICCs can avoid multiple skin punctures, provide more reliable
venous access and increase patients’ satisfaction (Thiagarajan et al., 1997; Schwengel et al.,
2004). Thus a PICC is a preferable option for children requiring medium or long term access.
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Moreover, as a PICC is inserted through a peripheral vein, risks of pneumothorax, hydrothorax,
and hemorrhage that may happen with central venous catheters inserted into major veins are
avoided (Levy et al., 2010). Therefore, since the 1970s, PICC lines have been increasingly used
as the preferable longer term venous access device option in paediatric patients, particularly for
patients in the neonatal intensive care unit (NICU) (Tully et al., 1981).
1.5.4 Complications related to peripherally inserted central catheters
Complications may lead to extended inpatient days, increased treatment costs and patient
discomfort (Webster et al, 2008; Ezingeard et al, 2009; Haddad et al, 2006; Chambers et al,
2002). PICCs have been popularized not only because of their ability to reduce hospitalized days
and costs but also because of their less frequent complication rate than PIV and other catheters
(Fairhall, 2008). Although PICCs have many advantages compared to PIVs and other catheters,
they are still associated with some problems of insertion or maintenance which may necessitate
premature removal of the catheters (Loughran et al., 1995). However, any procedure can carry
risk, which requires careful consideration of the tradeoff between benefits and risks. Careful
insertions and following the instructions for insertion and maintenance procedures of PICCs
reduce the risk of complications (RNAO, 2004). Nurses and Interventional Radiologists’ (IRs)
assessments of an individual patients potential risk factors include 1) site selection; 2) infection
prevention and control methods such as hand hygiene, skin antisepsis, antiseptic solution,
assessment of client risk factors, screening; 3) catheter material; 4) tip position; 5) dressing type,
frequency of dressing change, client tolerance; 6) type of securing device which was applied to
attach the catheter in order to prevent migration ; 7) flushing/locking (RNAO, 2004). To confirm
or diagnose a complication, over and above the clinical symptoms and signs, imaging
examinations such as doppler ultrasonography or venography are often required.
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1.5.4.1 Definition of complications
(1). Catheter related infection (CRI)
Catheter related infection (CRI) has been defined several ways as: fever or elevated white blood
cell (WBC) or both; positive blood culture from the PICC, positive PICC tip culture, or positive
peripheral blood culture with no other source (Hampton et al., 1998). Infection is mainly
detected from lab examinations. A similar definition can be found in the study by Moureau et al.
“Catheter infection is identified through laboratory findings such as positive blood and catheter
cultures” (Moureau et al., 2002). Local CRI and catheter related blood-stream infection (CR-
BSI) belong to this category. If the organism grows from the proximal catheter segment,
accompanied with inflammation such as erythema, warmth, swelling or tenderness at the
insertion site, local CRI is presented (Pearson, 1996). If the organism grows from the catheter
segment and/or the blood of a patient is infected, CR-BSI can be diagnosed (Pearson, 1996). This
complication can occur in both adult and pediatric population.
(2). Phlebitis
Phlebitis is defined as a spectrum of clinical findings ranging from local inflammation at the
insertion site to a tender, erythematous, and palpable venous cord extending from the insertion
site and traveling along the arm” (Turcotte et al., 2006). It commonly presents as a local
inflammation of the vein accompanied with pain, erythema, edema, streak formation and/or
palpable cord (Hertzog &Waybill, 2008, Pearson, 1996). When phlebitis occurs, symptoms such
as redness, swelling, pain, skin warm to touch and a tender venous cord can be found in patients
which help make the diagnosis. Phlebitis is usually diagnosed by clinical signs and symptoms of
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localized pain or sonographic examination instead of laboratory microbiological examination
(Hampton et al., 1998). This complication can occur in both adult and pediatric population.
(3). Occlusion
Occlusion usually results from either external or internal mechanical obstruction. It is defined as
“the inability to use the catheter for the assigned therapy due to obstruction” (Hampton et al.,
1998). Increased vigilance is required if external occlusion occurs as patients may face a higher
risk of pulmonary embolism from thrombotic obstruction in the vein. This is in contrast to
internal occlusion which usually results from clotted blood or drug precipitate within the lumen
of the line (Hampton et al., 1998). At the same time, excluding the extended hospitalized days,
occlusion may lead into higher costs, patient discomfort, or increase in the risk of catheter related
sepsis. Tissue plasminogen activator (TPA) is usually injected into the catheter as the first choice
to declot the internal occlusion. If the catheter remains occluded, replacement is then required
which can be attempted over a guide wire (Hoffer et al., 1999). This complication can occur in
both adult and pediatric population.
(4). Thrombosis
One of the typical causes of external occlusion is thrombosis which is defined as “the formation
of a blood clot attached to the exterior aspect of the catheter or to the venous wall in relation to
the catheter” (Turcotte et al., 2006). Upper extremity deep venous thrombosis (DVT) is a
specific type of thrombosis which presents as “a painful and swollen arm, or may be
asymptomatic” (Hertzog & Waybill, 2008). This complication can occur in both adult and
pediatric population.
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(5). Malposition
The most suitable position of the central catheter tip is at the junction between the superior vena
cava and the right atrium (Connolly, et al, 2000). If the catheter tip is not in an appropriate
position, other complications such as thrombosis may be more likely to occur because of
malposition (Eastridge & Lefor, 1995). Malposition can happen at the time of insertion, or
develop later due to the change of intrathoracic pressure or catheter migration (Bowe-Geddes et
al., 2005). In Turcotte’s paper, catheter malposition was defined as accidental movement or
removal of the PICC (Turcotte et al., 2006). For example, a PICC could easily migrate outwards
during the process of dressing change or the patients’ accidental dislodgment the catheter with
activity. Confirmation of the catheter’s position on a chest X-ray is important, because
malposition can cause many complications such as venous thrombosis, phlebitis etc (Bowe-
Geddes et al., 2005). Careful catheter securement is important in order to prevent migration or
malposition. Many signs are used to discern malposition; for example, the external catheter’s
length will be increased; the neck or chest may possibly seem swollen; patient may feel pain or
discomfort during the infusion and/or there is no blood return (Paulson & Miller, 2008). When
malposition occurs, reposition is usually the first step to be considered. If reposition cannot solve
the problem, a new catheter is required (Hughes, 2006). This complication can occur in both
adult and pediatric population.
(6). Leakage/breakage
Leakage is defined as “infiltration of nonvesicant fluid into the tissue outside a vein” (Moureau
et al., 2002). The quality of the catheter or improper care can cause leakage/ breakage (Hughes,
2006). Leakage/breakage can be identified by clinical signs, fluoroscopy, or venography. For
example, if the dressing seems wet, or the line leaks during flushes, a leakage/breakage
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complication should be considered. Damaged catheters can either be repaired using specific
repair tool kits, or exchanged for a new catheter (Hughes, 2006). This complication can occur in
both adult and pediatric population.
1.5.4.2 Classifications of complications
There are different classification systems of catheter related complications. Complications can be
classified into insertion complications and post-insertion complications. Pain, difficulty
advancing the catheter, damage to the catheter or veins, bleeding, nerve damage and embolism
can occur during insertion. In comparison, catheter occlusion, fracture or break, catheter related
bloodstream infection, thrombosis, phlebitis and edema may happen after insertion (Paulson &
Miller, 2008). Many steps are taken to prevent complications during insertion such as carefully
assessing the patient, optimizing comfort, avoiding excessive force. On the other hand,
procedures such as heparinization, flushing, aseptic technique should be taken in order to prevent
the post-insertion complications (Paulson & Miller, 2008).
Complications can also be classified as major or minor complications. Major complications are
defined as “an adverse event which a specific treatment, prolongation of hospitalization or re-
hospitalization is required”, for example, upper limb deep venous thrombosis (DVT) (Periard et
al., 2008). For those complications that do not require treatments or interventions, prolonged
hospitalization for more than 24 hours, or do not require re-hospitalization are considered minor
complications (Periard et al., 2008).
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Additionally, complications can be divided into infectious or mechanical complications. For
infectious complications, according to the American Centers for Disease Control and
Prevention’s (CDC), there are three categories: exit site infection, catheter colonization, catheter-
related bloodstream infection (CR-BSI) (O'Grady et al, 2002). Mechanical complications include
catheter occlusion, catheter dislodgement or migration, and at the time of insertion they include
hemorrhage, vascular spasm, or arterial puncture. (Hampton et al., 1998)
Another classification approach is based on catheter dysfunction. Catheter dysfunction is defined
as inability to use the catheter normally. It can be divided into thrombotic and nonthrombotic
dysfunction. Thrombotic dysfunction is defined as “thrombus accumulation within a catheter
resulting in partial or complete blockage”. While nonthrombotic dysfunction is defined as
“inability to use the catheter as a result of causes other than thrombosis”. (Moureau et al., 2002).
1.5.4.3 Complication rates
Research reports that catheter complication rates are influenced by a variety of factors such as
the insertion mode, diameter of the PICC, lumen number, and patient immune status (Ng et al.,
1997, Grove et al., 2000). Complication rates are reported using the absolute incidence, or
incidence per 1,000 catheter days.
(1). Complication rate in the general population
It is estimated that 40% of PICCs have to be removed before therapy completion due to
complications (Turcotte et al., 2006). More specifically, 6% of PICCs are removed prematurely
due to phlebitis (Turcotte et al., 2006). There is a wide range of complication rates reported in
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the literature. For example, the quoted incidence of thrombosis is as low as 2% or as high as 25%
(Ng et al., 1997, Periard et al., 2008). Similarly, the incidence of sepsis varies within a range of
0.4%-25.7%, or between 0.1-8 episodes of sepsis per 1,000 catheter days. The infection rate is
reported as approximately 7%, or 0.4–3.4/1,000 catheter days in these studies (Ng et al., 1997;
Cardella et al., 1996; Periard et al., 2008; Smith et al., 1998). Yamamoto’s study reveals that the
complication rate for leakage is 1.87% (Yamamoto et al, 2002). The incidence of DVT
associated with PICCs is reported to be much less than that associated with other VADs (Dubois
et al., 2007). However, another systematic review (Maki, et al., 2006) conclude that a range of
50,000 to 500,000 catheter related blood stream infections (CR-BSI) occur each year in USA, of
which PICCs have a rate of 0.5 per 1,000 catheter days while CVCs have a rate 2.7 per 1,000
catheter days.
(2). Complication rate in pediatrics
Compared to the general population, complication rates related to PICCs in pediatrics are
relatively low; only 30 per cent of PICCs are removed for complication (Racadio, et al., 2001;
Thiagarajan, et al., 1997). In Dubois’s study, infection and thrombosis are the main
complications and the complication rates are respectively 6% and 0.3%. In Racadio’s study, the
total complication rate was only 3.8%. 1.7% of the 1096 PICC lines became occluded; 1.5%
occurred phlebitis; 0.2% of the patients got infections (Racadio, et al., 2001). In Itzhak’s study,
twenty-six catheters of the 279 PICCs (9.3%) were dislodged accidentally, 13.6% of PICCs were
removed because of infection and 4.6 per cent were removed due to phlebitis. PICC associated
BSI rate was 4.3% (1.4 per 1,000 days). In another study by Thiagarajan, 7% of PICCs were
occluded and 8% are dislodged by accident. The incidence of catheter associated sepsis was 2%
and suspected infection accounts for 8%. However, in Crowley’s study, the incidence of
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infection was 0.93 per 1,000 catheter dwell days (Crowley, et al., 1997). In another study, thirty-
eight PICCs were occluded and seven were accidentally dislodged among 269 PICCs.
Malposition was about 1.5% in Frey’s study as well (Frey, 1995).
1.5.4.4 The management of complications in relation to PICCs in pediatrics
Careful management can help reduce complication rates. Many approaches have been advocated
for catheter maintenance in order to reduce complications and improve patients’ outcomes. For
example, the “StatLock” securement device is used instead of tape or sutures to hold the line.
“Statlock” securement, made up of an adhesive-backed anchor pad with hinged clamps, is
reported safer and less time consuming than suture securement (Yamamoto et al., 2002; Held-
Warmkessel, 2001). Disinfecting the surface of the hub before access is strongly recommended
in order to prevent complications (Maki & Mermel, 1998). It has been reported that the longer
the PICC dwell time, the more complications a patient may encounter (Raad et al., 1993). It is
suggested to remove the catheter as soon as possible once it is no longer required. Keeping the
PICC dry helps reduce the risk of infection (Sanders, 2006, Periard et al., 2008). The use of
anticoagulation for prophylaxis in patients with a PICC tends to lower the rate of catheter-related
thrombosis (Paauw & Borders et al., 2008). Advantages of silicone catheters include greater
flexibility, decreased thrombogenicity, and decreased incidence of sepsis as compared with
polyethylene catheters. Verifying the central tip position of a PICC is essential to prevent
complications because improper position leads to many complications (Bowe-Geddes et al.,
2005). Recognized complications associated with incorrect tip position include: central venous
perforation; thrombosis and CVAD dysfunction (RNAO, 2004). In addition, securement devices
have been found to reduce the number of hospital days and complications (Sheppard et al. 1999
McMahon 2002) but require changing at least every seven days (CDC, 2002). Even if a
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complication occurs, timely and well considered treatment can minimize the chance of PICC loss
and reduce the number of re-hospitalization days. Common treatment strategies for
complications are listed in table 2 (Paulson & Miller, 2008). Phlebitis’s symptoms can be
difficult to distinguish from infection. An incorrect diagnosis will lead to unnecessary antibiotic
treatment or unnecessary premature removal of the catheter.
Table 2 Common treatments for catheter-related complications (Paulson& Miller, 2008)
Complication Treatment methods
Pain Pacifier, containment, site numbing, sedation
Nerve damage Individual care
Occlusion tPA
Catheter fracture or break Repair kit
Infection cleanse the site with alcohol, oral or intravenous antibiotics
Malposition Reposition or remove
Deep Venous Thrombosis Chest X-ray, Doppler ultrasound, anticoagulant therapy, remove
Phlebitis Warm packs or remove
Edema Exercise or remove
If the catheter leaks and/or breaks, the dressing requires to be removed. The line requires to be
flushed carefully and at the same time, a repair kit used. If the repair fails, the catheter should be
replaced.
Redness at the exit site of a PICC can be indicative of a site infection. If there is no swelling and
pain at the site, the infection is considered in early stage. Cleansing the exit site with alcohol and
keeping the dressing dry are the proper way to manage the site. If patients have already
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experienced pain and swelling, oral antibiotics are recommended for those patients. Intravenous
antibiotic therapy can be applied if the infection persists.
Measuring the external part of a PICC and comparing it with the original measurement at the
time of placement is one way to monitor for migration/malposition. If movement is detected, a
chest X-ray is required to review the tip position in order to choose appropriate treatment. If
malposition occurs, the first priority is to adjust the line into the proper position. If not possible,
the line may need to be removed or exchanged.
Patients with a PICC may develop a swollen arm and/or hand with bleeding, cyanosis, pain in the
arm or shoulder. If patients have these symptoms, 0.9% saline is used to flush the PICC, andif
the patients feel pain during the flushing, one possible reason is an internal catheter fracture. This
can be confirmed with linogram. If the patient does not feel any pain during the flush, deep
venous thrombosis (DVT) is considered. Chest X-ray and Doppler Ultrasound are required to
review the catheter and the vein. If thrombosis is confirmed, anticoagulant therapy(eg. Heparin)
is commenced to treat the thrombosis. TPA is considered as a very effective approach to dissolve
a thrombus; however, TPA is expensive and very potent with significant associated risks, and
used rarely.
If the patient reports pain in the shoulder, neck or chest, possible causes could be that, the tip pf
the catheter could have migrated into an improper location, requiring a chest X-ray to determine
its position. It is also possible that leakage/breakage may have occured. At this time, flushing the
catheter with saline and a linogram is required to determine the type of complication. As each
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PICC is a valuable resource for the patient, removal is the last approach or option to be
considered.
1.5.5 Costs related to peripherally inserted central catheters
Previous studies have only focused on economic evaluation of PICCs in the general population.
In Schwengel’s study, the PICC insertion cost was measured by collecting the data of three
aspects of labor (anesthesiologist and phlebotomist time), equipment (PICC trays) and operating
room time costs. This study also showed that the total estimated insertion cost varied from US
$173.58 to US $440.70, which was more expensive than a PIV as the average cost for a PIV was
only US $108.49 (Schwengel et al., 2004). In Periard’s study, it was estimated that the insertion
cost related to a PICC was about US $690 per patient. More specifically, in that study, the author
also measured the material cost related to PICC insertion was US $210; angiography suite US
$265. The PICC maintenance cost was US $27 per patient per catheter for each insertion while
PIV maintenance cost was only US $18 per patient in 2006. From Periard’s study, we can also
know that as for the procedure time, nurses spent 4.1 hours per patient on average to manage the
PICC while PIV required 5.5 hours during the entire catheter dwell time. Therefore, for nurses’
salary, the estimate cost was US $165 in the PICC group; however, PIV was higher than PICC,
about US $219 (Periard, 2008). Smith’s study also calculated the PICC insertion cost which was
US $500 (Smith et al., 1998). Harattas’ study assessed a PICC insertion cost to be US $401,
which was close to Smith’s study (Horattas et al., 2001). Similarly, a PICC insertion costs CA
$270 in Murphy’s study. And the total cost of insertion, maintenance and managing
complications was CA $344 (Murphy et al., 2008). Cowl et al. used cost per day instead of total
cost to measure the PICC cost. In Cowl’s study, the PICC insertion and maintenance cost was
US $22.32+/-2.74 per day for hospitalized patients who required TPN therapy (Cowl et al.,
2000).
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Complications are associated with additional costs over and above the total costs associated with
PICCs as they require specific examinations and treatments. For example, the treatment costs for
a blood-stream infection (BSI) ranged from US $10,000 up to US $35,000 (Donowitz et al.,
2001). Similarly, another study pointed out that BSI would extend hospital length of stay by an
additional 10 to 20 hospital days, with extra cost of US $4,000 to US $56,000 per episode (Maki,
et al., 2006).
Very few studies have focused on the break down costs associated with PICCs. Most of them
only calculated a portion of the health system costs such as the insertion costs or complication
treatment costs (Table 3). They did not consider other cost components such as patient/ family
productivity loss, travel costs, home care costs as we discussed above from the societal
perspective. Moreover, they did not stress the point whether PICCs yield cost-savings compared
to other catheters (e.g. PIV). Therefore, further research on costs related to PICCs is required. In
order to address the costs clearly, this study describes the average and/or median cost
components as well as the total cost in details. At the same time, factors that affect the total cost
of a PICC are also detected. Theoretical cost comparison between PICC and PIV was also
applied in this study.
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Table 3 Cost information listed in the papers
1st author Published Year Cost items included Cost per total PICC
dwell time
Schwengel 2004 Total cost (labor, equipment and
operating room cost)
US $440.70
Periard 2008 Insertion cost
Material cost
Maintenance cost
US $690.00
US $210.00
US $27.00
Smith 1998 Insertion cost US $500.00
Murphy 2008 Insertion cost CA $270.00
Donowitz 2001 Complication treatment cost US$10,000- US
$35,000
Cowl 2000 Insertion and maintenance cost
per hospitalized day
US $22.32+/- 2.74
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Chapter 2 Methods
This chapter describes the methods used for this study. It is divided into six sections. The first
section introduces the systematic review regarding PICC costs in pediatrics. The second section
provides an overview of the study design, including the study population, variables used in this
study. The third part presents details of measurements of different cost components. The fourth
section describes the statistical analysis used in this study followed by the fifth section of
sensitivity analysis adopted. Ethics are presented at the end of this chapter.
2.1 A systematic review of peripherally inserted central catheters
A systematic literature search was conducted using PUBMED (1946-2010), CINAHL (1981-
2010), Cochrane library (1995-2010), EMBASE (1948-2010) databases to capture all relevant
studies. At the same time, Health Technology Assessment (HTA) reports from Canadian Agency
for Drugs and Technologies in Health (CADTH), Centre for Reviews and Dissemination (CRD)
including DARE and NHS EED, Paediatric Economic Database Evaluation (PEDE) were also
searched for pertinent studies. The search period was limited to those databases’ coverage.
Medical Subject Headings (MeSH) terms were used in this study to retrieve relevant articles.
Terms used in this study were "Catheterization, Central Venous", "Costs and Cost Analysis",
"Infant", "Child, Preschool", "Child", "Adolescence", and "Pediatrics". This study aimed to
search articles related to "Catheterization, Central Venous or Peripheral" and "Costs and Cost
Analysis" in infant, child preschool, child, adolescent or pediatrics by restricting our search to
articles where "Catheterization, Central Venous or Peripheral" was a major subject. Therefore,
the search language was (MM “Catheterization, Central Venous” OR MM “Catheterization,
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Peripheral”) AND (MH “Cost and Cost Analysis”) AND (MH “Infant” OR MH “Child,
Preschool” OR MH “Child” OR MH “Adolescence” OR MH “Pediatrics”). The following study
designs were included: practice guidelines, systematic reviews, meta-analyses, reviews,
randomized controlled trials, and controlled clinical trials. Types of articles such as letters,
editorials/commentaries, and lectures were excluded for this systematic review. All papers
identified as potentially relevant were initially assessed for inclusion by reviewing the titles and
abstracts by one master student. In order to be included, the articles had to meet the following
criteria: 1) The study population had to be limited to infants, child preschool, children or
adolescents; those who studied the whole population or the adults instead of pediatrics were
excluded; 2) The study had to focus on peripherally inserted central catheter; those studies
focusing on central venous catheters, midline catheters, or peripheral venous lines were excluded
from this study; 3) Cost must be reported as one of primary or secondary outcome measures;
those studies that did not provide actual cost numbers were excluded; 4) The study had to be
written in English. Inclusion and exclusion criteria were listed in the following Table 4 (Table
Based on the criteria discussed above, evidence was initially selected and reviewed based on
titles and abstracts. Studies that could not be excluded with certainty were retrieved and
reviewed in their entirety based on the inclusion/exclusion criteria described above (Table 5).
There were 134 papers reviewed in total which related to PICC cost. However, 69 papers of them
were excluded as duplicated citations; 3 papers were excluded because they were not written in
English; and 59 papers were not selected for this systematic review because the papers were not
relevant to PICCs, not pediatric population, or cost was not one of their primary or secondary
outcomes. Finally, only 3 papers were retained for analysis in terms of PICC cost in pediatrics.
(Schwengel et al., 2004; Moore et al., 2006; Van Winkle et al., 2008). A data extraction sheet
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was also developed in order to collect the relevant data using Microsoft Excel®. This included
information about the 1st author’s name, year published, study design as well as key outcome
variables and their limitations. Results will be presented in Chapter 3.
Table 4 Inclusion and exclusion of systematic review
Inclusion Exclusion
Focus on pediatric population Studies based on adult population or the
whole population
Focus on PICCs Focus on other catheters such as central
venous catheters, peripheral intravenous
lines, midlines etc.
Cost must be one of the primary or
secondary outcomes
No actual cost numbers provided
Written in English Presented in other languages such as
French, Chinese, etc.
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Table 5 Chart of included and excluded papers
Database Coverage MeSH terms No. of
papers
retrieved
Exclusion
reasons
No. of papers
retained for
analysis
PUBMED 1946-2010 (MM “Catheterization, Central Venous” OR
MM “Catheterization, Peripheral”) AND (MH
“Cost and Cost Analysis”) AND (MH
“Infant” OR “Child, Preschool” OR “Child”
OR “Adolescence” OR “Pediatrics”).
83 57 repeated
20 not relevant
3 not English
3
CINAHL(EBSCOhost) 1981-2010 Same as above 3 3 not relevant 0
The Cochrane Library 1995-2010 Same as above 9 3 repeated
6 not relevant
0
EMBASE(Ovid
MEDLINE (R) )
1948-2010 Same as above 14 1 repeated
13 not relevant
0
CADTH(HTA) 1990-2010 Same as above 0 0 0
DARE 1994-2010 Same as above 2 2 not relevant 0
NHS EED 1968-2010 Same as above 21 6 repeated
15 not relevant
0
HTA 1989-2010 Same as above 0 0 0
PEDE 1980-2010 Same as above 2 2 repeated 0
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2.2 Overview of the cost analysis
2.2.1 Study population and the inclusion and exclusion criteria
A retrospective cohort of pediatric patients with PICCs inserted in IGT at SickKids between
January 1, 2008 and Dec. 31, 2008, was reviewed to determine the costs associated with having a
PICC. All PICC cases were followed until the PICC was removed, usually within two years,
from 2008 to 2009. The inclusion criteria were patients who underwent PICC insertion
procedures during the study period in the department of IGT in SickKids. Initially, 1,181 PICC
related procedures in 2008 were identified.
The exclusion criteria were as follows;
1) Patients who underwent other procedures such as catheter replacement, removal, or reposition
instead of a primary PICC insertion were excluded as they did not represent a new PICC
placement. Therefore, 564 patients were excluded due to this criterion.
2) Patients who did not reside in Ontario were excluded as these patients may have different
insurance plans from Ontario. Thus, 25 patients were excluded because of this.
3) Patients who transferred from or to other hospitals could not be followed due the unavailable
data; therefore, 12 patients were ruled out.
4) Some patients could not be followed due to missing data in the patients’ medical records. For
this reason, 19 patients were eliminated.
5) Patients who died in the PICU (21 patients) were excluded because relevant cost information
requires special application for data release.
6) Day surgery patients who had their PICC insertions with no subsequent hospital admission
were excluded because of limited data availability. Therefore, 16 patients were excluded because
of this reason.
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Of 1,181 PICC procedures identified in 2008, 564 were excluded because they were not having a
primary insertion procedure. Twenty-five patients who did not reside in Ontario and 19 patients
who could not be followed due to missing information, 12 patients who transferred from or to
other hospitals, 21 patients who died in the PICU and 16 in day surgery patients were excluded
due to data limitation. Finally, 524 patients with 573 PICCs inserted were retained for analyses
(Figure 2).
Figure 2 Flow diagram of Inclusion and Exclusion Criteria:
Patients retained for analysis n= 524
Excluded n= 93
l Patients living outside of Ontario n= 25 l Patients died in PICU n=21 l Day surgery patients n=16 l Transferred from or to other hospitals n=12 l Patients lost to follow up n= 19
Patients included n= 617
All patients with PICC related procedures in 2008 n= 1181
Excluded because not primary insertion procedures n= 564
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2.2.2 Data Collection
A search was run using the IGT-ESH database (a dedicated Interventional Radiology database in
the Image Guided Therapy department, IGT) to identify all patients who underwent a successful
PICC insertion in IGT during the study period (Appendix 3). The ESH database generated an
excel spreadsheet with information on patients age, sex, weight, date of procedure, time of
procedure, type of procedure, type of line used, operator information, sedation information,
procedural complications, procedural costs (broken down by equipment costs, labor costs and
material costs). Eligible cases were then cross referenced with the Vascular Access Database
which is an excel spreadsheet database managed and updated daily by the Vascular Access
Database administrator with information on all patients requiring vascular access services. For
the purpose of this study the database administrator pulled an excel spreadsheet from the
Vascular Access database during the study time-period which contained columns with the
patients age, date of birth, date of death (if applicable), sex, hospital in-patient unit, weight,
primary diagnosis, reason for insertion , line number (if this was the patients first line or had
previous lines), removal date, dwell days, type of catheter, manufacturer of the catheter, access
route, date of complication and type of complication (if applicable) and reason for removal.
Information of patients’ address, ward unit, lab examinations, emergency room visits, and
sedation methods were extracted from the database of the Electronic Patient Chart System (EPC)
using patients’ medical record numbers (MRN). One master student extracted these data and
entered them into excel spreadsheet. EPC was also used to retrieve those missing data if there
were any missing data in the excel sheet generated from ESH and Vascular Access Database, if
possible. The Picture Archiving and Communication Systems (PACS) of the Hospital for Sick
Children (SickKids) were utilized too to double check to make sure the reliability of the Vascular
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Access Database. All of these four databases, ESH, PACS, EPC, Vascular Access Database,
were linked or cross-referenced by patient medical record number as personal identifiers. And all
the Excel spreadsheets were combined and merged into one excel sheet and imported to a SPSS
software (Statistical Package for the Social Sciences, version 17.0, SPSS Inc., Chicago, IL, USA)
for analysis. After import, patient personal information such as MRN and address was then
deleted for encryption purpose. This final dataset for this research was stored in the computer of
the student room. A password was set for this dataset file. Only the person who can access to the
computer with access account and know the password as well can open this dataset (Figure 4).
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Figure 3 Flow chart of data collection process, encryption, analysis, and storage
2.2.3 Perspective of this study
The perspective taken in this cost analysis was that of the society. According to U.S. Public
Health Service Panel on Cost-Effectiveness in Health and Medicine (PCEHM)’s definition,
adopting a societal perspective means that all costs and types of resources of value to the entire
society should be considered no matter who paid the cost or who received the benefit. As said,
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this perspective can offer the most comprehensive estimation of costs. In this study, all cost
components associated with the catheters were calculated.
2.2.4 Potential factors associated with peripheral inserted central catheters’ cost
Potential independent variables of costs in this study were selected based on Andersen and
Newman’s behavior model on health services utilization (Andersen & Newman, 1973) and/or
because those independent variables were identified from previous papers (Schwengel et al.,
2004; Periard, 2008; Smith et al., 1998; Horattas et al., 2001; Murphy et al., 2008; Cowl et al.,
2000). This model includes several types of variables classified as “predisposing”, “enabling”,
and “need for care”. “Predisposing factors” are defined as factors that wield effects by increasing
or decreasing a person’s motivation to undertake a behavior (Green & Kreuter, 2005). In
Andersen’s model, it means broadly to all factors that may predispose a person to need and/or
use a service. “Predisposing” includes demographic factors (e.g. age, sex), social structural
factors (e.g. education, occupation) and factors associated with health beliefs (e.g. attitudes,
values). “Need” factors means individualized perceived health status and function capacity such
as problems with daily activities, comorbid conditions, perceived health and mental status that
may influence a person’s utilization of a service. “Enabling” characteristics represents those
variables that may boost or impede individual health care services utilization such as financial
status, informal social supports and insurance condition. There are two types of enabling factors:
community enabling factors and personal/family enabling factors (Andersen & Newman, 1973;
Kempen & Suurmeijer, 1991).
In this study, variables such as age, sex, weight were selected as the predisposing factors for
analysis. In the “need” group, variables such as patients’ primary diagnosis, ward, catheter
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insertion reason, access vein, type of anesthesia, catheter information including the size, type and
manufacturer, catheter dwell days, inpatient days, removal reason, complication during the
catheter dwell period were all included. Due to the data limitation, no financial status or
insurance information can be captured, there is no factor belonging to the “Enabling” category
(Table 6).
Table 6 Variables used in this study and their classification
classification Variables used in this study
predisposing Age, sex, weight,
need Patient primary diagnosis, ward, catheter insertion reason, access vein, type
of anesthesia, catheter size, catheter dwell days, inpatient days, line type,
line manufacturer, cuffed/uncuffed, lumen number, removal reason,
complication, home health care condition, insertion date, removal date,
admission date, discharge date
2.3 Measurement of cost components
To do an optimal economic evaluation, it is required to consider the resources consumed from
the four cost component perspectives: cost to the health sector, cost to other sectors, cost to the
patient/family, and cost attributed to productivity losses (Drummond et al., 2005). The cost to the
health sector is the direct medical cost which includes the items such as hospitalization,
physician visits, drugs, and so on. The cost to other sectors depends on their characteristics. Cost
to patient/family members is mainly deemed as out-of-pocket expenses such as traveling to the
hospital, copayments and other expenditures in the home. Opportunity costs, that is, the value of
the alternative choice of using those resources is the most suitable method of estimation (Liljas,
1998). Due to the illness, patients and their family members may be affected on their time at
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work or productivity efficiency. The parental opportunity cost is measured by their time loss due
to take care of their children (Drummond et al., 2005).
2.3.1 Costs components associated with peripheral inserted central catheters
Previous studies have described the PICC as a preferable approach to vascular access but do not
provide a breakdown of the various cost components associated with having a PICC line in
children (Schwengel et al., 2004; Cheong et al., 2004). To our knowledge, there has been no
study focusing on detailed cost analysis in terms of different cost components related to PICCs.
In this study, both direct and indirect costs were included. “Direct cost” usually means the
resources consumed by the program when compared to other options, while “indirect cost”
usually denotes the time consumed by the patients or their family members (Drummond et al.,
2005). For the purpose of this study, direct costs include: the insertion cost, outpatient
management cost, complication cost, consultation cost, removal cost and travel cost. For the
indirect cost, parents’ productivity loss was considered by the measurement of time. Details were
listed as follows (Table 7). Regarding the insertion costs, we considered three aspects: material
costs, labor costs and equipment costs. In the event of a post insertion line complication, the line
might need to be repaired, exchanged, or repositioned, laboratory tests and other imaging
examinations might be required, patients may attend a clinic or visit an Emergency Room (ER);
sometimes they were given medications for treatments. All of these components were
incorporated into the cost component of a complication. Removal costs were recorded as well. A
PICC was removed by either a vascular access nurse (if uncuffed, or cuffed in situ for less than 4
weeks) or by an interventional radiologists (if cuffed and in situ for longer than 4 weeks) with
different associated costs. In addition, travel costs incurred with the patients and their families
was one of the cost components included. As patients who came to the hospital were usually
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suffering from a severe disease, they seldom walked or used the public transportation to the
hospital. It was assumed that all patients traveled to SickKids by car or by plane. The cost of
home care nursing was calculated as the outpatient management cost. With respect to indirect
cost, parents’ productivity loss was considered during hospital days.
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Table 7 Cost components associated with PICCs
Cost
classification Cost components Cost details Cost resources
Direct cost Insertion cost Material (PICC itself, the gowns, gloves, a radiology tray with instruments,
needles, syringes, and preparation set etc)
ESH database
Labor (Interventional Radiologist, technician, nurse, anesthetist)
Equipment (Fluro Scopy, ultrasound, overhead, maintenance, suite)
Complication cost Repair/replace/reposition procedure ESH database, OHIP Schedule of Benefits,
Physicians’ expert opinion Lab ( complete blood count, culture)
Imaging ( ultrasound, linogram, chest x-ray, venogram)
Medication for complication treatment
Emergency/Clinic visits
Nurse assessment cost Assessment before insertion, removal & after complication occurs Prorated nurse salary from SickKids
Nurses’ expert opinion
Inpatient cost Professional services, medical imaging, unit medications, nursing, laboratory
tests, overhead and equipment costs of a ward stay (cleaning staff), physician
services
Decision Support Case Costing of SickKids
hospital
Removal cost Nurse/Interventional Radiologist Salary level from SickKids
Travel cost By car or by air Google map, airline’s ticket price, km
reimbursement rate
Home care cost Home care nurse A paper (Guerriere et al.,2010)
Indirect cost Productivity loss Parent productivity loss Statistics Canada
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2.3.2 Cost measurement and valuation
Both the direct cost and indirect cost were considered in this study. All costs were measured in
2008 dollars as these patients had catheters inserted in 2008, and their relevant costs, such as
insertion costs, complication costs, and hospital ward costs also took place in 2008. However,
for air travel costs, data were acquired with a two year lag period and combined with all other
costs without adjustment for inflation under the assumption that inflation was zero for air travel
costs based on expert opinions.
2.3.2.1 Insertion cost
PICC insertion costs were derived from ESH –IGT system with patient level cost data. ESH-IGT
system is designed to capture procedural information on a case performed in IGT which enables
users to track the detailed case costing on labor, equipment, and materials used during any IGT
procedure3. The International Classification of Illness 10th revision (ICD-10) codes are applied
for patient diagnosis in ESH (Appendix 3). There are three portions comprised in the insertion
cost: material cost, labor cost and equipment cost. Material cost are the costs of PICC itself, the
gowns, gloves, a radiology instrument tray with instruments, needles, syringes, and a preparation
set etc. As for the labor cost (Interventional Radiologist, Interventional Radiology technician,
Interventional Radiologist nurse, and anesthetist), ESH also tracked all the labor activities related
to every patient case procedure prorated to the duration of the procedure. For the equipment cost,
it tracks the amount of usage of pertinent equipment used in the procedure such as fluoroscopy,
3 ESH-IGT website: http://www.esh.ca/index.html
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ultrasound, overhead (including electricity, water, and capital equipment use), maintenance, and
the Intervention Suite. One of the equipment cost is the cost of Interventional Suite used for a
PICC insertion. It was calculated by the number of hours and case utilization capacity, including
the costs of linens, cleaning the room, and sterilization. This system provides a robust search
engine to extract data into an Excel file during the patient case procedure. The technologist
creates search profiles and produces one spreadsheet with the information and then uses “point
and click” to select any relevant data from the case. Due to different material, labor and
equipment resources consumed, each line insertion incurs a different cost. Details about ESH-
IGT database can be found in Appendix 3.
2.3.2.2 Inpatient cost
A daily ward cost was used to estimate the inpatient cost for SickKids. This includes professional
services, medical imaging, medications, nursing, lab tests, overhead (including administration,
laundry, housekeeping, and other centralized institution costs) and equipment costs during
hospital stays. Ward costs were calculated by multiplying the per diem ward cost and the length
of stay. Total length of stay was the number of days from the date of the line insertion to the date
of discharge. Relevant cost for this study was provided by Department of Decision Support Case
Costing of SickKids Hospital. They randomly pulled 10 patients from each service (ie, 10
patients from a medical ward, 10 patients from a surgical ward, 10 patients from a medical
surgical unit) and ran their 2nd last day before discharge cost to get a generalizable number for
each ward cost. The per diem cost for the cardiac ward, the Neonatal Intensive Care Unit
a medical ward, the medical surgical ward, and a surgical ward were $3,325, $3,807, $1,791,
$2,768, and $1,859, respectively. In addition, physician consultation cost was also required to be
included. It was assumed that one physician would assess each line once for the post procedure
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period. For a general pediatric physician consultation, the cost for a general assessment is $165.5
per episode according to the Ontario Health Insurance Plan (OHIP) Schedule of Benefits (SoB)
billing code A265.
2.3.2.3 Nurse assessment costs
Before a line insertion, prior to removal, and when a complication occurs, nurses will assess the
patient’s status. The assessment costs were estimated according to the nurses’ hourly wage.
Nurses’ income includes the salary plus an additional 23% 4 fringe benefit. Then it is further
multiplied by 52/46 to account for vacations and holidays (Guerriere et al., 2010). If the fringe
benefits and vacation salary are all taken into calculation, then the hourly pay for one nurse is
$67.04. Each of the three nurses was asked to estimate the minimum, maximum and average
assessment time in terms of different situations (Table 8). As there are three nurses in IGT who
provide their assessment time for each activity, it seems more appropriate to use the average time
instead of median time. The average assessment time prior to a PICC insertion is 0.33 hour. Thus
the nurses’ cost for an insertion assessment is $22.12 per case in total. Similarly, as the
assessment time for a removal is 0.25 hour on average, the cost for assessment prior to removal
will be $16.76 per case. Due to different severity, the assessment cost for different complications
was variable. The average assessment time is 0.25 hour for each thrombus, dislodgement, block
and malposition. As for infection, it is estimated to require 0.33 hour for each assessment, while
breakage and leakage requires 0.75 hour on average including repair time (Table 8).
4This information can be obtained from this website http://riweb.sickkids.ca/hr/budgets.html
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Table 8 Nurse complication assessment time and their cost on average
Complication Average assessment time(H) Assessment cost(CA$)
Thrombosis 0.25 16.76
Infection 0.33 22.12
Break/leak and repair 0.75 50.28
Dislodgement 0.25 16.76
Block 0.25 16.76
Malposition 0.25 16.76
2.3.2.4 Complication treatment cost related to catheters
Each individual’s complications were collected from the Vascular Access Database in SickKids.
PACS and EPC systems were used to cross reference for potentially overlooked or omitted
complications. As a complication occurs, nurse assessments, emergency or clinic visits, lab tests,
imaging examinations, and medicine may be required. Treatment approach for complications
depends on the variety and severity of the problem. Records of imaging examinations were
obtained from the PACS System. Both clinic and inpatient medical history was reviewed from
the EPC database, including lab tests, ER visits or clinic visits to avoid missing data. Costs of all
relevant activities are taken into consideration, including nursing assessment time
In cases of infection, laboratory blood cultures are performed to make the diagnosis and
antibiotic therapy is used for treatment. Imaging examinations might be required as well. In
addition, patients might need to visit emergency room (ER) or clinics if they are not staying at
the hospital. Occasionally, the line will be removed.
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Expert advice from the thrombosis team in the Division of Haematology/Oncology of SickKids
indicated that patients with a PICC related thrombosis would visit the clinic three times on
average to follow up the thrombosis case and would be treated with low molecular weight
heparin (LMWH) for three months. In the meantime, monitoring anti-Factor Xa levels and three
Doppler Ultrasound examinations were usually required.
If the catheter was broken, a repair toolkit would be used by a vascular access nurse to repair the
break. When the repair cannot fix the problem, or for some PICCs there is no repair kit, then the
line will require removal as soon as possible or have it exchanged. Involvement of other services
such as ER/clinic visits is determined on a case by case situation and was obtained from the EPC
system.
For PICC dislodgements, a chest X-ray is required to confirm the dislodgement and tip position. .
Malposition usually requires reposition for treatment. Chest X-ray is required to make sure the
tip’s position. If the patient requires ongoing infusion therapy, exchange of the catheter is
necessary. In another situation, if the catheter is blocked, flushing and unblocking treatment are
necessary to unblock the line. Patients might be given a dose of tissue plasminogen activator
(tPA) and a chest-x ray or a linogram imaging examination performed. Other tests or
examinations depend on a case by case situation. Different complications and their treatment
options are recorded in Table 9.
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Table 9 Complications and their treatment cost details
Complication ER/clinic visits Treatment Laboratory test Imaging Others
Thrombosis 3 clinic times LMWH (3 months) Anti-Xa monitoring ultrasound * 3 Syringes, needles, alcohol, etc
Infection Varies with different patients Antibiotics Blood culture N/A Swab, sterile acohol wipe, syringe, needle,
Break/leak ER visit, Repair kit Varies with different
patients
N/A Dressing pack, saline, syringe, needle, Sodium
Chloride, sterile strips, sterile acohol wipe etc
Dislodgement ER visit Exchange N/A Chest x ray N/A
Block Varies with different patients Flush or unblocking tPA x-ray
linogram
Dressing pack, sterile gloves, syringes, green
needle, Saline, etc
Malposition Varies with different patients Reposition in IGT N/A Chest x ray Vary with different patients
Note:1) N/A, not applicable;
2) Low molecular weight heparin (LMWH);
3) Emergency Room(ER);
4) Tissue plasminogen activator (tPA)
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1. Emergency Room/Clinic visit costs
After discharge, costs of subsequent ER and clinic visits were usually not included as these were
primarily for the disease treatment rather than related to the PICC/PIV line related issues.
However, if the visit to the clinics or ER was related to a catheter complication, relevant costs
were considered. For the pediatric physician consultation cost in clinic, the fee for a general
assessment is $165.5 per episode according to the Ontario Health Insurance Plan (OHIP)
Schedule of Benefits (SoB) billing code A265. Patients do not need the ER service when they
stay in the hospital. But after discharge, patients may require ER services under emergent
situation; sometimes ambulance services may be also required. ER associated costs were drawn
from Guerriere et al.’s study, which was CAD $181 per visit in 2008 which fully allocated the
direct and an appropriate share of overhead costs associated with the treatments (Guerriere, et
al., 2010; Coyte, et al., 2001). An ambulance cost is assigned a $240.00 per visit by the
calculation of Ministry of Health and Long Term Care (MOHLTC). So each ER visit costs
$421.00 per visit (ER cost plus ambulance cost) in total if the ambulance is required.
2. Lab test costs
For laboratory test costs, the assumption is that only those patients with complications will
require additional laboratory tests. When referring to in-patients, the lab costs were included in
the ward cost. Three laboratory tests were assigned from OHIP SoB: bacteriology test,
biochemistry test and haematology test. The main lab tests were blood samples taken for
complete blood count (CBC), and blood cultures. For example, if the patient has a thrombosis,
CBC test is required; however, in the incidence of infection, they may need blood culture tests.
Labor, materials, supervision (LMS) units are the basis for OHIP billing by laboratories. They
are used to calculate the laboratory service prices. From OHIP SoB, we found that each CBC
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was 16 LMS units (OHIP SoB code: L393); blood culture was 30 LMS units (OHIP SoB code:
L624). According to the MOHLTC’s rule, one LMS unit was 51.7 cents. Therefore multiplying
the LMS units with their unit values of 51.7 cents, we could assure the estimates of cost: $ 8.27
for per CBC test; $15.51 for per blood culture test.
3. Imaging examination costs
Interventional imaging costs were captured from ESH database such as linogram and venogram.
The cost of a linogram is $161.82 and venogram is $106.61. Chest X ray and ultrasound costs
were captured using unit costs assigned from OHIP SoB. The unit cost included three
components of cost: technology cost, professional fee and facility fee. The total cost drawn from
OHIP SoB for each Chest X ray (SoB code: X090) was $38.53 which included technology costs
$15.30, professional fee $6.75, and facility fee $16.48. Similarly, the total cost for each
ultrasound (OHIP SoB code: J207 or J507) was $62.11 with a technology cost of $22.60,
professional fee $16.35 and $22.16 facility fee.
4. Procedure costs
IGT procedure costs were captured from ESH system as well. Here is a table for some procedure
costs. One cost from a patient is shown as an example of the cost of each procedure. Different
patients faced different costs based on different situations; but usually those costs should be are
similar to the costs listed here. Some examples of procedure name and costs are listed in the
following table 10.
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Table 10 Examples of procedure costs included
Procedure name Procedure cost
CVL PICC reposition $217.32
CVL PICC removal Nurse $38.56
Interventional Radiologist $143.12
CVL PICC exchange $1741.71
CVL Resuturing $22.76
CVL PICC repair by nurse $113.61
CVL PICC Flush $132.63
CVL PICC unblocking $223.47
Note: CVL - central venous line
5. Other relevant costs
Other relevant costs such as material costs used for treatment of complication while in IGT were
extracted from ESH system. As different patients use different quantity of materials or devices,
the costs will vary, examples of costs of materials or devices used are listed in the following
table 11.
Table 11 Examples of materials and tool’s costs
Examples of relevant stuff for complication treatment Costs
omnipaque 300 20 ml $38.07
syringe ll 10 cc $0.80
sodium chloride 0.9% inj 10ml $3.50
syringe tb slip tip 5cc $0.36
Syringe LL 3cc $0.59
Tegaderm 6X8.5cm $0.18
Catheter repair kit $109
Needle hypo 27G-1-1/4 $0.03
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2-0 Prolene $2.25
Needle blunt fill 18GA *1.5 $0.08
Adhesive mastisol liquid $2.69
Blade sterile no.11 $0.36
Boundary Table cover $10.39
Soln Nacl 0.9% 250ml JB1322LP $1.00
Sharps Container $4.95
2.3.2.5 Removal Cost
PICCs can be removed either at the hospital or at home but must be removed by a trained
professional such as IRs, vascular access nurse, or community care nurse. Many factors can
influence the reason for line removal such as end of therapy, a complication, or a change in the
type of therapy required. If the PICC line is uncuffed or in situ for less than 4 weeks and the line
is not adherent to the skin, nurses can remove the line directly. Nurse removal costs, obtained
from ESH system, is $38.65 on average, including the material cost $11.80 and $16.76 nursing
time. When a cuffed line is removed after more than 4 weeks, by an IR, the cost for removal is
$165.11 on average, including the material cost $11.80, IR suite cost $75.00, and IR labor cost
$78.31.
2.3.2.6 Travel cost
Travel cost, defined as an out-of-pocket cost assumed by parents/family members, was included
from the societal perspective. It was assumed that most families arrived at the hospital by car.
However, because SickKids is a tertiary care centre, patients traveled from all over Ontario, at
times requiring air transportation methods. (Table 12).
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Table 12 Travel approaches and their cost estimation
Distance to
the hospital
Travel way Live in
ward
Go home
daily
Cost estimation
<= 430km Auto (only on
admission and
discharge day)
Yes No Use reimbursement rate in SickKids for
driving to the hospital for research
purpose and parking fees.
>430km Airline Yes No Tango price for one adult plus one child
of the flight tickets from Air Canada,
West Jet and Porter Airlines
We assumed that if the driving distance was closer or equal than 430 kilometer (km), parents
would drive to the hospital first based on expert opinions. It was assumed that those families who
resided further than 430 km would travel by air to Toronto. It was also assumed that at least one
parent would stay on the ward with their child at all times. Assumption was that the parents
would drive to the hospital on the day of admission and drive back home after discharge. As
patients’ home addresses can be obtained from the database, the distance from their home to the
hospital can be measured by Google map. The kilometer reimbursement rate at SickKids for
driving to the hospital for research purpose was used to estimate the driving cost in this study,
which amounted to $0.35 cent per kilometer plus $11 per day for parking. Thus, the travel cost
for each visit was the reimbursement rate per km multiplied by the distance, plus parking fees.
The total travel cost was the cost per parking plus one round trip by car.
It was assumed that if the patient’s home was further than 430km from the hospital the patient
would travel by air to the hospital and stay with their child on the ward. . Prices were traced for
one year from June 15, 2010 until June 3, 2011 on Aircanada, West Jet and Porter Airlines.
Tango price (Lowest price in a day) of the flight ticket for one adult plus one child was searched
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on these three airlines’ websites. In all cases, the nearest airport to the patient’s residence was
selected to determine air travel costs.
2.3.2.7 Home care cost
After discharge, patient’s PICCs are managed by the home care nurses. Home care nurses visit
daily to change dressings and perform general PICC maintenance such as flushing the line daily
and giving the medications. The home care days were measured from date of discharge until the
day of lines’ removal. To determine the cost of home-based professional services, the result of
the study of Guerriere et al. was used. The cost per home care visit for nursing and personal
supports (e.g. occupational therapy, physical therapy) was CA$88 per visit in 2008, including
23% of overhead cost (Guerriere et al., 2010). The payment rates for professional home care cost
in Guerriere’s study were obtained from home care agencies and an inflation factor was taken
into consideration as well. As this study was also aimed at Ontario home-based profession
services’ cost, we applied this cost for the home care costs too. Consequently, the home care
nursing cost was estimated at $88 per visit.
2.3.2.8 Indirect cost estimates
Productivity loss was calculated in this study to estimate the indirect cost. Parents/family
members’ absence from work or usual activities was an important index to measure this in direct
cost. Human capital cost was the most common method to calculate the cost of time lost. Most
people choose to use this approach as it is easier to apply and less expensive, though deficiencies
may exist (Liljas, 1998; Hodgson, 1983) Based on Howard’s research, during their
hospitalization, it was assumed at least one of their parents was present with the patient and
missed a full day of work (Hancock-Howard et al, 2010). So in this study we would have the
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same assumption that every admitted child would have one parent to take care of them; the other
parent still retained their full time job. To value the productivity loss from labor market, average
hourly aged-based earnings calculated by Statistics Canada were assigned for this study.
According to the Statistics Canada’s calculation, the average hourly wage for people aged 25-50
years old was $23.87 during April 2008 to April 2009 (Statistics Canada 2007). The parent
income also includes the salary plus an additional 23% fringe benefit. Then it will be further
adjusted by 52/46 to account for vacations and holidays (Guerriere et al., 2010). The total
indirect cost was assigned as $23.87/hour multiplied by the inpatient days.
2.4 Cost components associated with PIVs
If a PICC had not been place, this cohort of patients would have to have their treatments given
through peripheral IV. In this scenario, the patient demographics, diagnosis, and duration of
therapy would be the same. However, they would not be able to have some of their treatment at
home. As PIVs and PICCs can in many instances be substituted for each other as an infusion
device, catheter dwell days were assumed to be the same in order to finish the same treatment
period. Therefore, in the PIV group, it was assumed that the total catheter dwell days would be
the same as the PICC group. Based on this assumption, the main difference for these two groups
would be inpatient days. PICC patients if stable from their disease can be discharged earlier with
the PICC in situ and receive their health care at home, whereas PIV patients cannot. They have
to stay in the hospitals for the entire infusion therapy because of the frequent exchanges of the
lines. Therefore, in the PIV group, inpatient days were assumed to be the date of admission to the
date of removal of the line and end the therapy. The inpatient days for the PIV group are
expected to be longer than the PICC group.
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If the PIV dwell time is longer than 72 hours, the risk of complications such as thrombosis,
phlebitis is increased. Scheduled line replacement has been proposed to prevent such
complications (O’Grady et al, 2002). Therefore, the PIV was assumed to be replaced every three
days during the treatment period. For the PIV insertion, on average it requires two nurses 30
minutes to insert the IV (in house data from the IV team) based on the nurses’ expert opinion. It
was estimated at $50 in total for each PIV insertion, including the nursing time cost, the cost of
mexiline and other supplies used.
When compared to a PICC, management of the PIV is simpler, and does involve repairs or
repositioning the lines. Usually the PIV would simply be removed or replaced with a new line
inserted instead due to complications, assuming it is possible to place a new line successfully. In
contrast to PICCs, assessment time for a PIV is quite short or not necessary at all. Thus physician
and nurse assessment time costs were not considered in this study. If a complication occurs with
a PIV, removal of the PIV is usually the first resort. As removal of a PIV takes only a matter of
seconds, we assumed that the removal cost and related complication treatment cost were not
factored into the calculation. If intravenous therapy is still required after a PIV complication,
reinsertion a new PIV at a new site is sometimes all that is required, which would cost $50, at a
minimum.
For the travel cost, ward cost and cost of parents’ productivity loss, similar estimation
approaches to PICCs, the unit travel cost per day would be the same. The only difference is the
longer inpatient days for the PIV group. As we said before, patients with a PICC inserted can be
discharged earlier and receive home care instead of staying in the hospital; however, pediatric
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patients with PIV inserted cannot usually go home. The whole infusion period must be finished
in hospital. Thus it is not necessary to consider the home care cost.
Four cost components were considered for the PIV group: insertion cost, travel cost, ward cost
and cost of parents’ productivity loss. Most of the estimation approach and assumptions were the
same as the PICC cost estimation except the insertion cost. The insertion cost for the PIV is
much lower than the PICC.
2.5.1 Statistical analysis software
Statistical Package for the Social Sciences, version 17.0 (SPSS Inc., Chicago, IL, USA) was used
to analyze data in our study to conduct analyses.
2.5.2 Descriptive analysis
Descriptive analyses on all pertinent variables included in this study were generated in this study.
For those continuous variables (e.g. age, weight, etc), mean, median, range and sum were
reported to describe the central tendency. However, for those categorical variables (e.g. sex,
reason for PICC, etc), frequency and percentage were used to measure the dispersion. To analyze
these variables, as patients may have more than one catheter during their therapy period, the case
unit was based on the catheter instead of the patient.
2.5.3 Multivariate linear regression model
A multivariable linear regression model was used to assess variables associated with the total
cost of a PICC. All cost components associated with a PICC were aggregated to get the total cost
of a PICC. The dependent variable was defined as the total cost associated with a PICC. All
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pertinent variables as mentioned before were placed into this multivariable linear regression
model as independent variables to identify the determinants associated with the total cost of a
PICC: age, sex, weight, patient primary diagnosis, ward unit, distance to the hospital, catheter
insertion reason, access vein, type of anesthesia, catheter size, catheter dwell days, line type, line
manufacturer, cuffed/uncuffed, lumen number, removal reason, complication, death and home
health care condition.
The multivariate linear regression model is listed as follows:
Total cost of a PICC = a + b0D + b1X1+ b2X2…. + bnXn + c1 (D* X1) + c2 (D* X2)…. + cn (D*
Xn) +ξ.
In this model, “a” is the intercept in this regression model which is the cost spent on a PICC
under the circumstances when all pertinent independent variables equal zero. “ξ” is the error
term. “D” means the total catheter dwell days which is defined as the period from the date of
insertion to the date of removal of the line. ‘X1’, ‘X2’... and ‘Xn’ are the variables we mentioned
before that is used to explain the total cost. The series of bn are the unstandardized regression
coefficients that can be used to weight the independent variables. Interaction terms were also
considered in this model too. As this study mainly focuses on the catheter dwell days of the lines,
the interaction between the variable “catheter dwell days” and other variables such as age, sex,
weight, etc are taken into consideration. The series of D* Xn are the interaction terms and cn are
the relevant coefficients of those interaction terms. The magnitude of the difference in the R2
statistic of models with or without the interaction term could be used to assess the significance of
that interaction.
In this regression model, P values less than 0.05 was considered to be statistical significant. R2
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and adjusted R2 were selected to assess how much the outcome can be explained by the selected
independent variables. The F statistic test was also tested to check whether the hypothesis that
each coefficient equals zero is rejected (P value <0.05). The T statistic of each coefficient was
applied to check each variable’s significance (P<0.05),
There are three major multiple regression procedures to do the regression analysis: simultaneous
entry of independent variables, stepwise and hierarchical regression. As this study aims to
determine the best subset of X’s to explain the dependent variable, stepwise regression is more
appropriate. That is, at each step, independent variables can be entered or removed by assessing
their importance. To further examine the relationship between the total cost of a PICC and
permanent independent variables, stepwise regression procedure is used to put those independent
variables in the model.
2.5.4 Cost comparison between peripheral intravenous therapy and peripherally inserted central
catheter
The insertion cost for a PICC is usually expected to be higher than a PIV; however, there is an
increasing tendency for PICCs to result in lower costs than a PIV as PICC patients can be
discharged earlier, thereby yielding savings in ward costs. As the catheter dwell days increase,
the total cost for PIV is expected to be eventually higher than those for a PICC. Consequently, if
the total cost of a PICC is initially greater than that for a PIV and if costs increase more rapidly
for a PIV than for a PICC, a point will be reached when both procedures entail similar costs. If
catheter dwell days were to increase further, a PICC would be associated with lower costs than a
PIV. For example, in Figure 3, the dashed curve line depicts the total costs associated with the
PICC while the solid line represents the total costs associated with a PIV. The dashed curve and
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the solid curve can be divided into three segments for this graph, segment A, segment B and
segment C. Segment A means the insertion point. At this point, due to the insertion costs, the
cost curve will not start at the origin. Segment B starts after the insertion and ends before the
cross-point. It refers to short-term catheter-dwell-days and indicates that over this period total
costs associated with PICCs will be higher than those for a PIV because of the greater insertion
cost of the PICCs. The cross point D* (Figure 3) occurs where total costs for PIVs and PICCs are
the same. For shorter dwell-days, a PIV is less costly than a PIC; however, for longer dwell-days,
a PICC is less costly. Segment C starts after the cross point. Along this segment, PICCs cost less
than a PIV primarily because of the lower inpatient ward cost.
Figure 4 Theoretical model of capturing the breakeven dwell days when PIV and PICC have the
same total costs
To assess whether PICCs are cost saving, another multivariate linear model for a PIV was built.
The multivariate linear regression model is listed as follows:
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Total cost of a PIV = e + f0D+ f1Y1+ f2Y2+…. + fnYn+ k1 (D*Y1) + k2 (D*Y2) +…. + kn (D*Yn)
+η.
Interaction terms were also considered in this model.
In this model, “e” is the intercept in this regression model which is the cost spent on a PIV under
the circumstances when all pertinent independent variables equal zero. “η” is the error term. “D”
means the total catheter dwell days which is defined as the period from the first date of insertion
to the last date of removal of the line when therapy is finished. ‘Y1’, ‘Y2’... and ‘Yn’ are the
variables we mentioned before to explain the total cost. The series of fn are the regression
coefficients that can be used to weight the independent variables. Interaction terms were also
considered in this model, the interaction between the variable “catheter dwell days” and other
variables such as age, sex, weight, etc are taken into consideration. The series of D* Yn are the
interaction terms and Kn are the relevant coefficients of those interaction terms. The magnitude
of the difference of R2 with or without the interaction term for this model was also used to assess
the significance of that interaction.
As we mentioned above, this study aims to assess the theoretical circumstances where a PICC
will become a cost saving catheter. That is, we analyze the data to find the breakeven dwell days
D* when the total cost of a PIV equals the total cost of a PICC. Before the breakeven dwell days
D*, total cost of a PICC is more expensive than a PIV, but after that point, the PICC will provide
cost savings.
2.5.5 Regression diagnosis of the multivariate linear regression models
As the best case scenario was that independent variables will significantly correlate with the
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dependent variable but will have low correlations among themselves, correlations of these
independent variables were checked first. When there are correlations among the independent
variables to some degree, multicollinearity will occur. As it will make determining the
importance of a given explanatory factor difficult to identify, diagnosis of multicollinearity is
required. The tolerance and Variance Inflation Factor (VIF) are used to test the problem of
multicollinearity of the independent variables (Myers, 1990). If the value of tolerance is less than
0.2 or VIF is greater than 4, it suggests multi-collinearity; if the tolerance was less than 0.1 or
VIF is great than 10, it strongly indicates multi-collinearity. When multicollinearity occurs, the
variable with more clinical significance is considered to keep in the model; otherwise, priority
was given to the variables with more statistical significance (Myers, 1990).
To develop a good explanatory relation between independent and dependent variables, regression
diagnosis is required. Linear regression models have three primary characteristics: linearity,
homogeneity of variance, and normally distributed residuals. For multiple linear regressions,
multicollinearity is also required to be checked. Therefore, we will check the linearity,
multicollinearity, homogeneity of the variance and the normality.
Influential data are those points with different patterns of relationship between the independent
variables and the outcome, which can make a large difference in the result. There are two kinds
of influential data, outliers and leverage points. Outliers can bring large residual which may
indicate model misfit. It suggests a sample peculiarity or data entry error. Leverage points are
those extreme points which may cause changes in the standard errors of regression coefficients
estimates. To identify those potential influential data, Cook’s distance is used to measure how
much the residuals would change if the current case were deleted from the calculations. If
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Cook’s distance is greater than 1, careful scrutiny is required. If the Cook’s distance is greater
than 4, potentially serious outliers may occur (Barnett, V. & Lewis, T. 1994).
Linearity between each explanatory factor and the dependent variable can be checked by the
scatter plot of the outcome against each explanatory factor. Homogeneity of variance means the
error variance should be constant. A well-fitted model should not have any pattern to the residual
plotted against the fitted value. Scatter plot is also used in this study to check the regression
assumption of homogeneity of variance (UCLA Academic Technology Services)
For linear regression, one of the assumptions is that the error term should be normally
distributed. There are many ways to check normality assumption. Normal Q-Q plot is applied in
this study to check the assumption of normality. If the normality is violated and the distribution
is skewed, transformations of the explanatory factor variable or dependent variable such as log
transforms are required to avoid abnormal distribution (Johnson & Kuby, 1999). Cost data are
usually skewed with a small number of very high costs but may not necessarily be treated as
outliers. Log-transformation of the dependent variable is often undertaken to ensure that the
assumption of normality of the residuals under the classical model (Rascati, et al, 2001)
2.6 Sensitivity analysis
Sensitivity analyses were conducted to test the robustness of the conclusion. One-way sensitivity
analyses were performed based on their plausible range or extreme values. There are two types
of uncertainty. One is parameter uncertainty; and the other is the structure uncertainty
(Guidelines for the economic evaluation of health technologies: Canada, 2006). Both structural
uncertainty and parameter uncertainty were analyzed in this study. Another regression with the
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inpatient costs omitted was tested for structural uncertain purpose. For parameter uncertainty,
five variables were required to be tested in sensitivity analysis which was made based on
assumptions or professional opinions: nurse assessment time, parents’ time lost per day, home
care cost per day, travel cost per day, inpatient ward cost, were considered to alter in multilevel
conditions in terms of our theoretical model using plausible values for each parameter or
plausible alternatives for each assumption. Tornado diagram was used to present the one way
sensitivity analysis. The horizontal axis describes the total cost associated with PICCs per
patient, and the vertical axis is parameters analyzed. All of these variables were ordered from
widest to narrowest based on the parameter’s range. A dotted line was used to depict the base
case for each parameter. Bars were used to represent the range of each parameter in our analysis
(Guidelines for the economic evaluation of health technologies: Canada, 2006).
2.7 Ethics
This study was approved by the Research Ethics Review Board of the Hospital for Sick Children
(Appendix 5). As these data were already captured in the hospital’s databases, patients’ personal
information such as name, medical record number were deleted in this study, this research
involves only minimal risk and anonymous data collection. Thus informed consent from these
patients was not needed.
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Chapter 3 Results
This chapter describes the systematic review and presents the findings of this study. The results
are shown in four sections. The first section describes the systematic review results. The
following two sections will give the descriptive analysis of variables associated with PICCs and
PIV. The fourth and fifth sections present the results of the multiple linear regression models.
Then the breakeven dwell days when a PICC will become cost saving is discussed. After that,
regression diagnosis is presented to check the assumptions of the regression model. Finally, one
way sensitivity analysis is presented to deduct uncertainty.
3.1 Systematic review results of peripherally inserted central catheter costs
There were 3 papers retained for review of the costs of PICCs in pediatrics. Based on these
papers, details about each paper’s cost result are listed as follows in table 13 (Table 13). The 1st
author’s names, year of study, study type, main cost items and limitations were extracted from
these three papers. Moore’ s study provided the total inpatient charge for a PICC ranging from
US$3,706.02 to US$28,792.16 with an average charge of US$14,209.81 for an average 4.11
hospital days in which the insertion cost ranged from US$1,363 to US$1,954 including the costs
of fluoroscopy, PICC placement, and insertion equipment cost. In addition, the outpatient
management cost for antibiotic therapy ranged from US$1,382 to US$1,889 for 14 days (Moore
et al., 2006). Van Winkle’s study estimated the average daily cost for a PICC at home was
US$115 while the average daily cost for a PICC as an inpatient was US$1,185. All costs for
medications, equipment, nursing, and outpatient physician visits were included as calculating the
PICC at home cost. All general billable costs were comprised in the inpatient cost estimation
(Van Winkle, et al., 2008). In Schwengel’s study, it mentioned that the lowest total cost for a
PICC per patient was US$173.58 and the highest total cost for a PICC per patient was
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US$440.70. The cost estimations include the labor time (anesthesiologist & phlebotomist),
equipment (PICC trays & IV catheters), and operating room time costs (Schwengel et al., 2004).
However, there were flaws in these studies. First, all of these three papers’ sample size was
no more than one hundred, which may cause bias. Second, all papers did not provide details on
how the costing numbers were obtained. Finally, these three papers did not consider indirect
costs associated with PICCs. As the three papers calculated different cost items, meta-analysis is
not used in this review due to data heterogeneity.
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Table 13 Systematic review for PICC cost results
1st author Year
published
Sample
size
Study
type
Cost items Limitations
Moore 2006 45 Retrospective 1. Inpatient hospital charges: average US$14,209.81, range
(US$3,706.02, US$28,792.16);
2. Direct PICC-associated costs: range (US$1,363,
US$1,954)
3. Outpatient at-home PICC antibiotic therapy cost: range
(US$1,382, US$1,889).
1. Small sample size
2. Rough direct costs
3. Lack of indirect cost
Schwengel 2004 96 Randomized
control trial
Insertion cost, range (US$173.58, US$440.70), underestimated insertion
cost
Van Winkle 2008 86 retrospective 1. Average daily cost for home health treatment US$115 per
patient
2. Average daily inpatient cost US$1,185 per patient
1. Small sample size
2. lack of indirect cost
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3.2 Descriptive analysis of peripherally inserted central catheter
(1) Demographic variables
There were 524 patients who underwent 573 PICC insertions during this study period (Jan.1-
Dec.31, 2008) at IGT in SickKids. Among the 524 patients, 482 unique patients had one PICC
inserted during the study period; 35 patients had two PICCs insertions; while 7 patients had three
PICCs inserted during the study period. For our analysis, we use ‘per catheter’ as the basic unit
for analysis. Of these procedures, 53.9% (or 309) were performed on males and 46.1% (or 264)
performed on females (Table 14). The average age of the study population was 4.79 years old
with a median age of 1.10 years old. Similarly, the average weight was 19.00 kilogram (kg) with
a median weight of 9.30 kg. The average travel distance from the hospital was 81.66 kilometer
(km) with a median distance 42.60 km far away from the hospital (Table 17).
(2) Patient primary diagnosis, ward unit inpatient days and catheter dwell days
The most common primary diagnosis for these patients, using ICD-10 to classify, were digestive
problems, disease of circulatory systems, and disease of blood and certain disorders in immune
mechanism, which accounted for 19.3%, 11.2% and 11.2%, respectively. A patient’s ward unit
was analyzed by the wards they stayed in on the second last day of admission, prior to discharge.
Among the 573 patients, 84 patients stayed in NICU, which accounts for 14.7%; 53 patients
stayed in a medical ward, which accounted for 9.2%. 189 patients (33%) stayed in a surgical
ward and 243 patients (42.4%) stayed in a medical surgical ward. Four patients stayed in CCCU
(Table 14).
The total number of inpatient days for the newly inserted PICC was 20,186.00 days for 570 cases
during the study time period in 2008. Three patients’ data were missing either the admission date
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or discharge date. The average hospital stay per patient was 37 days with the median days of 22
days. Similarly, the total catheter dwell days were calculated from the date of insertion to the
removal date of the line. The cumulative catheter dwell days were 29, 058 days with a mean of
51 days and median time of 27 days (Table 17).
(3) Insertion and removal information
The most common reason for PICC placement was medication administration and antibiotic
therapy (MEDS/ABX), which accounted for 50.3% of the total catheter insertions. The next most
common reason was administration of total parental nutrition (TPN). It was estimated that 21.1%
PICC lines were used for TPN plus medical therapies. An additional 16.9% were used for TPN
only treatment. A further 6.6% PICCs were used for chemotherapy treatment (Table 15).
Of the total 573 line insertions, 26.0% of catheters were inserted while patient was under general
anesthesia/sedation administered by an anesthesiologist (called GA). Only 3.5% were provided
with sedation administered by the IR team; most catheter insertions (70.3%) were provided with
local anesthesia with or without sucrose. Sixty five percent of PICCs were placed via the basilic
vein. The brachial vein was used in a 26.8% of cases. Other veins such as cephalic vein were
also used for access, but in fewer cases which only accounted for 5.9% in total (Table 15).
Among all these patients, 79.4% lines were removed because of end of therapy; 12.0% PICCs
were removed due to complications but without requiring or reinserting a new PICC; 6.1%
patients had their PICC removed due to a complication and had a new subsequent PICC inserted.
Both VANs and IRs could remove the catheters. As for the removal, 44.7% catheters were
removed by VANs while 46.6% were removed by IRs (Table 16).
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(4) Line information
As for the type of PICC, 87.3% catheters were single lumen catheters and only 12.7% catheters
were double lumen catheters. Generally the patients were provided with size 3 French or size 4
French catheters, which accounted for 83.6% in total. 93.9% of catheters were cuffed catheters;
only 6.1% catheters were uncuffed catheters. Almost 81.5% catheters used in IGT were silicone
catheters supplied by COOK Medical. 7.5% of the catheters used in IGT were Power PICC
(BARD) (Table 15).
(5) Descriptive analysis of cost components (Unit: Canadian dollar)
With respect to the insertion, three components (material, labor, equipment costs) were analyzed
respectively. The mean of material, labor and equipment costs per case were $441.78, $647.60,
$338.69 with the median costs of $383.37, $541.50, $300.56, respectively. The mean total
insertion cost, including the three components, was $1,428.07 with a median of 1,280.79. As the
total catheter dwell days were 29,058 days, the total insertion cost can also be presented as
$28.16/day. At least one of the parents/family members in each family was assumed to take
leave from their job and stay with the child in the ward during admission. Therefore, parent
productivity loss was the main indirect cost component. The average productivity loss was
$4,711.43 with a median cost of $2,801.82 per case or $92.23/day (Table 17 & Table 18).
As for the complication, 199 catheters had a PICC related complications which accounted for
34.73% of the total number of the cases. If expressed in terms of catheter dwell days, it
calculates as 6.85 complications per 1,000 days. Different complications required nurse
consultation and the associated treatments in order to treat those complications. The
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complication cost averaged over the entire study in the total 573 catheters. However, among 199
catheters with complication, 139 catheters occurred one complication; 43 catheters had two
complications; 11 catheters had three complications; and 6 catheters had four complications.
Some catheters may have more than one complication. There were 38 malpositions, 49
38 dislodgements, 15 thrombosis, 57 breakages or leakages, 76 blockages, and 9 other
complications such as swelling in total. The average complication treatment cost was $499.53
with a median cost $217.32 from the 199 lines. The total complication costs spent associated
with PICCs among the 524 patients was $117,390.19, or $4.03/day. When a complication
occurred, e.g. infection, a lab test was the primary way to detect and diagnose the problem. If we
looked at these 199 catheters, 61 cases required lab examinations because of the complication,
including CBC, blood culture, etc. The total laboratory cost was $1,624.15 for the 61 catheters,
with a mean cost $26.62 and median cost $28.95 per case. Meanwhile, in some circumstances,
imaging was also required. 102 patients underwent imaging examinations because of
complications. The total fee for imaging examinations, including ultrasound, linogram, and
venogram, was $8,525.40 with a mean cost of $83.58 and a median cost of $ 62.10 per case.
Thirty-four patients used the medical emergency services. $22,734.00 was spent on ER service
with the average cost $668.65, and a median cost of $421.00. There were different travel
methods for these patients, by car or by air. The total estimated travel cost incurred by parents
was $235,071.81 with a mean cost of $ 412.41 and a median cost of $256.03 per patient, or
$8.09/day. 248 patients went home earlier with their PICCs inserted, which accounts for 47.3%.
When the patients were at home, home care nurses will tend the patients, their lines and change
of their dressings and dealt with some minor complications. The average home care cost of a
PICC was $3,153.98 with a median cost of $ 176.00, or $61.94/day on average. The average
ward cost for total admission was $95,174.58 with a median cost of $53,911.00 or $1,778.50/day
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during patients’ hospital stays. Adding up all the different cost components, we calculatedthe
total cost related to PICC. The average total cost per PICC (including the inpatient ward cost)
was $100,193.62 and the Median cost was $57,872.24. The minimum and maximum costs were
respectively $1653.38 and $171,199.01. There was $5.74*107 in total spent on these 573
catheters in this study, taken the catheter dwell days into consideration, the total cost associated
with a PICC per day was $1975.74. Total direct cost accounted for 94.31% of the total cost while
the indirect cost was 5.69% of the total cost associated with PICCs. In the direct cost category,
inpatient cost would influence the total costs significantly as it accounted for 86.90%.
Comparatively speaking, other cost components represent less, most of them less than 1.00%
(Table 17 & Table 18).
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Table 14 Descriptive analysis of demographic characteristics and line information of PICCs
Note
*NICU- Neonatal Intensive Care Unit
**CCCU- Cardiac Care Unit
Variable Frequency Percent
Sex 573 Male 309 53.9 Female 264 46.1 Ward 573 Medical ward 53 9.2 Surgical ward 189 33.0 Medical surgical ward 243 42.4 NICU* 84 14.7 CCCU** 4 0.7 Type of line 573 Double 73 12.7 Single 500 87.3 Primary diagnosis 509 Disease of digestive system 128 19.3 Disease of circulatory system 74 11.2 Disease of blood and blood forming organs, certain disorders in immune mechanism
74 11.2
Manufacturer 573 COOK 467 81.5 BARD 43 7.5 MedComp 34 5.9 Others 29 5.1 Cuff/uncuff 573 Cuffed 538 93.9 Uncuffed 35 6.1
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Table 15 Descriptive analysis of insertion related variables of PICCs
Note: * GA – General Anesthesia ** LA- Local Anesthesia
Variable Frequency Percent Line insertion reason 573 MEDS/ABX 288 50.3 TPN+MEDS 121 21.1 TPN 97 16.9 Chemotherapy 38 6.6 Others 29 5.1 GA* 573 Yes 149 26.0 No 424 74.0 Sedation 573 Yes 20 3.5 No 553 96.5 LA** 573 Yes 403 70.3 No 169 29.5 Access vein 573 Basilic vein 373 65.1 Brachial vein 154 26.8 Cephalic vein 34 5.9 Others 12 2.1
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Table 16 Descriptive analysis of removal and complication related variables of PICCs
Note: * Complication frequency was also expressed as frequency per 1,000 catheter dwell days.
** Death was caused by patients’ disease, not by the PICC.
Variable Frequency Percent
Removal reason 573 End of therapy 455 79.4 complication without a new catheter inserted 69 12.0
Complication with a new catheter inserted 35 6.1
Others 14 2.5 Removal person 573 Vascular access nurse 256 44.7 Interventional radiologist 267 46.6
Others 50 8.8 Complication* 199 Block 59 or 2.03/1,000 days 0.30 Breakage 37 or 1.27/1,000 days 0.19 Dislodgement 22 or 0.76/1,000 days 0.11 Infection 29 or 1.00/1,000 days 0.15 Malposition 28 or 0.96/1,000 days 0.14 Thrombosis 7 or 0.24/1,000 days 0.03 Others 17 or 0.58/1,000 days 0.08 Death 522 Yes** 47 8.2 No 475 82.9
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Table 17 Descriptive analysis of demographic variables and time variables of PICC (continuous variables)
Note: * The sample size of inpatient days and catheter dwell days are all 570, instead of 573. Three patients’ inpatient days and catheter
dwell days’ information were missed in the patient medical record.
Continuous variable Sample size Mean (per catheter)
Std. deviation (per catheter)
Median (per catheter)
Maximum (per catheter)
Minimum (per catheter)
Age(yrs) 573 4.79 5.93 1.10 17.98 0.00 Weight(kg) 573 19.00 21.20 9.30 120.00 0.60 Distance(km) 573 81.66 124.17 45.40 1385.00 0.60 Inpatient days (day) *570 35.41 54.865 21.00 755.00 1.00 Catheter dwell days (day) *570 51.16 70.87 27.00 537.00 1.00 Insertion time (hour) 573 1.19 0.53 1.08 6.08 0.25
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Table 18 Descriptive analysis of cost variables of PICC
Note:
* The sample size of total travel cost and inpatient cost are both 570 because three patients’ inpatient days’ information were missed and
travel cost and ward cost cannot be calculated.
Cost variable Sample size
Cumulative cost (CA$)
Percentage (%)
Mean (per catheter) (CA$)
Std. deviation
Median (per catheter) (CA$)
Min(per catheter) (CA$)
Max (per catheter) (CA$)
Direct cost 5.47*107 94.31 Insertion material cost 573 253,140.95 0.44 441.78 138.44 383.37 217.92 1,150.94 Insertion labor cost 573 371,076.61 0.64 647.60 392.23 541.50 34.79 4,181.40 Insertion equipment cost 573 194,068.41 0.33 338.69 166.82 300.56 20.04 1,766.90 Total insertion cost 573 818,285.97 1.41 1,428.07 619.84 1,280.79 440.04 6,728.35 Travel cost 570 251,542.43 0.43 438.99 605.43 284.71 15.13 8,327.40 Inpatient cost 570 5.04*107 86.90 90,352.10 1.64*105 50,358.60 1,956.00 2.87*106 Removal cost 573 54,017.42 0.09 94.27 67.04 38.65 0.00 165.11 Total complication cost 573 117,039.19 0.20 204.87 504.78 0.00 0.00 5,434.50 Nurse assessment cost 573 24,657.80 0.04 43.03 25.15 31.11 21.12 265.75 Home care cost 573 1.80*106 3.10 3,144.35 6,266.44 176.00 0.00 41,624.00 Indirect cost 3.15*106 5.68 Total productivity loss 570 3.15*106 5501.59 144,174.80 3,055.36 190.96 144,174.80 Total PICC cost 573 5.84*107 101, 212.39 173,059.50 58,777.85 3,486.29 3.03*106
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Table 19 Descriptive analysis of cumulative cost and cost per day of PICC
Note:
* The sample size of total travel cost and total ward cost are both 570 because three patients’
inpatient days’ information were missed and travel cost and ward cost cannot be calculated.
Cost variable (CA$) Sample size
Cumulative cost
Cost per day
Direct cost Insertion material cost 573 253,140.95 12.06 Insertion labor cost 573 371,076.61 17.68 Insertion equipment cost 573 194,068.41 9.24 Total insertion cost 573 818,285.97 38.99 Total travel cost *570 251,542.43 11.98 Total ward cost *570 5.04*107 2401.60 Removal cost 573 54,017.42 2.57 Total complication cost 573 117,039.19 5.58 Nurse assessment cost 573 24,657.80 1.17 Home care cost 573 1.80*106 85.77 Indirect cost Total productivity loss *570 3.15*106 150.10 Total PICC cost 573 5.80*107 2763.75
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3.3 Descriptive analysis of a theoretical peripheral intravenous therapy (PIV)
Under this assumption, a total of 36,480 inpatient days for PIV with a mean of about 64 days and
a median of 36 days was obtained. For the PIV group, the inpatient days was counted from the
date of hospital admission date to the date of end of therapy. The total insertion cost for the PIV
group would be $494,350.00 with a mean of $867.28 and a median of $450.00. If we considered
the catheter dwell days, the insertion cost can be presented as $17.01/day/line. Due to different
inpatient days, the cost components which related to inpatient days such as travel cost, indirect
cost would be different as well. The total travel cost was $421,351.88 or $14.50 per day per case.
The average cost per case was $736.63 with a median cost of $435.67. The total market value for
parent lost productivity time was $6.97*106 and the productivity loss cost per day was $239.87.
The average productivity loss was $12,221.44 per case and the median loss was $6874.56. As
pediatric patients with PIV cannot be discharge with a peripheral IV, the cost for outpatient home
care cost was zero. The significant cost difference between PIV group and PICC group would be
ward cost and parent productivity losses due to different hospital admission periods. The total
ward cost was $9.07*107 ($3,116.97/ day) with a mean cost of $158,899.71 and a median cost of
$89,232.00. Thus, adding up all of these cost components, we could get that the total cost for
PIV group was 9.85*107($3,388.22/day), with a mean cost of $172,123.70 and a median of
$96,518.67 (Table 20).
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Table 20 Descriptive analysis of PIV
Continuous variable Sample size
Mean (per catheter)
Median (per catheter)
Minimum (per catheter)
Maximum (per catheter)
Std. deviation (per catheter)
Sum(in total)
Inpatient days (day) 570 37.31 22.00 1.00 755.00 56.65 36,480.00 PIV dwell days (day) 568 51.16 27.00 1.00 537.00 70.87 29,058.00 Total insertion cost (CA$) 570 867.28 450.00 50.00 8,950.00 1,178.98 494,350.00 (17.01/day) Total travel cost (CA$) 572 736.63 435.67 7.56 5,948.38 839.57 421,351.88 (14.05/day) Total inpatient cost (CA$) 570 158,899.71 89,232.00 2,768.00 1,522,850 196,451.11 9.06*107 (3,116.97/day) Total productivity loss (CA$)
570 12,221.44 6,874.56 190.96 102,927.44 14,620.54 6.97*106(239.87/day)
Total PIV cost (CA$) 572 172,123.70 96,518.67 57.56 1.62*106 212,157.61 9.85*107(3388.22/day)
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3.4 Multiple linear regression model of peripherally inserted central catheter (PICC)
Multiple linear regression analysis was used to explain factors that were associated with
variations in the total cost using SPSS. Stepwise procedure was selected to put all the relevant
variables in the model. That is, at each step, the independent variables can be entered or
removed. Each explanatory factor will be reassessed based on its importance to make sure the
accuracy of the model. The logarithmic transformation was used to make sure the dependent
variable was normally distributed. Therefore, “Log10PICCcost” was applied as the dependent
variable in the linear regression model. All those factors in the Anderson’s model as well as
other pertinent variables were put into the equation as the independent variables. Interactions
terms between “catheter dwell days” and other independent variables were also taken into
consideration. Table 21 presents the regression results. Six variables plus one interaction term
were revealed to be significant independent variables: age, male, complication, catheter dwell
days, ward, community, and interaction term (catheter dwell days* community). In this model,
the R is 0.683; R2 is 0.467; and the adjusted R2 is 0.459 in the model indicating that 46.7% of the
variance in total costs of a PICC is accounted by the combination of the six independent
variables and the interaction term (R2=0.467, adjusted R2=0.459). The F statistic equals 63.77,
which is highly significant (P value < 0.0001). It indicates that the simultaneous test of each
coefficient (beta) is 0 is rejected. To determine the contribution of each independent variable in
this model, we examined the coefficients table below (Table 21).
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Table 21 Determinants of total cost associated with a PICC
Variables Unstandardized Coefficients T value P value 95.0% confidence
interval for B
B (Estimate) Standard Error Lower Upper
Intercept 4.395 0.054 81.767 <0.001 4.290 4.501
Age -0.010 0.002 -4.055 <0.001 -0.014 -0.005
Male 0.063 0.026 2.432 0.015 0.012 0.114
Complication 0.110 0.029 3.798 <0.001 0.053 0.167
Catheter dwell days 0.010 0.001 14.400 <0.001 0.009 0.012
Ward 0.105 0.016 6.643 <0.001 0.074 0.135
Home care 0.042 0.019 2.239 0.026 0.005 0.079
catheter dwell
days* home care
-0.009 0.002 -12.495 <0.001 -0.011 -0.008
The coefficient table allows us to assess the usefulness of each explanatory factor in the model,
as indicated by the significance of t statistic. In our example, the six independent variables
mentioned above plus one interaction term are significant independent variables of the dependent
variable “Log10PICCcost”. All of these variables’ P values are less than 0.05. From this
coefficient table, we could know that the multiple linear regression model can be as follows:
Log10PICCcost = 4.395 – 0.010age + 0.063male + 0.110complication + 0.010catheter dwell days
+ 0.105ward + 0.042home care– 0.009catheter dwell days* home care
In this equation, Log10PICCcost was used to be the dependent variable. According to Zhou’s
study, the results with log transformation should be carefully and correctly interpreted. The null
hypothesis based on log-transformation cost data may not be equivalent to the null hypothesis
based on the original cost data (Zhou, et al, 1997). Therefore, the back-transformation of the log-
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transformed cost data is necessary. In this situation, we can use properties of logs to do back
transform. For example, in our study, we regress Log10PICCcost= a + bXn + error. If we do the
back transform, we can say that increasing X by one unit will increase the mean of total PICC
cost by 10b. Therefore, the regression equation can be transformed as follows:
PICC|totalcost = 24,831–1.023age + 1.156male + 1.288complication + 1.023catheter dwell days +
1.0355ward + 1.102home care– 1.021catheter dwell days* home care
3.5 Multiple linear regression model for peripheral intravenous therapy (PIV)
Using the same methodology as with the PICCs, multiple linear regression model of the PIV
group was also used to explain factors influencing the total cost of a PIV. Stepwise procedure
was also used. To ensure the dependent variable normally distributed, the logarithmic
transformation of PIV total cost was considered. Therefore, “Log10PIVcost” was applied as the
dependent variable. Table 22 presents the regression results (Table 22). Only two variables were
revealed to be significant independent variables: catheter dwell days and ward. In this model, R
equals 0.645 and the adjusted R2 equals 0.413 now indicating that 41.3% of the variance in total
costs of a PIV can be accounted by the combination of catheter dwell days, age, male and
ward..The F statistic equals 100.883, which is highly significant (P value < 0.0001). It indicates
that the simultaneous test of each coefficient (beta) is 0 is rejected. To determine the contribution
of each independent variable in this model, we examined the coefficients table below. From this
coefficient table, we can know that the coefficients for catheter dwell days and ward are 0.006,
and 0.094, respectively. T test results show that both coefficients are under 0.001. However, for
age and male, their p values are larger than 0.05. In order to keep consistency with the former
PICC regression equations, age and male are still remained in the PIV regression model.
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Table 22 Determinants of total cost associated with a PIV
Variables β T p 95% C.I.
Lower Upper
Intercept 4.485 66.589 <0.001 4.357 4.702
Catheter dwell days 0.006 18.647 <0.001 0.005 0.006
Age -0.005 -1.564 0.118 -0.010 0.001
Male -0.018 -0.548 0.584 -0.083 0.047
Ward 0.094 4.694 <0.001 0.055 0.133
From this coefficient table, we could know that the multiple linear regression model can be as
follows: Log10PIVcost = 4.5485+ 0.006catheter dwell days -0.005Age – 0.018Male +0.094Ward
In this equation, Log10PIVcost was used to be the dependent variable. Therefore, the back-
transformation of the log-transformed cost data is necessary. The regression equation can be
transformed as follows:
PIV|totalcost = 35,359+1.014catheter dwell days – 1.012Age – 1.042Male + 1.242Ward
3.6 Breakeven dwell days of catheter dwell days
From the above regression analysis, we know the regression models for PICC and PIV are:
(1) Log10PICCcost = 4.395 – 0.010age + 0.063male + 0.110complication + 0.010catheter dwell
days + 0.105ward + 0.042home care– 0.009catheter dwell days* home care
(2) Log10PIVcost = 4.5485+ 0.006catheter dwell days -0.005Age – 0.018Male +0.094Ward
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From these two equations, we know that catheter dwell days are dependent on several factors
such as age, complication, ward, etc. As our main focus in this study is the catheter dwell days,
sample means for all the other related factors in the two regression equations were assigned into
these equations in order to detect the breakeven dwell days of the catheter dwell days under the
circumstance when Log10PICCcost equals Log10PIVcost.
Therefore we can get that,
(3) Log10PICCcost = 4.718 + 0.0055catheter dwell days
(4) Log10PIVcost = 4.701+ 0.006catheter dwell days
As we discussed before, the breakeven dwell days D* was the point when the total cost of a PIV
equals the total cost of a PICC. Before the breakeven dwell days D*, total cost of a PICC is more
expensive and a PIV, but after that, the PICC will be a cheaper way. If Log10PICCcost equals
Log10PIVcost, we can get this equation as follows:
4.718 + 0.0055catheter dwell days=4.701+ 0.006catheter dwell days
Rearranging this equation, we can get 0.0005 catheter dwell days = 0.017
We can determine that the breakeven catheter dwell days were 34 days. That is, when the
catheter dwell days equals 34 days, the total cost associated with these two catheters will be the
same. After that, PICCs will be cost saving.
Using this as a baseline, we then consider how extreme values to each regression variable may
shift the cut point. Firstly, we will look at the home care. Patients with PICCs have the
possibility to receive home care while patients with PIV cannot. If they receive home care, the
value will be “1”, otherwise it will be “0”. If all patients receive home care, that is, home care
equals “1”, the breakeven dwell days will decrease to 7.6 days under the condition that all the
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other factors are still assigned with their mean values. Similarly, if we assume that home care is
free, those patients who are discharged earlier and get home care will not pay any fees for home
care services. Under this situation, the break-even dwell days will become 7.7 days. This is to
say, home care, is a cheaper alternative for hospital care and will lead to cost saving.
If patient occurs complication, the value will be “1”, otherwise will be “0”. At this situation,
same as home care, all the other factors are still assigned with their mean values except catheter
dwell days and complication. When complication equals “1”, that is, all patients are assumed to
have complications, the break-even dwell days will increase to 199.7 days because of the
complication treatment cost. However, in this real world, not all patients will have
complications. Therefore, under this situation, the break-even dwell days should be always less
than 199.7 days.
As we discussed above, inpatient ward cost accounts for a large proportion of the total cost
which may result in the structure uncertainty. Thus we excluded the inpatient ward cost and
recalculated the break-even dwell days. Under this situation, the break-even dwell days are 35.7
days, which are similar with 34 days. Therefore, though inpatient ward cost accounts for more
than 80%, it will not influence the break-even dwell days.
Age is a continuous variable with the minimum value approximates to “0” and maximum value
approximates to “18”. Therefore, we use “0” and “18” as this variable’s extreme values. When
age approximates “0”, the breakeven dwell dayswill become close to 125 days if we assume all
patients are 0 year-old. However, if all patients are assumed to be 18 years old,, the breakeven
dwell dayswill be approximate to 0 days. This is to say, for a general pediatric population, the
breakeven dwell days should lie between 0 days to 125 days.
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Ward unit is a categorical variable valued from “1” to “5”. Thus, “1” and “5” are used to be the
extreme values for ward units. Similarly to the other regression variables, when all patients stay
in ward unit with the value of “5”, the breakeven dwell days will be 76 days. However, if
patients move to a less intensive care ward, the breakeven dwell days will be lower as well.
3.7 Regression diagnosis
Normal Q-Q plot of the total cost was used to check the assumption of normality (left in Figure
4). As those points are not approximate to the line, normality assumption is violated if using the
total cost as the dependent variable. To figure out the problem of normality, logarithmic total
cost was applied as the dependent variable. Normal Q-Q plot of the “log10PICCcost” was
presented right in figure 5 (Figure 5). Right now, normality assumption is matched.
Figure 5 Normal Q-Q plot of the total cost and normal Q-Q plot of Log10PICCcost
Cook’s distance is used to identify the influential data points. In our study, the range of Cook’s
distance is from 0.000 to 0.300, which is much smaller than 1. Influential data points will not be
a problem in this study. Scatter plot is used to check the assumption of linearity and homogeneity
of variance (Figure 6). There is no any pattern to the residual plotted against the fitted value. So
these assumptions are well fitted.
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Figure 6 Scatter plot of PICCs
Same regression diagnosis procedure as PICC, Normal Q-Q plot of the total cost was used to
check the assumption of normality (left in Figure 7). However, the total cost for PIV is not
normally distributed. To figure out the problem of normality, logarithmic total cost of PIV was
applied as the dependent variable. Normal Q-Q plot of the ‘log10PIVcost’ was presented in the
right of figure 7 (Figure 7). After logarithmic transformation, the normality assumption is
matched.
Figure 7 Normal Q-Q plot of total PIV cost and Normal Q-Q plot of Log10PIVcost
Cook’s distance for PIV is used to identify the influential data points. As the range of Cook’s
distance is from 0.000 to 0.593, which is much smaller than 1, there is no problem of influential
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data points. The Durbin Watson statistic result is 1.941, which lies between 1.5 and 2.5. Thus
independent assumption is well fitted. The tolerance value for “catheter dwell days” is 0.999,
indicating that there is no multicollinearity problem. Scatter plot is used to check the assumption
of linearity and homogeneity of variance. There is not any pattern to the residuals plotted against
the fitted value. So these assumptions are well fitted.
3.8 Sensitivity analysis of peripherally inserted central catheter costs
(1) Structure uncertainty
As we mentioned before, two types of uncertainty were considered, structure uncertainty and
parameter uncertainty. As inpatient cost accounts for 86.9% of the total costs associated with
PICCs, it will significantly influence the total costs associated with PICCs. Therefore, inpatient
cost may be a potential factor of structure uncertainty. In order to avoid or lessen structure
uncertainty, another regression was run without inpatient cost. Without inpatient cost, only three
independent variables mentioned above plus one interaction term are significant independent
variables of the dependent variable “Log10PICCcost”. They are complication, catheter dwell days
and home care, and interaction term. All of these four variables’ P values are less than 0.05. In
this model, the R is 0.728; R2 is 0.530; and adjusted R2 equals 0.525 in the model indicating that
53.0% of the variance in total costs of a PICC is accounted by the combination of the six
independent variables and the interaction term (R2=0.530, adjusted R2=0.525). The F statistic
equals 115.259, which is a high significant (P value < 0.0001) (Table 25).
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Table 23 Determinants of total cost associated with a PICC without inpatient cost
Effect Unstandardized Coefficients T value P value 95.0% confidence
interval for B
B (Estimate) Standard Error Lower Upper
Constant 3.726 0.027 136.281 <0.001 3.672 3.780
Complication 0.131 0.021 6.347 <0.001 0.090 0.171
Catheter dwell days 0.003 0.001 19.050 <0.001 0.002 0.003
Home care -0.046 0.010 -4.473 <0.001 0.090 0.171
Insertion time 0.081 0.019 4.156 <0.001 -0.067 -0.026
Age -0.004 0.002 -2.345 0.019 -0.001 -0.061
Compared to the model with inpatient costs, the R square was much improved. More variances
can be explained by this model. Without inpatient costs, only five variables affect the total costs
associated with PICCs: home care, complication, catheter dwell days, insertion time, and age.
The variables of ward and sex are no longer significant factors now. However, insertion time is
affecting the total cost now.
(2) Parameter uncertainty
For parameter uncertainty, five variables were required to be tested in sensitivity analysis which
was based on assumptions or professional opinions: nurse assessment time, parents’ time lost per
day, home care cost per day, travel cost per day, inpatient ward cost. Tornado diagram was used
to present the one way sensitivity analysis. The horizontal axis describes the total cost associated
with PICCs per patient, and the vertical axis is parameters analyzed. Extreme value was used to
define each variable’s range. All of the four parameters’ lower values were zero. For the nurse
assessment time, according to their self-estimation, the longest time was 45 minutes. Therefore,
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nurse assessment time can range from 0 to 45 minutes. For the parents’ time lost per day, the
upper extreme value is 24 hours. Thus, the range of the parents’ time lost per day would be from
0 to 24hours. The reimburse rate for travel cost in SickKids is $ 0.35/km now. The extreme
upper value can be $3/km, which is the taxi’s flag down fare. If higher than that, people will take
a taxi to the hospital instead of driving themselves. Thus, the range of reimburse rate for travel
cost is from $0.35/km to $3.00/km. For the home care cost, the extreme upper cost can be $176.
Thus home care costs ranges from $0 /day to $176/ day. The maximum and minimum value for
inpatient ward cost is extracted from Ontario Case Costing Initiative (OCCI), which is a costing
database to support decision making. The acute inpatient, day surgery, ambulatory care and
rehabilitation care data were collected by OCCI. A standard case costing methodology was
developed by OCCI and applied in those participating hospitals to ensure the data quality. In the
fiscal year 2008-2009, the lowest direct cost on average per diem is $303.18; the highest direct
cost on average per diem is $1925.01. According to the case costing support group in SickKids,
the highest inpatient cost per day can be $3807.00. Therefore, in our sensitivity analysis, the
range of inpatient cost per day can be from $303.18 to$3807.00.
All variables were ordered from widest to narrowest based on the parameter’s range. A dotted
line was used to depict the base case for each parameter. Bars were used to represent the range of
each parameter in our analysis. The X axis was the total costs associated with PICCs. X axis
crosses at $58,415,197.92 with Y axis as the base value, which is also the average total cost.
Upper extreme value and lower extreme value were labeled in this graph too. From the tornado
diagram, we can know that if these uncertain parameters changes, the total cost associated with
PICCs will not change much, except the inpatient cost and home care cost (Figure 8). However,
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as we mentioned before, inpatient ward cost will not change much about the breakeven dwell
days. Home care, as a potential alternative cost-saving method, should be used more in the
Figure 8 Tornado diagram for sensitivity analysis
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Chapter 4 Discussion
This chapter will discuss the results and provide suggestions for other researchers. In section one,
the quality of the papers retrieved for the systematic review will be assessed. In section two we
will discuss the results of the study and the factors including various cost components and
complication rates that might affect our findings. Subsequently, section three and section four
present the limitations and generalization of this study. Finally, policy implications are described
in section five.
4.1 Quality assessment of the papers retrieved for the systematic review
The three studies reviewed are clearly described in the systematic review criteria. All three
papers were clearly focused on the pediatric population instead of adult population. Moore’s
study was based on a regional children’s hospital from 1989 to 2004. They selected sixteen
patients who received a PICC as the study population and 26 patients received oral antibiotics as
the control group. The results show that oral antibiotic therapy is sufficient. Use of PICC therapy
should be limited. Van Winkle’s study was more concerned about the cost comparison between
inpatient and outpatient; therefore, thirty four patients at one hospital from 2003 to 2006 were
included for analysis as the patients must complete both inpatient and outpatient treatment
sessions. This study presents that outpatient treatment with PICCs are cost saving devices.
However, Schwengel’s study did not mention the exact hospital type and study period but it did
mention the study population was 96 pediatric patients from neonates to 14-yr-olds. This study
was a randomized controlled trial which focused on the cost and complication comparison
between PICCs and PIVs. The outcomes indicate that PICCs should be chosen in patients who
require more than four days of in-hospital postoperative care, very frequent blood sampling or IV
access is required. Since this systematic review for PICC cost retrieved papers from the main
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four databases (PUBMED, CINAHL, EMBASE, COCHRANE LIBRARY) and four special
economic evaluation databases (HTA, NHS EED, DARE, PEDE), there is a very low probability
that some relevant studies might have been omitted. But these studies were all based on single-
centre study patient population, which limited the sample size. Selection bias might incur as the
same sample size and the results may not be generalizable to other settings. In addition, the costs
provided in these studies are pretty broad; calculation details are not presented. And some of the
cost components such as travel cost or complication treatment costs are not considered in the
three papers too. None of the three papers calculated indirect costs, making the comparison
between them difficult. Due to lack of cost data, meta-analysis cannot be applied in the part of
systematic review.
4.2 Comparison between the literature reviews and this study
In Schwengel’s study, it mentioned that the lowest insertion cost was US$173.58 and the highest
insertion cost was US$440.70 for a PICC per patient. The cost estimations include the labor time
(anesthesiologist & phlebotomist), equipment (PICC trays & IV catheters), and operating room
time costs (Schwengel et al., 2004). This is much lower than Moore’s and our study. In Moore’s
study, the insertion cost ranged from US$1,363 to US$1,954 including the costs of fluoroscopy,
PICC placement, and insertion equipment cost. Compared to our study, the average insertion cost
is CA$1,428.07 with a median of $1,280.79. The costs in Schwengel’s study are much lower
than Moore’s study and our study. This is because the insertion cost lacks of the cost of IR labor
cost, and material costs. In our study, the per diem inpatient ward cost is from CA$1791.00 to
CA$3807.00. Van Winkle’s study comprises all general billable costs as the inpatient cost
estimation. The average daily inpatient cost for a PICC was US$1,185 (Van Winkle, et al.,
However, in Moore’s study, the range of inpatient cost per day for a PICC is much broader,
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which ranges from US$926.51 to US$7198.04. It is possibly because Moore’s study has a larger
sample size and patients’ conditions may vary differently. Furthermore, the outpatient
management cost for antibiotic therapy ranged from US$98.71 to US$134.93 per day (Moore et
al., 2006). In another study, it was estimated the average daily cost for a PICC at home was
US$115. Our study uses the CA$88 per visit, which is comparable, thought a little bit lower than
Moore’s results (Van Winkle, et al., 2008).
However, there are flaws in these studies. Firstly, all of the three studies are small, no more than
one hundred, which may cause bias. However, our study’s sample size is much larger, which
may be more representative. Secondly, all the three studies focus on the insertion costs but do not
provide details on how the costing numbers were obtained. Though Schwengel’ study provides
how they calculate the insertion cost, IR labor cost, material cost, and some equipment cost are
not taken into consideration. Finally, these three papers did not consider other cost components
associated with PICCs. For example, all of the three papers did not consider the complication
costs associated with PICCs, removal cost, travel cost, or indirect cost.
4.3 Factors influencing the results
There were many factors that can affect the total cost of catheters. Except the various cost
components that would influence the total cost directly, the multiple linear regression results
showed that six factors such as catheter dwell days, complication, and ward could also have
significant influence on the total cost for the PICC total cost in the linear regression equation.
PICC|totalcost = 24,831–1.023age + 1.156male + 1.288complication + 1.023catheter dwell days +
1.0355ward + 1.102home care– 1.021catheter dwell days* home care
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From this equation, we learn that the younger the patient is, the higher the cost associated with a
PICC. This is reasonable as younger children may require special care services and specific
equipments for insertion procedures. In addition, younger children may lack cooperation with the
doctors or nurses, which may bring more complications such as catheter dislodgement, increase
the difficulty of insertion, or require more anesthesias for the insertion procedure. As sex is a
binary variable with “1” and “0”. Male is defined as “1” and female is defined as “0”. Therefore,
from this equation, male patients may result in higher costs according to this model. It is obvious
that more complications will lead to higher associated costs for PICCs. Careful maintenance of
the catheter dwelling time is important. Once a complication occurs, immediate treatment of the
complication is required to avoid more severe complications. From the linear regression model,
we also know that the longer catheter dwell days will be associated with increased PICC related
costs. The diagnosis is the deciding factor as to what ward unit the child is on. Those children
with severe conditions will be sent to the ward units with more intensive care. As the ward unit
variable is a categorical data, the bigger the value is, the more intensive care patient will receive
in those ward units. Thus, units providing intensive care such as the NICU will incur higher costs
than general ward such as medical wards. As we have analyzed in the result section, patients who
were discharged home and had their line cared for in the community will save the cost. A PICC
is preferable for medium and long term infusion therapy as allowing for earlier discharge and
savings related to hospital. This strengthens the conclusion that home care, as the extended
health care services out of hospitals, is less costly and is regarded commonly as an important
alternative to hospital care. The general tendency in the future is to transfer care from the
hospital settings to less costly home and home care based services (National evaluation of the
cost-effectiveness of home care, 2002).
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From the results, we also know that the breakeven dwell days of catheter dwell days depends on
the patients’ age, sex, the ward unit and whether a complication occurs. The breakeven dwell
days of catheter dwell days can be estimated once the patients’ age, sex, the ward unit, and
complications were known. Therefore, we assigned the variables with their average value, we
can detect that the breakeven dwell days of catheter dwell days are 34 days.
As inpatient ward cost will account for 86.9% of the total costs with PICCs, it will significantly
influence the total costs associated with PICCs. In the sensitivity analysis, multiple linear
regression model without inpatient ward cost was analyzed. Compared to the model with
inpatient costs, the R square was much improved. More variances can be explained by this
model. Without inpatient costs, five variables affect the total costs associated with PICCs: home
care, complication, catheter dwell days, insertion time, and age. Without inpatient ward cost, sex
and ward are not influencing factors any more. In this model without inpatient ward cost,
insertion time will affect the total costs associated with PICCs. Except insertion time, other
factors are the same with the model with inpatient ward cost. The longer the insertion time is, the
higher total cost it will be.
As we mentioned before, the unit for our analysis is “per catheter” instead of “per patient” while
some patients have more than one catheter inserted during the study period; therefore, bias may
exist for those patients with multiple catheters. In order to alleviate this influence, another
regression was run only with the first insert PICCs. Thus the sample size will become 524 since
we assume one patient only insert one catheter. Those patients’ secondary catheter and/or third
catheter were deleted. Now the new regression equation is as follows, of which R equals 0.656
and the adjusted R square equals 0.422.
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Log10PICCcost = 4.361 – 0.011age -0.072male + 0.094complication + 0.011catheter dwell days
+ 0.107ward + 0.063home care– 0.01catheter dwell days* home care
Compared to the equation before with all the PICCs, no big differences were found. The six
factors, age, male, complication, catheter dwell days, ward, and home care are still significant
factors for the total cost of PICCs. Since their sample sizes are different, the mean of these
factors are also changed. Table 24 presents the new univariate analysis results of these factors.
Table 24 New descriptive analysis results of the significant factors
Variables N Mean Median Std.
deviation
Min Max Sum
Age 524 4.908 1.188 5.972 17.984 2571.783
Male 524 0.538 1.000 0.499 0.000 1.000 282.000
Complication 524 0.320 0.000 0.469 0.000 1.000 170.000
Ward 524 2.630 3.000 0.883 1.000 5.000 1380.000
Catheter dwell days 524 51.920 27.000 72.783 1.000 537.000 27048.000
Home care 524 0.6000 1.000 0.922 0.000 1.000 312.000
Similarly as before, under this equation, the breakeven dwell days can be calculated if we assign
the factors with their mean values. Now the two equations can be simplified as follows
Log10PICCcost= 4.617 + 0.005 catheter dwell days
Log10PIVCost=4.548 + 0.006 catheter dwell days
Using the two equations of PICC cost and PIV cost, we can get that the breakeven dwell days are
69 days now, which is longer than 34 days. This may be because those patients who require
secondary or third catheters usually have longer catheter dwell days than those who only require
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one catheter. Thus, compared to patients with PIVs, these patients with PICCs are more possible
to be discharged earlier and get home care, which will avoid the unnecessary hospital cost.
4.4 Limitations
There are several limitations in this study. As this is a retrospective study, it mainly depends on
the completeness of the patient chart records; potential confounders may exist too. Even though
data is captured from the hospital database, missing data is inevitably an issue. For example,
some patients’ home addresses are missing; therefore we are unable to measure the distance from
their home to the hospital. Then we will loss the patient’s travel cost data. Some patients’
discharge date were missing or unclear, this is associated with difficulty as calculating the
inpatient days. In order to solve this problem, average distance and average inpatient days were
used to define those missing data to avoid losing information. However, this may bring bias to
our study results. In addition, for the systematic review, as we only consider those studies
published by English, publication bias may exist as well.
Secondly, this study does not have a control group. All patients referred to IGT had PICCs
insertions instead of PIVs. For our secondary objective, in order to discuss under what
circumstances PICC will be cost saving, a theoretical PIV control group was created. We
assumed that patients, who use PICCs as their intravenous devices, could have in theory used
PIVs instead. Under this situation, the PIV control group has identical demographic
characteristics as the PICC group. However, using a theoretical control group does not reflect all
actual clinical scenarios. For example, the travel approach that patients and their family members
selected might be different with our assumptions. Therefore, the results should be interpreted
cautiously and generalization of the results needs to be interpreted with care. There are
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limitations to use of PIVs as it must be clinically appropriate to use PIVs for infusion therapy
without skin burns, without frequent blood sampling requirement, and not all treatment
medicines can be infused via a PIV. For example, if patient requires concentrated TPN for
treatment, a PIV is not an appropriate device for infusion purpose. And in reality, frequent vein
punctures will lead to patient’s discomfort. Therefore, we cannot say these two catheters are
equivalent under every situation.
Thirdly, there are many difficulties when obtaining cost data at a hospital level, which may lead
to a biased estimation, either overestimated or underestimated. Many assumptions are made in
order to estimate the costs. For example, inpatient cost was estimated by the patients’ last 2nd day
before discharge cost to get a generalizable number for each ward, instead of patient-level case
costing. Indirect cost might be underestimated since we only considered the parent productivity
loss. Productivity lost incurred by other family members instead of parents has not been included
due the difficulty of data collection. This led to the underestimation of the indirect cost. For PIV,
complication treatment costs were not taken into consideration as we assumed that patients’ PIV
lines would be removed as soon as complication occurs. But actually for PIV groups, they have
associated complication costs. In this study, we did not include the cost of treating a skin burn,
the cost of a temporary jugular or femoral line if they cannot get a PIV, and the cost savings for
all the phlebotomy saved. This may underestimate the actual cost issue of PIVs. PICCs can avoid
repeated punctures as the catheter can stay in the vein for a long time while PIV cannot. Some of
the assumptions are based on professional experts’ opinions for variance price and resource use
inputs. Bias may exist due to subjective opinions. Furthermore, we haven’t considered the
quality of life assessment for those patients with PICCs as it avoids the physical and
psychological pain of repeated PIV pokes and blood work.
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4.5 Generalization
The data used in this study is collected from a single-centre. As a tertiary pediatric hospital, the
costs observed here in SickKids may not be representative for outside hospitals. And this study
only focuses on the costs in pediatrics, adults would face different catheter conditions and/or
various costs which make generalization from this study difficult. However, according to the
research (John Eng, 2003), to calculate how many individuals should be studied, the formula for
the sample size is as follows
= ( / )
n-Sample size; σ-variance; E-sample error ; and Zα/2-Confidence level
If we regard the sample error as 10%, only 96 patients are required to represent the total
population; while if we decrease the sample error to 5%, 384 patients are necessary to be
included. As the study sample size, 573 lines, is significant and costs are estimated
comprehensively, conclusions of this study can still be generalized to many other economic
evaluations. Other studies associated with different medical devices/equipments could use a
similar approach to estimate.
The results of this study are likely most applicable to larger hospitals, particularly pediatric
hospitals, in developed countries. The main concern is that different countries have different
costs for these procedures. For those without an Interventional department, they need to
frequently use different procedures or interventions to insert PICCs or look for substitutes of
PICCs. Many have nurse inserted PICC programs with lower insertion costs but lower success
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rates. In addition, different preference on catheter selection may influence the application of
PICC too. All of these may affect this study’s generalization as well.
4.6 Further study direction Further studies of cost comparison between PICCs and other catheters are necessary using an
actual control group instead of using a theoretical control group. Studies should focus more on
better and accurate cost calculation approaches to estimate the costs associated with PICCs.
Moreover, the study should be a randomized control trial study in order to avoid potential bias.
As patients with PICC inserted can be discharged earlier and get home care instead of staying in
hospital, they can be more engaged in the daily activities. Moreover, inserting PICCs will avoid
unnecessary needle punctures caused by the PIV insertions. Therefore, patients have better
quality of life. However, in this study, quality of life assessment is not included which can be a
potential future study direction. We can also do more cost comparisons between PICCs and other
vascular access devices instead of PIVs. Furthermore, patients with different diagnosis may
occur various situations. It is necessary to do subset analysis in terms of diagnosis in the future
study direction.
4.7 Policy implication
The results of this study inform the health policy issue that PICCs can be a cost saving device for
intravenous therapy compared to PIV. A PICC is a commonly used venous access device for
patients who require antibiotic therapy, chemotherapy and TPN, particularly in children.
Although the total costs may be affected by many factors such as age, sex, complication, etc, the
PICCs can be still cost saving if the catheter dwell days are longer than 34 days under all the
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other influencing factors’ value are fixed. Besides, according to the literature review, PICCs are
a preferable choice compared to PIVs as PICCs can avoid unnecessary pain, complications, and
reduce the inpatients days.
Information collected on how costs vary between patients, over the dwell time of the catheters
and in different venous access devices, may help the policy makers responsible for maximizing
the benefits from resource allocations. As SickKids is the largest pediatric hospital in Canada
and lots of children have their PICCs inserted in SickKids, how to maximize the resources’
utilization is a hot topic in order to reduce the governmental financial pressure as most of the
costs related to catheters or hospital fees are insured by Ontario Health Insurance Plan (OHIP).
Information gleaned from this economic study reveals that a PICC is preferable for medium and
long term therapy as compared to PIVs.
Financial savings and benefits to the health care system can be captured by choosing the right
approach in appropriate circumstances. In order to deliver better health care with limited
resources, one of the important shifts is from the hospital to the home. Patients used to spend
prolonged hospital days in the past decades, which had dramatically driven the health care cost.
However, greater utilization of home care has brought about a decreasing health care cost (Coyte
and McKeever, 2001; Coyte and Stabile, 2001). This study provides the cost details of PICCs
and identifies many of the determinants influencing PICC costs. The main reason PICCs can be a
cost saving device is because patients can be discharged earlier and get their care outside
hospitals. Thus it can save a large amount of hospitalized expenditures. This strengthens that the
importance of home and home care, as the extended health care services out of hospitals, is less
costly and is regarded commonly as an important alternative of hospital care.
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However, there are still many flaws in this study and further research can be done to improve the
accuracy of cost estimation. A similar approach can be used to assess the associated costs of
other medical devices.
4.8 Conclusion
As stated before, this study aims to estimate the average/median costs of the different cost
components associated with PICCs in pediatric patients from a societal perspective. With respect
to the insertion, the mean of total insertion cost, including labor cost, material cost and
equipment cost, is $1,428.07 with a median of 1,280.79. The average productivity loss was
$4,711.43 with a median cost of $2,801.82 per case or $92.23/day. Among 199 cases with
complication, the average complication treatment cost would be $499.53 with a median cost
$217.32. The total estimated travel cost incurred by parents was $235,071.81 with a mean cost of
$ 412.41 and a median cost of $256.03 per patient. 248 patients went home early with their
PICCs inserted, which accounts for 47.3%. The average home care cost of a PICC was $3,153.98
with a median cost of $ 176.00, or $61.94/day on average.
As for the second question, the multiple linear regression model elaborates that six factors can
influence the total costs associated with PICCs. These factors are age, sex, complication, home
care, ward unit and catheter dwell days. Younger children, longer catheter dwell days, male
patients, patients with complications, and patients staying in more intensive care wards will incur
greater total costs. Patients discharged earlier who get the home care services can save costs.
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To detect whether PICC will yield cost-savings compared to its use of PIV, the relationship
between total costs associated with PICCs and catheter dwell days are also presented in this
study. Under the circumstance that other influencing factors such as age, male, complication are
fixed, the PICC will yield cost-savings if the catheter dwell days are longer than 34 days.
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Appendices
Appendix 1 Picture of a PICC and a PIV
Picture of a PICC
Uncuffed PICC, trimmed to length with attached extension tubing
Resource: http://faculty.mercer.edu/summervill_j/iv.htm
Picture of a PIV
PIV with attached extension tubing
Resource: http://faculty.mercer.edu/summervill_j/iv.htm
Appendix 2 Copyright permission of Jonathan Rosenfeld by email
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Appendix 3 Esh Database
Esh software Design & Implementation Ltd. focuses on providing hospitals and other healthcare
facilities with expertise and software that includes commercial hospital and clinical applications,
custom design software, research databases, interface development. Since 2000, ESH has been
created to implement in diagnostic imaging labs in North America. ESH is an enterprise
application that provides pre-to-intra-to-postoperative case coverage for diagnostic imaging,
cardiac catheterization lab and surgical procedures. This application offers a unique data
infrastructure that gives physicians and administrators all the tools necessary to track patient
related activities and data. From the medical to administrative aspects under one integrated
solution. ESH provides physicians with a comprehensive applicathion that: 1) Displays on-line in
real time a complete patient record with reference to patient encounters history; 2) Tracks all
inventory, equipment, billing codes, staff and drugs used during the procedure; 3) Applies ICD
codes for patient diagnosis; 4) Integrates sedation and anesthetic records with the individual
patient case and displays patient hemodynamics charts; 5) Allows a physician to electronically
record the patient information; 6) Tracks the pathology results from the lab and stores the
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pathology report in the patient’s case file; 7) Provides the physicians with on-line real time M &
M Rounds and Reports tracking process; 8) Supports comprehensive teaching files by allowing
the physician to store converted DICOM images in each patient case; 9) Provides a robust search
engine to extract data into Excel file for preparing academic papers and research studies based on
the data collected during the patient case procedure.
The patient case gives the users “drop down pick list” features that save time in typing the data.
The desktop of the ESH database is showed in the following picture.
Appendix 4 ICD-10 Illness and Injuries Tabular Index
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Source: Canadian Institute for Health Information (2001). Final Report: The Canadian
Enhancement of ICD-10 (Internal Statistical Classification of Disease and Related Health
Problems, Tenth Revision).
http://secure.cihi.ca/cihiweb/en/downloads/codingclass_icd10enhan_e.pdf
Appendix 5 The first page and last page of the Ethical approval.
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Copyright Acknowledgements
The author wishes to thank the following for permission to reproduce copyright material. The
information contained in the following Figure describes the PICC insertion simulation. The
author used this simulation picture to describe the insertion site and the rested site of the PICC in
order to give the reader some ideas on how this catheter works. This figure was captured from
Jonathan Rosenfeld. Email permission was obtained from Jonathan Rosenfeld.
