Clearing an occluded central venous catheter with alteplase is just as effective as replacing the line, but costs significantly less.
A large, retrospective, industry-funded study has concluded that treatment with alteplase costs about $1,400 less than replacing the line. Differences in radiologic, nursing, and surgical costs accounted for most of that, Frank R. Ernst, Pharm.D., and his colleagues wrote online in the Journal of Hospital Medicine (J. Hosp. Med. 2014 May 14 [doi: 10.1002/jhm.2208]).
The additional finding that length of stay was not a main cost driver lends credence to the idea that alteplase could be a good choice whether patients only need line clearance, or are already in the hospital for other reasons, wrote Dr. Ernst of Premier Research Services, Charlotte, N.C., and his coauthors.
"If patients are admitted for a noncardiovascular condition and have central venous catheter occlusion, using alteplase to clear the ... occlusion, along with implementing strategies to manage the underlying disease to reduce the length of stay, becomes a powerful opportunity to impact cost," the investigators wrote.
"Among patients who may come to the hospital for just the ... occlusion, the length of stay should be short. There may be no significant opportunity to reduce the length of stay in those cases, but opportunities to decrease core hospital resource utilization with alteplase make this approach beneficial if the patient can tolerate it."
The retrospective study comprised data on 34,579 patients who had been treated for a central venous catheter (CVC) occlusion. Of these, 33,551 were treated with 2 mg alteplase. The other 1,028 had the CVC replaced.
More than half of the cohort were older than 65 years, but patients who got alteplase were an average of 2 years younger than those who had surgery (63 vs. 65 years). Significantly more of those in the alteplase group had serious comorbidities, including chronic obstructive pulmonary disease, liver and renal disease, and diabetes with complications. Catheter replacements were more commonly done in teaching hospitals than in nonteaching hospitals (58% vs. 42%). Larger hospitals also did more replacements: up to 42% of those with 300 or more beds, but no more than 12% for those with 299 or fewer beds.
After adjustment for baseline characteristics, the daily charge for patients treated with alteplase was $317 less than for those who had the line replaced. This translated to an average savings of $1,419 per patient.
Those savings accrued in different departments, and for different periods, the authors said. For example, in the preocclusion period, cardiology/electrocardiography costs were lower for those in the replacement group – but in the postocclusion period, they were lower in the alteplase group. Many other hospital charges were also lower for the replacement group during the preocclusion period (lab, nursing, surgical, pharmacy, radiology, and intensive care costs), but higher in the postocclusion period.
In an unadjusted analysis of readmissions, there were no statistically significant differences between groups in either the 30- or 90-day rates. Neither diagnoses of heart failure, heart attack, nor cancer altered this finding.
The authors, one of whom is Dr. Alpesh N. Amin, an adviser to Hospitalist News, noted that the findings are limited by the issues inherent in every retrospective database study, including an inability to access the clinical information that would have affected decision-making.
Genentech, which markets alteplase, funded the study. Dr. Ernst is an employee of Premier, which Genentech contracted to perform the study. Several of the coauthors reported financial relationships with Genentech.