Cost-effectiveness-analysis of ultrasound guidance for central venous catheterization compared with landmark method: a decision-analytic model

Abstract

Background Ultrasound guidance for central venous catheterization is a commonly used alternative to the conventional landmark method. Because from the German perspective, the cost-effectiveness of ultrasound guidance is unclear, this study examined the cost-effectiveness of ultrasound guidance versus the landmark method for adults undergoing a central venous catheterization. Methods A decision-tree based model was built to estimate the costs of averted catheter-related complications. Clinical data (e.g. arterial puncture, failed attempts) were obtained from a Cochrane review and a randomized controlled trial, whilst information about cost parameters were taken from a German hospital of maximum care. The analysis was conducted from the perspective of the German Statutory Health Insurance. Results were presented as incremental cost-effectiveness ratios. To assess the parameter uncertainty, several sensitivity analyses were performed (deterministic, probabilistic and with regard to the model structure). Results Our analysis revealed that ultrasound guidance resulted in fewer complications per person (0.04 versus 0.17 for the landmark method) and was less expensive (€51 versus €230 for the landmark method). Results were robust to changes in the model parameters and in the model structure. Whilst our model population reflected approximately 49% of adults undergoing a central venous catheterization cannulation per year, structural sensitivity analyses (e.g. extending the study cohort to patients at higher baseline risk of complications, pediatric patients, or using real-time/indirect catheterization) indicated the cost-effectiveness of ultrasound guidance for a broader spectrum of patients. The results should be interpreted by considering the assumptions (e.g. target population) and approximations (e.g. cost parameters) underpinning the model. Conclusions Ultrasound guidance for central venous catheterization averts more catheter-related complications and may save the resources of the German Statutory Health Insurance compared with landmark method. Electronic supplementary material The online version of this article (10.1186/s12871-019-0719-5) contains supplementary material, which is available to authorized users.

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“…The femoral venous puncture guided by anatomical landmarks was amply compared to the femoral venous puncture guided by ultrasonography. The latter showed evidence of a significant increase in success rate of the procedure 13,14 and reduced the number of attempts and the number of complications related to the puncture. 13 Additionally, the average cost of the ultrasonography-guided procedure was lower than that of guided by anatomical landmarks.…”

“…13 Additionally, the average cost of the ultrasonography-guided procedure was lower than that of guided by anatomical landmarks. 14 Both experienced operators and residents showed better results with the ultrasonography-guided method, although skilled operators experienced a more modest benefit when compared to physicians under training. 15 Puncture of the femoral vein guided by ultrasonography diminishes the cost and the chance of complications, while it increases the safety and success rate of the procedure.…”

Application of plan-do-check-act management to improve first-attempt insertion success rates of internal jugular vein catheterization for standardized training residents in an intensive care unit

“…The use of ultrasound in vascular puncture and catheterization is the most basic application. Many studies have reported that ultrasound-guided central venous catheterization can improve the success rate of puncture, reduce the length of puncture duration and reduce the incidence of complications related to puncture and catheterization [ 8 , 9 ]. However, puncture and catheterization with ultrasound guidance does not mean that the approach can be selected casually.…”

Current practice, education and recommendations for training of central line insertion for trainees and fellows in adult intensive care units across Australia and New Zealand

“…Concerningly, although it is well reported that ultrasound use in CVAD insertion not only decreases complications 18 but is also cost‐effective, 18 only a minority of intensivists recommended ultrasound training, and that a fraction of the ICU fellows do not use ultrasound regularly. A six‐step systematic approach for ultrasound‐guided CVAD insertion has been recommended, which includes sequential steps from identifying location and patency of vein to real‐time ultrasound‐guided puncture and confirming needle, wire and catheter 16 .…”