Trends in Central Venous Catheter Insertions by Anesthesia Providers: An Analysis of the Medicare Physician Supplier Procedure Summary From 2007 to 2016

Abstract

BACKGROUND: Central line insertion is a core skill for anesthesiologists. Although recent technical advances have increased the safety of central line insertion and reduced the risk of central line–associated infection, noninvasive hemodynamic monitoring and improved intravenous access techniques have also reduced the need for perioperative central venous access. We hypothesized that the number of central lines inserted by anesthesiologists has decreased over the past decade. To test our hypothesis, we reviewed the Medicare Physician Supplier Procedure Summary (PSPS) database from 2007 to 2016. METHODS: Claims for central venous catheter placement were identified in the Medicare PSPS database for nontunneled and tunneled central lines. Pulmonary artery catheter insertion was included as a nontunneled line claim. We stratified line insertion claims by specialty for Anesthesiology (including Certified Registered Nurse Anesthetists and Anesthesiology Assistants), Surgery, Radiology, Pulmonary/Critical Care, Emergency Physicians, Internal Medicine, and practitioners who were not anesthesia providers such as Advanced Practice Nurses (APNs) and Physician Assistants (PAs). Utilization rates per 10,000 Medicare beneficiaries were then calculated by specialty and year. Time-based trends were analyzed using Joinpoint linear regression, and the Average Annual Percent Change (AAPC) was calculated. RESULTS: Between 2007 and 2016, total claims for central venous catheter insertions of all types decreased from 440.9 to 325.3 claims/10,000 beneficiaries (AAPC = −3.4, 95% confidence interval [CI], −3.6 to −3.2: P < .001). When analyzed by provider specialty and year, the number of nontunneled line insertion claims fell from 43.1 to 15.9 claims/10,000 (AAPC = −7.1; −7.3 to −7.0: P < .001) for surgeons, from 21.3 to 18.5 claims/10,000 (AAPC = −2.5; −2.8 to −2.1: P < .001) for radiologists, and from 117.4 to 72.7 claims/10,000 (AAPC = −5.2; 95% CI, −6.3 to −4.0: P < .001) for anesthesia providers. In contrast, line insertions increased from 18.2 to 26.0 claims/10,000 (AAPC = 3.2; 2.3–4.2: P < .001) for Emergency Physicians and from 3.2 to 9.3 claims/10,000 (AAPC = 6.0; 5.1–6.9: P < .001) for PAs and APNs who were not anesthesia providers. Among anesthesia providers, the share of line claims made by nurse anesthetists increased by 14.5% over the time period. CONCLUSIONS: We observed a 38.3% decrease in claims for nontunneled central lines placed by anesthesiologists from 2007 to 2016. These findings have implications for anesthesiology resident training and maintenance of competence among practicing clinicians. Further research is needed to clarify the effect of decreasing line insertion numbers on line insertion competence among anesthesiologists.

Beyond the Procedure Log: Using Individualized Learning Plans to Set Learner-Specific Milestones for Procedural Skills Acquisition

“…Although minimizing the number of procedures performed by novices and deliberately allocating limited procedural learning opportunities have evident benefits, an unintended consequence of shifting who performs certain procedures could be compression of procedural work. Reallocation of procedural work to specialists and advanced practice providers is already occurring 38–40 ; however, shifting the percentage of trainees engaging in certain procedures could result in an additional workload, either for those trainees who are performing those procedures or for more senior members of the care team, such as fellows or attending physicians. On the basis of experiences during the COVID-19 pandemic, the rapid development of dedicated procedural services could likely address any emergency work compression 22 ; however, compression remains a realistic potential pitfall of an ILP-based approach to procedural education.…”

“…ILPs are likely to maximize the educational benefit of a limited learning resource. Because invasive procedures are increasingly performed in the emergency department by critical care, nephrology, and pulmonology specialists 38 or by specially trained allied health care practitioners, such as nurse practitioners with a procedural focus, 39,40 procedural learning opportunities are becoming a more limited resource at many academic institutions. 10 ILPs seek to modify learner behavior in the CLE to align current learning actions with future goals.…”

Implementation of ultrasound after central venous catheter insertion: A qualitative study in early adopters

“…3 Despite widespread availability and demonstrated advantages in safety and workflow efficiency, POCUS has had a slow rate of adoption for CVC position confirmation. 2,13 Descriptive surveys identify hospital policy or politics, perceived standard of care, and lack of comfort as barriers. 13,14 Although surveys are useful for obtaining quantitative value, they do not provide contextual and often authentic assessment of why or how an issue exists.…”

“…1 Although there is some decrease in overall CVC insertion, it remains a very frequent procedure. 2 Point of care ultrasound (POCUS) has become widely used to ensure safe and accurate vascular insertion because of practice guidelines promoting routine use. 3–5 Historically, the proportion of aggregate adverse events, such as catheter malposition and pneumothorax was 15% but newer advances in catheter material, shorter catheter duration, and increased comfort with ultrasound guidance during CVC insertion has decreased the adverse event rates closer to 5% in some series.…”

“…3–5 Historically, the proportion of aggregate adverse events, such as catheter malposition and pneumothorax was 15% but newer advances in catheter material, shorter catheter duration, and increased comfort with ultrasound guidance during CVC insertion has decreased the adverse event rates closer to 5% in some series. 2,6–9 In spite of this decrease in complications after POCUS guided CVC insertion, it has been standard practice for over 50 years to obtain a chest X-ray (CXR) to confirm appropriate catheter position and exclude pneumothorax following CVC placement. However, several studies including three meta-analysis have demonstrated that mechanical complication rates have decreased and that POCUS is an effective alternative to CXR for confirming catheter position and excluding pneumothorax.…”