Outcomes in CVC Occlusions

Long‐term central venous catheters (CVCs) facilitate care for patients with chronic illness by providing easy venous access for laboratory tests, administration of medication, and parenteral nutrition. However, several complications resulting from the use of CVCs, including sepsis, extravasation of infusions, and venous thrombosis, can increase associated morbidity and mortality. These complications can also interrupt and delay treatment for the underlying disease and thereby affect outcomes. One of the most common CVC complications is catheter occlusion.[1]

Catheter occlusion occurs in 14% to 36% of patients within 1 to 2 years of catheter placement.[2, 3, 4, 5, 6, 7, 8] A catheter occlusion can be partial or complete, and can occur secondary to a variety of mechanical problems, including an uncommon, but potentially life‐threatening, pinch‐off syndrome. Medication or parenteral nutrition can also cause occlusion, which can be acute or gradual, with increasingly sluggish flow through the catheter. Inappropriate concentrations or incompatible mixtures can cause medications to precipitate within the catheter lumen.

Occlusions are either thrombotic or nonthrombotic. One autopsy study of patients with a long‐term CVC found that a fibrin sheath encased the catheter tip in every case.[9] An occluded catheter may compromise patient care[9, 10]; it may cause cancellation or delay of procedures, it potentially interrupts administration of critical therapies including vesicants, it may result in risk of infection, and it potentially leads to catheter replacement. This can further complicate care, leading to increased length of stay (LOS) and hospital costs.

To better understand resource utilization, LOS, and cost implications of alteplase compared with catheter replacement, we conducted a preplanned, retrospective analysis of hospitalized patients captured between January 2006 and December 2011 in the database maintained by Premier. The Premier database is a large, US hospital‐based, service‐level, all‐payer, comparative database, with information collected primarily from nearly 600 geographically diverse, nonprofit, nongovernment community and teaching hospitals.

METHODS

RESULTS

This study included 34,579 patients who first had a CVC insertion and then were treated for a CVC occlusion by receiving a replacement CVC (n=1028) or by receiving alteplase (2 mg) administration (n=33,551) during the same hospitalization (Table 1). Patients who received alteplase tended to be younger (6019 vs 6220 years old). More than 50% were at least 65 years of age. Twelve percent of alteplase patients were black, whereas 18.5% of catheter‐replacement patients were black.

Alteplase patients were significantly more likely to have a diagnosis of chronic pulmonary disease, liver disease, renal disease, chronic diabetes (ie, diabetes with complications), and cancer. There was an equivalent number of urban and rural hospitals across the 2 groups of patients (Table 2); however, there were regional differences including a higher proportion of catheter‐replacement patients from the East North Central and Middle Atlantic areas and a lower proportion of catheter‐replacement patients from Mountain and Pacific states. Catheter‐replacement patients more frequently were treated in teaching hospitals and in hospitals of larger size.

After covariate adjustment for baseline measurements significantly related to each outcome, average daily post occlusion costs were estimated to be $317 lower for alteplase recipients than for patients who received catheter replacement ($317; 95% confidence interval [CI]: $238‐$392; P<0.0001) (Table 3). Average adjusted total post occlusion costs were $1419 lower for alteplase recipients than for patients who received catheter replacement ($1418; 95% CI: $307‐$2458; P=0.012).

Contributing to the lower cost were certain revenue‐center specific costs (Table 4). Total room and board costs were different between the alteplase and catheter‐replacement groups in both the pre‐ and postocclusion periods; this was related to the difference between the 2 comparison groups in postocclusion LOS of about 0.3 days (Table 5). However, the differences favored alteplase use over catheter replacement. Cardiology/electrocardiography costs were lower for catheter replacement in the preocclusion period but lower for alteplase use in the postocclusion period. Emergency department costs were higher for catheter replacement in both periods, as were respiratory costs in the same manner. Additionally, costs for laboratory tests, nursing, operating room/surgery, pharmacy, radiology, supplies, and ICU room and board were lower in the preocclusion period but higher in the postocclusion period for catheter‐replacement patients. It was unclear why the pharmacy costs after catheter replacement would have increased for catheter‐replacement patients in contrast to the decrease for alteplase‐treated patients, but because this occurred at an average daily basis as well, it appeared that catheter‐replacement patients may have received additional medications. Average adjusted postocclusion LOS was similar for alteplase and catheter‐replacement recipients (P=0.24), suggesting that decreased total costs were due to reasons other than shorter LOS.

Unadjusted 30‐ and 90‐day readmission rates were 24.6% and 35.1% for CVC replacement and slightly lower at 23.7% and 33.9% for alteplase (Table 3), respectively. Odds of readmission after adjusting for patient and hospital factors were not significantly different at 30 days (odds ratio [OR]: 1.048, 95% CI: 0.899‐1.221; P=0.55) or at 90 days (OR: 1.051, 95% CI: 0.915‐1.207; P=0.48) (Table 5). Subgroup analyses for patients with a diagnosis of heart failure, myocardial infarction, and cancer revealed similar results.

DISCUSSION

The cost of healthcare in the United States has risen at an outstanding rate compared with other countries. Our percentage of gross national product spent on healthcare is on the order of 16% to 18%, almost twice as much as the next most industrialized country in terms of healthcare expenditure.[11] In the current era, finding opportunities to reduce healthcare costs without negatively impacting quality of care is the name of the game. Professional societies have come together under the campaign of Choosing Wisely: An Initiative of the ABIM (American Board of Internal Medicine) Foundation to help educate clinicians and patients on cost‐containment strategies.[12] Research that demonstrates opportunities to reduce cost will help healthcare providers choose wisely among diagnostic and therapeutic options for patients. Our study demonstrated that the use of a drug such as alteplase in clearing CVC catheter obstruction was significantly less costly to the hospital than catheter replacement.

Cathflo Activase (alteplase: Genentech, South San Francisco, CA), the only FDA‐approved thrombolytic for the restoration of central venous catheter function, is the current standard treatment for catheter occlusions in the United States. A dose of 2 mg in 2 mL is instilled in patients weighing 30 kg or 110% of the internal lumen volume of the catheter not to exceed 2 mg in 2 mL for those patients weighing <30 kg. Haire et al. showed that a 2‐mg dose of alteplase was more effective than urokinase (5000 IU) for treating radiographically proven thrombotic occlusion of a CVC after a dwell time of 120 minutes.[13] In the Cardiovascular thrombolytic used to Open Occluded Lines (COOL) trial, one 2‐mg dose of alteplase cleared the catheter occlusion after 120 minutes in 74% of patients, compared with only 17% of patients who received a placebo. Studies have confirmed the safety and efficacy of alteplase administered at various time intervals in different long‐term catheters, including peripherally inserted central catheters, with major hemorrhage reported in 0.3% of patients.[14, 15, 16]

Adding to the knowledge of patient outcomes from clinical studies, many health outcomes studies have demonstrated benefit in cost containment through decreasing LOS, which one can argue is just shifting the cost to an earlier part of the stay. Even though this is highly beneficial, it does not address the core resource utilization within the hospital. Our study found its cost benefit not in the LOS, but in decreasing core resource utilization such as radiology, lab, nursing, and supplies. If patients are admitted for a noncardiovascular condition and have CVC occlusion, using alteplase to clear the CVC occlusion along with implementing strategies to manage the underlying disease to reduce the LOS becomes a powerful opportunity to impact cost. Among patients who may come to the hospital for just the CVC occlusion, the LOS should be short. There may be no significant opportunity to reduce the LOS in those cases, but opportunities to decrease core hospital resource utilization with alteplase make this approach beneficial if the patient can tolerate it.

Limitations of the study include the retrospective and administrative nature of the database used, which is unable to provide certain clinical measures as would be available at the patient's bedside when treatment choices are being made. Had they been available, we might have included them in our assessment of whether patients who underwent CVC replacement were significantly different from those who received alteplase. In addition, not all hospitals in the database had charge masters that facilitated identification of CVC replacements or reinsertions, requiring the use of CPT‐4 codes and evidence of new CVCs being placed or inserted. Certain patients were excluded if there was conflicting information about whether the CVC was new within the hospital stay or dwelling in the patient prior to admission. Also, dialysis patients were excluded because they were not part of any approved indication for alteplase 2 mg, and this group is particularly prone to catheter obstruction. As such, they represent more complicated cases than the norm; this exclusion may have limited the overall generalizability of the study. The study also relied on charge master (billing) data to identify the use of alteplase and other treatments, where there is the potential, albeit minimal, for inaccuracies in the data. Of greater importance, the study relied on ICD‐9 coding to identify comorbid conditions, and as in other studies using similar data sources, such methods are subject to coding errors and omissions. However, many of the listed limitations above were not thought to be different between the comparison groups or more problematic for this study than for other studies based on similar data sources.

CONCLUSION

Among patients treated for an occluded CVC, alteplase‐treated patients had lower daily postocclusion costs and lower total postocclusion costs than patients who received catheter replacement. Differences in costs did not appear to be driven by differences in postocclusion LOS. Readmissions at 30‐ and 90‐day periods were found to be similar between alteplase recipients and catheter‐replacement patients.

Long‐term central venous catheters (CVCs) facilitate care for patients with chronic illness by providing easy venous access for laboratory tests, administration of medication, and parenteral nutrition. However, several complications resulting from the use of CVCs, including sepsis, extravasation of infusions, and venous thrombosis, can increase associated morbidity and mortality. These complications can also interrupt and delay treatment for the underlying disease and thereby affect outcomes. One of the most common CVC complications is catheter occlusion.[1]

Catheter occlusion occurs in 14% to 36% of patients within 1 to 2 years of catheter placement.[2, 3, 4, 5, 6, 7, 8] A catheter occlusion can be partial or complete, and can occur secondary to a variety of mechanical problems, including an uncommon, but potentially life‐threatening, pinch‐off syndrome. Medication or parenteral nutrition can also cause occlusion, which can be acute or gradual, with increasingly sluggish flow through the catheter. Inappropriate concentrations or incompatible mixtures can cause medications to precipitate within the catheter lumen.

Occlusions are either thrombotic or nonthrombotic. One autopsy study of patients with a long‐term CVC found that a fibrin sheath encased the catheter tip in every case.[9] An occluded catheter may compromise patient care[9, 10]; it may cause cancellation or delay of procedures, it potentially interrupts administration of critical therapies including vesicants, it may result in risk of infection, and it potentially leads to catheter replacement. This can further complicate care, leading to increased length of stay (LOS) and hospital costs.

To better understand resource utilization, LOS, and cost implications of alteplase compared with catheter replacement, we conducted a preplanned, retrospective analysis of hospitalized patients captured between January 2006 and December 2011 in the database maintained by Premier. The Premier database is a large, US hospital‐based, service‐level, all‐payer, comparative database, with information collected primarily from nearly 600 geographically diverse, nonprofit, nongovernment community and teaching hospitals.

METHODS

RESULTS

This study included 34,579 patients who first had a CVC insertion and then were treated for a CVC occlusion by receiving a replacement CVC (n=1028) or by receiving alteplase (2 mg) administration (n=33,551) during the same hospitalization (Table 1). Patients who received alteplase tended to be younger (6019 vs 6220 years old). More than 50% were at least 65 years of age. Twelve percent of alteplase patients were black, whereas 18.5% of catheter‐replacement patients were black.

Alteplase patients were significantly more likely to have a diagnosis of chronic pulmonary disease, liver disease, renal disease, chronic diabetes (ie, diabetes with complications), and cancer. There was an equivalent number of urban and rural hospitals across the 2 groups of patients (Table 2); however, there were regional differences including a higher proportion of catheter‐replacement patients from the East North Central and Middle Atlantic areas and a lower proportion of catheter‐replacement patients from Mountain and Pacific states. Catheter‐replacement patients more frequently were treated in teaching hospitals and in hospitals of larger size.

After covariate adjustment for baseline measurements significantly related to each outcome, average daily post occlusion costs were estimated to be $317 lower for alteplase recipients than for patients who received catheter replacement ($317; 95% confidence interval [CI]: $238‐$392; P<0.0001) (Table 3). Average adjusted total post occlusion costs were $1419 lower for alteplase recipients than for patients who received catheter replacement ($1418; 95% CI: $307‐$2458; P=0.012).

Contributing to the lower cost were certain revenue‐center specific costs (Table 4). Total room and board costs were different between the alteplase and catheter‐replacement groups in both the pre‐ and postocclusion periods; this was related to the difference between the 2 comparison groups in postocclusion LOS of about 0.3 days (Table 5). However, the differences favored alteplase use over catheter replacement. Cardiology/electrocardiography costs were lower for catheter replacement in the preocclusion period but lower for alteplase use in the postocclusion period. Emergency department costs were higher for catheter replacement in both periods, as were respiratory costs in the same manner. Additionally, costs for laboratory tests, nursing, operating room/surgery, pharmacy, radiology, supplies, and ICU room and board were lower in the preocclusion period but higher in the postocclusion period for catheter‐replacement patients. It was unclear why the pharmacy costs after catheter replacement would have increased for catheter‐replacement patients in contrast to the decrease for alteplase‐treated patients, but because this occurred at an average daily basis as well, it appeared that catheter‐replacement patients may have received additional medications. Average adjusted postocclusion LOS was similar for alteplase and catheter‐replacement recipients (P=0.24), suggesting that decreased total costs were due to reasons other than shorter LOS.

Unadjusted 30‐ and 90‐day readmission rates were 24.6% and 35.1% for CVC replacement and slightly lower at 23.7% and 33.9% for alteplase (Table 3), respectively. Odds of readmission after adjusting for patient and hospital factors were not significantly different at 30 days (odds ratio [OR]: 1.048, 95% CI: 0.899‐1.221; P=0.55) or at 90 days (OR: 1.051, 95% CI: 0.915‐1.207; P=0.48) (Table 5). Subgroup analyses for patients with a diagnosis of heart failure, myocardial infarction, and cancer revealed similar results.

DISCUSSION

The cost of healthcare in the United States has risen at an outstanding rate compared with other countries. Our percentage of gross national product spent on healthcare is on the order of 16% to 18%, almost twice as much as the next most industrialized country in terms of healthcare expenditure.[11] In the current era, finding opportunities to reduce healthcare costs without negatively impacting quality of care is the name of the game. Professional societies have come together under the campaign of Choosing Wisely: An Initiative of the ABIM (American Board of Internal Medicine) Foundation to help educate clinicians and patients on cost‐containment strategies.[12] Research that demonstrates opportunities to reduce cost will help healthcare providers choose wisely among diagnostic and therapeutic options for patients. Our study demonstrated that the use of a drug such as alteplase in clearing CVC catheter obstruction was significantly less costly to the hospital than catheter replacement.

Cathflo Activase (alteplase: Genentech, South San Francisco, CA), the only FDA‐approved thrombolytic for the restoration of central venous catheter function, is the current standard treatment for catheter occlusions in the United States. A dose of 2 mg in 2 mL is instilled in patients weighing 30 kg or 110% of the internal lumen volume of the catheter not to exceed 2 mg in 2 mL for those patients weighing <30 kg. Haire et al. showed that a 2‐mg dose of alteplase was more effective than urokinase (5000 IU) for treating radiographically proven thrombotic occlusion of a CVC after a dwell time of 120 minutes.[13] In the Cardiovascular thrombolytic used to Open Occluded Lines (COOL) trial, one 2‐mg dose of alteplase cleared the catheter occlusion after 120 minutes in 74% of patients, compared with only 17% of patients who received a placebo. Studies have confirmed the safety and efficacy of alteplase administered at various time intervals in different long‐term catheters, including peripherally inserted central catheters, with major hemorrhage reported in 0.3% of patients.[14, 15, 16]

Adding to the knowledge of patient outcomes from clinical studies, many health outcomes studies have demonstrated benefit in cost containment through decreasing LOS, which one can argue is just shifting the cost to an earlier part of the stay. Even though this is highly beneficial, it does not address the core resource utilization within the hospital. Our study found its cost benefit not in the LOS, but in decreasing core resource utilization such as radiology, lab, nursing, and supplies. If patients are admitted for a noncardiovascular condition and have CVC occlusion, using alteplase to clear the CVC occlusion along with implementing strategies to manage the underlying disease to reduce the LOS becomes a powerful opportunity to impact cost. Among patients who may come to the hospital for just the CVC occlusion, the LOS should be short. There may be no significant opportunity to reduce the LOS in those cases, but opportunities to decrease core hospital resource utilization with alteplase make this approach beneficial if the patient can tolerate it.

Limitations of the study include the retrospective and administrative nature of the database used, which is unable to provide certain clinical measures as would be available at the patient's bedside when treatment choices are being made. Had they been available, we might have included them in our assessment of whether patients who underwent CVC replacement were significantly different from those who received alteplase. In addition, not all hospitals in the database had charge masters that facilitated identification of CVC replacements or reinsertions, requiring the use of CPT‐4 codes and evidence of new CVCs being placed or inserted. Certain patients were excluded if there was conflicting information about whether the CVC was new within the hospital stay or dwelling in the patient prior to admission. Also, dialysis patients were excluded because they were not part of any approved indication for alteplase 2 mg, and this group is particularly prone to catheter obstruction. As such, they represent more complicated cases than the norm; this exclusion may have limited the overall generalizability of the study. The study also relied on charge master (billing) data to identify the use of alteplase and other treatments, where there is the potential, albeit minimal, for inaccuracies in the data. Of greater importance, the study relied on ICD‐9 coding to identify comorbid conditions, and as in other studies using similar data sources, such methods are subject to coding errors and omissions. However, many of the listed limitations above were not thought to be different between the comparison groups or more problematic for this study than for other studies based on similar data sources.

CONCLUSION

Among patients treated for an occluded CVC, alteplase‐treated patients had lower daily postocclusion costs and lower total postocclusion costs than patients who received catheter replacement. Differences in costs did not appear to be driven by differences in postocclusion LOS. Readmissions at 30‐ and 90‐day periods were found to be similar between alteplase recipients and catheter‐replacement patients.

Long‐term central venous catheters (CVCs) facilitate care for patients with chronic illness by providing easy venous access for laboratory tests, administration of medication, and parenteral nutrition. However, several complications resulting from the use of CVCs, including sepsis, extravasation of infusions, and venous thrombosis, can increase associated morbidity and mortality. These complications can also interrupt and delay treatment for the underlying disease and thereby affect outcomes. One of the most common CVC complications is catheter occlusion.[1]

Catheter occlusion occurs in 14% to 36% of patients within 1 to 2 years of catheter placement.[2, 3, 4, 5, 6, 7, 8] A catheter occlusion can be partial or complete, and can occur secondary to a variety of mechanical problems, including an uncommon, but potentially life‐threatening, pinch‐off syndrome. Medication or parenteral nutrition can also cause occlusion, which can be acute or gradual, with increasingly sluggish flow through the catheter. Inappropriate concentrations or incompatible mixtures can cause medications to precipitate within the catheter lumen.

Occlusions are either thrombotic or nonthrombotic. One autopsy study of patients with a long‐term CVC found that a fibrin sheath encased the catheter tip in every case.[9] An occluded catheter may compromise patient care[9, 10]; it may cause cancellation or delay of procedures, it potentially interrupts administration of critical therapies including vesicants, it may result in risk of infection, and it potentially leads to catheter replacement. This can further complicate care, leading to increased length of stay (LOS) and hospital costs.

To better understand resource utilization, LOS, and cost implications of alteplase compared with catheter replacement, we conducted a preplanned, retrospective analysis of hospitalized patients captured between January 2006 and December 2011 in the database maintained by Premier. The Premier database is a large, US hospital‐based, service‐level, all‐payer, comparative database, with information collected primarily from nearly 600 geographically diverse, nonprofit, nongovernment community and teaching hospitals.

METHODS

RESULTS

This study included 34,579 patients who first had a CVC insertion and then were treated for a CVC occlusion by receiving a replacement CVC (n=1028) or by receiving alteplase (2 mg) administration (n=33,551) during the same hospitalization (Table 1). Patients who received alteplase tended to be younger (6019 vs 6220 years old). More than 50% were at least 65 years of age. Twelve percent of alteplase patients were black, whereas 18.5% of catheter‐replacement patients were black.

Alteplase patients were significantly more likely to have a diagnosis of chronic pulmonary disease, liver disease, renal disease, chronic diabetes (ie, diabetes with complications), and cancer. There was an equivalent number of urban and rural hospitals across the 2 groups of patients (Table 2); however, there were regional differences including a higher proportion of catheter‐replacement patients from the East North Central and Middle Atlantic areas and a lower proportion of catheter‐replacement patients from Mountain and Pacific states. Catheter‐replacement patients more frequently were treated in teaching hospitals and in hospitals of larger size.

After covariate adjustment for baseline measurements significantly related to each outcome, average daily post occlusion costs were estimated to be $317 lower for alteplase recipients than for patients who received catheter replacement ($317; 95% confidence interval [CI]: $238‐$392; P<0.0001) (Table 3). Average adjusted total post occlusion costs were $1419 lower for alteplase recipients than for patients who received catheter replacement ($1418; 95% CI: $307‐$2458; P=0.012).

Contributing to the lower cost were certain revenue‐center specific costs (Table 4). Total room and board costs were different between the alteplase and catheter‐replacement groups in both the pre‐ and postocclusion periods; this was related to the difference between the 2 comparison groups in postocclusion LOS of about 0.3 days (Table 5). However, the differences favored alteplase use over catheter replacement. Cardiology/electrocardiography costs were lower for catheter replacement in the preocclusion period but lower for alteplase use in the postocclusion period. Emergency department costs were higher for catheter replacement in both periods, as were respiratory costs in the same manner. Additionally, costs for laboratory tests, nursing, operating room/surgery, pharmacy, radiology, supplies, and ICU room and board were lower in the preocclusion period but higher in the postocclusion period for catheter‐replacement patients. It was unclear why the pharmacy costs after catheter replacement would have increased for catheter‐replacement patients in contrast to the decrease for alteplase‐treated patients, but because this occurred at an average daily basis as well, it appeared that catheter‐replacement patients may have received additional medications. Average adjusted postocclusion LOS was similar for alteplase and catheter‐replacement recipients (P=0.24), suggesting that decreased total costs were due to reasons other than shorter LOS.

Unadjusted 30‐ and 90‐day readmission rates were 24.6% and 35.1% for CVC replacement and slightly lower at 23.7% and 33.9% for alteplase (Table 3), respectively. Odds of readmission after adjusting for patient and hospital factors were not significantly different at 30 days (odds ratio [OR]: 1.048, 95% CI: 0.899‐1.221; P=0.55) or at 90 days (OR: 1.051, 95% CI: 0.915‐1.207; P=0.48) (Table 5). Subgroup analyses for patients with a diagnosis of heart failure, myocardial infarction, and cancer revealed similar results.

DISCUSSION

The cost of healthcare in the United States has risen at an outstanding rate compared with other countries. Our percentage of gross national product spent on healthcare is on the order of 16% to 18%, almost twice as much as the next most industrialized country in terms of healthcare expenditure.[11] In the current era, finding opportunities to reduce healthcare costs without negatively impacting quality of care is the name of the game. Professional societies have come together under the campaign of Choosing Wisely: An Initiative of the ABIM (American Board of Internal Medicine) Foundation to help educate clinicians and patients on cost‐containment strategies.[12] Research that demonstrates opportunities to reduce cost will help healthcare providers choose wisely among diagnostic and therapeutic options for patients. Our study demonstrated that the use of a drug such as alteplase in clearing CVC catheter obstruction was significantly less costly to the hospital than catheter replacement.

Cathflo Activase (alteplase: Genentech, South San Francisco, CA), the only FDA‐approved thrombolytic for the restoration of central venous catheter function, is the current standard treatment for catheter occlusions in the United States. A dose of 2 mg in 2 mL is instilled in patients weighing 30 kg or 110% of the internal lumen volume of the catheter not to exceed 2 mg in 2 mL for those patients weighing <30 kg. Haire et al. showed that a 2‐mg dose of alteplase was more effective than urokinase (5000 IU) for treating radiographically proven thrombotic occlusion of a CVC after a dwell time of 120 minutes.[13] In the Cardiovascular thrombolytic used to Open Occluded Lines (COOL) trial, one 2‐mg dose of alteplase cleared the catheter occlusion after 120 minutes in 74% of patients, compared with only 17% of patients who received a placebo. Studies have confirmed the safety and efficacy of alteplase administered at various time intervals in different long‐term catheters, including peripherally inserted central catheters, with major hemorrhage reported in 0.3% of patients.[14, 15, 16]

Adding to the knowledge of patient outcomes from clinical studies, many health outcomes studies have demonstrated benefit in cost containment through decreasing LOS, which one can argue is just shifting the cost to an earlier part of the stay. Even though this is highly beneficial, it does not address the core resource utilization within the hospital. Our study found its cost benefit not in the LOS, but in decreasing core resource utilization such as radiology, lab, nursing, and supplies. If patients are admitted for a noncardiovascular condition and have CVC occlusion, using alteplase to clear the CVC occlusion along with implementing strategies to manage the underlying disease to reduce the LOS becomes a powerful opportunity to impact cost. Among patients who may come to the hospital for just the CVC occlusion, the LOS should be short. There may be no significant opportunity to reduce the LOS in those cases, but opportunities to decrease core hospital resource utilization with alteplase make this approach beneficial if the patient can tolerate it.

Limitations of the study include the retrospective and administrative nature of the database used, which is unable to provide certain clinical measures as would be available at the patient's bedside when treatment choices are being made. Had they been available, we might have included them in our assessment of whether patients who underwent CVC replacement were significantly different from those who received alteplase. In addition, not all hospitals in the database had charge masters that facilitated identification of CVC replacements or reinsertions, requiring the use of CPT‐4 codes and evidence of new CVCs being placed or inserted. Certain patients were excluded if there was conflicting information about whether the CVC was new within the hospital stay or dwelling in the patient prior to admission. Also, dialysis patients were excluded because they were not part of any approved indication for alteplase 2 mg, and this group is particularly prone to catheter obstruction. As such, they represent more complicated cases than the norm; this exclusion may have limited the overall generalizability of the study. The study also relied on charge master (billing) data to identify the use of alteplase and other treatments, where there is the potential, albeit minimal, for inaccuracies in the data. Of greater importance, the study relied on ICD‐9 coding to identify comorbid conditions, and as in other studies using similar data sources, such methods are subject to coding errors and omissions. However, many of the listed limitations above were not thought to be different between the comparison groups or more problematic for this study than for other studies based on similar data sources.

CONCLUSION

Among patients treated for an occluded CVC, alteplase‐treated patients had lower daily postocclusion costs and lower total postocclusion costs than patients who received catheter replacement. Differences in costs did not appear to be driven by differences in postocclusion LOS. Readmissions at 30‐ and 90‐day periods were found to be similar between alteplase recipients and catheter‐replacement patients.