Office-Based Tunneled Hemodialysis Catheter Removals: Evaluating Safety, Quality, and Cost

Abstract

<h3>Introduction/Objective</h3> Many surgical procedures have moved from the hospital environment to an office-based setting, giving providers and patients more flexibility without sacrificing safety nor quality of care. Dialysis patients are in a more vulnerable state and the chance of significant secondary morbidies are increased. Tunneled hemodialysis catheters (TDC's) are used for temporary dialysis access ports, commonly serving as a placeholder until an AV graft ormaturated fistula is ready for hemodialysis. Prolonged use of TDC's has an increased risk of bacteremia, catheter malfunction, sepsis, exit site infections, catheter fracture, and are also associated with increased mortality rates. Bedside removal of TDC's has been deemed a safe procedure in previous studies. Office-based settings are able to provide another site-of-service that could expedite and improve access to care. <h3>Methods</h3> A retrospective review of our office based TDC removals. All patients who had TDC removals from 1/22/2007 to 4/7/2020 were identified (13-year period). Procedures were performed in a vascular surgery in-office setting with sterile technique. The data recorded included: date of procedure, patient name, sex of patient, post-procedural complications, dateof last follow-up, performing physician, and whether the patient is deceased. Complications during and post procedure were recorded. Follow-up visits were done by means of office visitsand telephone encounters. Post-operative follow-up protocol for this study include the initial nurse visit (usually 1 week following the procedure), the subsequent 2 clinical post-proceduralencounters, and the last visit that the patient had at the office. <h3>Results</h3> A total of 524 TDC removals were performed from January 2007 to April 2020 (13-year period). 498 had follow-up. The average follow-up of patients after the procedure was 2.5 yrs. 33/429 patients had complications reported (7.69%). 69 of the patients who followed up were on paper charts that could not be accessed. Complications were classified as exit site erythema (n=13, 3.0%), infection (n=7, 1.6%), bruising (n=7, 1.6%), drainage without infection (n=2, 0.47%), and tenderness (n=4, 0.93%). Infection=assessed by physician and placed on antibiotics.None of the patients required hospitalization post-procedure due to procedural-related complications nor were there any procedural-related mortalities. The national average outpatient/ASC cost for TDC removal is $461 versus an average in-hospital cost of $733 (https://www.medicare.gov/procedure-price-lookup/cost/36589). Our office-setting average (per 60 min case) cost was $241.33. (Physician fee $143, Supplies $65, Staffing $20, Room $33.33/hour). Cost was evaluated per hour, so if the procedure can be performed faster thenthe costs will be less. Room costs are from patient entry to patient exit. <h3>Conclusion</h3> Hemodialysis patients need better access to care. TDC's should be removed as soonas possible, due to the high rate of complications associated with them. The office-setting provides an easier and expedited access for TDC removals in hemodialysis patients compared tothe hospital setting. TDC catheter removals are able to be taken out safely in an office-based setting. Offices provide low morbidity rate: 7.69%, all of which were minor, and none required hospital admission. There were no mortalities associated with the procedure. The office setting is more cost effective than the hospital setting for TDC removals: $461 ASC/ Hospital Outpatient vs. $733 in- hospital, and our costs being $ 241.33 per hour. TDC removals should be performed in a physician's office to provide a safer more cost-effective option for hemodialysis patients and the healthcare system.