Cost-Effectiveness of Routine X-Rays After Central Venous Catheter Removal: A Value-Based Analysis of Post-Removal Complications

Abstract

Background: Healthcare systems worldwide are increasingly burdened by rising costs, growing patient demand, and limited resources. In this context, cost-effectiveness analysis (CEA) plays a vital role in evaluating the clinical value of medical interventions relative to their costs. Despite the lack of evidence supporting their necessity, routine post-removal chest X-rays for central venous catheters (CVCs) are still performed in some hospitals due to persistent misconceptions about their benefits. This study seeks to address these misconceptions by examining the costs of routine imaging through a cost analysis of complication detection rates in a large inpatient cohort, with the aim of highlighting the inefficiencies of this practice and promoting evidence-based approaches. Methods: A retrospective cohort analysis was performed across four university hospitals in Salzburg, Austria, including 984 CVC removals conducted between 2012 and 2021. Comparisons were made between X-rays after primary catheter insertion and post-removal X-rays to isolate complications specifically associated with CVC removal. A simple cost-per-outcome analysis, a subtype of CEA, was chosen to determine the cost per complication detected. The approach incorporated activity-based costing, adjusted to 2024 price levels via the Austrian Consumer Price Index (CPI), to capture real-world resource utilization. Results: Complications related to CVC removal were identified in five cases (0.5%), including one catheter rupture due to self-removal, two failed removals, one hemothorax, and one case of intrathoracic bleeding. Of these, three complications were detected on X-rays, including a retained catheter fragment, signs of intrathoracic bleeding, and a hemothorax. Additionally, one asymptomatic patient had a likely incidental finding of a small pneumothorax, which required no intervention. The cost of routine X-rays was calculated at EUR 38.20 per X-ray, resulting in a total expenditure of EUR 37,588.80 for 984 X-rays. This corresponds to EUR 7517.76 per detected complication (n = 4). The odds of detecting a complication on an X-ray were 193 times higher in symptomatic patients than in asymptomatic patients (p < 0.001). Conclusions: This study confirms that complications following CVC removal are rare with only five detected cases. Routine imaging did not improve clinical decision-making, as complications were significantly more likely to be identified in symptomatic patients through clinical evaluation alone. Given the high financial cost (EUR 37,588.80 for 984 X-rays, EUR 7517.76 per detected complication), routine post-removal X-rays are unnecessary in asymptomatic patients and should be reserved for symptomatic cases based on clinical judgment. Adopting a symptom-based imaging approach would reduce unnecessary healthcare costs, minimize patient radiation exposure, and optimize resource allocation in high-volume procedures such as CVC removal.

Keywords: CEA; CVC; X-ray; central venous catheter; cost-effectiveness analysis; cost-per-outcome analysis; removal.