Cost-efficacy modeling of catheter reuse for percutaneous transluminal coronary angioplasty

Feasibility and safety of reprocessing of intracardiac echocardiography catheters for electrophysiology procedures - a large single center experience

PURPOSE

Intra-cardiac echocardiography (ICE) has become an important tool for catheter ablation. Adoption of ICE imaging is still limited because of its prohibitively high cost. Our aim was to study the safety and feasibility of ICE catheters reprocessing and its environmental and financial impact.

METHODS

This was a single center retrospective analysis of all consecutive electrophysiology procedures in which ICE catheters were used from 2015 to 2022. In total, 1128 patients were studied (70.6% male, mean age was 57.9 ± 13.2 years). The majority of procedures were related to atrial fibrillation ablation (84.6%).

RESULTS

For the whole cohort, 57 new ICE catheters were used. Consequently one catheter could be used for 19.8 procedures. New catheters were only used when the image obtained by reused probes was not satisfactory. There were no cases of ICE probe steering mechanism malfunction, no procedure related infections and no allergic reactions that could be attributed to the resterilization process. In total, there was 8.6% of complications not related to ICE imaging. Financially, ICE probe reprocessing resulted with 90% cost reduction (> 2 millions of Euros savings for the studied period) and 95% waste reduction (639.5 kg less, mostly non degradable waste was produced).

CONCLUSION

Our data suggests that ICE catheter reprocessing is feasible and safe. It seems that risk of infection is not increased. Significant economic and environmental savings could be achieved by ICE catheters reprocessing. Furthermore, ICE reprocessing could allow more extensive ICE usage resulting in safer procedures with a potential reduction of serious complications.

Economic Analysis of Reprocessing Single-Use Medical Devices: A Systematic Literature Review

Background.

Although an increasing number of medical devices are labeled “for single use only,” cleaning and reuse of single-use medical devices continues, because of the economic incentive. We conducted a survey of the economic literature to obtain the current evidence available and to assess the costs and benefits of reusing single-use medical devices.

Methods.

A comprehensive literature search was carried out to identify articles that compared single use and reuse of single-use medical devices and that met specific scientific criteria, including evaluation of economic outcomes. Each selected article was independently reviewed by 2 reviewers to extract cost and clinical outcome data and to assess the quality of the study.

Results.

Nine published articles met the selection criteria. The savings were about 49% of the direct cost. These savings would be offset by adverse-event costs, but none were detected. However, quality of the studies was generally poor.

Conclusions.

There is little available evidence of quality in the published literature to assess the practice of reuse of single-use medical devices. Moreover, data on clinical outcomes are missing and, where available, cannot be attributed specifically to the reuse of single-use medical devices.

Reprocessed arthroscopic shavers: evaluation of sharpness and function in a cadaver model

This study was designed to test limited arthroscopic shaver reuse following reprocessing and to compare the functional performance between new and reprocessed arthroscopic shavers in arthroscopic procedures using fresh cadaveric knees. A trial using arthroscopic procedures (menisectomy, synovectomy, and debridements) was conducted by experienced surgeons using cadaveric knees to determine whether the surgeons could correctly identify reprocessed shavers. Thirty-nine shavers were tested; the surgeons were given both new and reprocessed shavers. Thirteen of the 39 shavers were new and 26 were reprocessed (13 of which had also been sharpened). The surgeons were asked to assess whether each shaver was new or reprocessed and to indicate whether the shaver was functional or not. Cadaveric shavers were subsequently used in an engineering test developed to measure shaver blade sharpness. Comparisons in sharpness were made between new and reprocessed cadaveric shaver blades. The success rate in identifying reprocessed shavers was determined to be 42% (11 of 26), with an upper confidence bound of 60%, demonstrating that the ability to detect a reprocessed shaver is no better than chance (50%), with a margin of error of 10% (P=.0328). In addition, engineering sharpness testing demonstrated that new and reprocessed cadaveric blades exhibit equivalent sharpness. Surgeons were unable to distinguish reprocessed arthroscopic shavers that passed acceptance tests from new shavers based on functional characteristics. This outcome is not unexpected due to the fact that engineering testing of shaver blades used in the study indicated that they exhibited similar sharpness.

Acceptance criteria for reprocessed AcuNav catheters: comparison between functionality testing and clinical image assessment

The AcuNav-catheter is a vector-phased array ultrasound catheter that has shown great utility for both diagnosis and electrophysiological interventions. To test the feasibility of limited catheter reuse and to ensure that reprocessed catheters would produce acceptable clinical images, the present study compared the 2-D and Doppler image quality, as determined by clinical assessment, with the catheter's functional status as determined by the FirstCall 2000 transducer tester. Reprocessed catheters from four functional categories, two acceptable and two unacceptable, were used to collect images, 2-D and Doppler, from a porcine heart. The images were blinded and then rated by clinical evaluation. The study found that catheter images from all functional categories were found to be clinically acceptable except for those from the lowest unacceptable category. In addition, examination of tip deflection characteristics showed no significant difference between new and reprocessed catheters. We conclude that reprocessed AcuNav catheters that pass functional tests are able to produce clinical images, 2-D and Doppler, which are equivalent to their new counterparts.

Reuse of single use medical devices in Canada: Clinical and economic outcomes, legal and ethical issues, and current hospital practice

Objectives:The aim of this study was to assess the evidence that reuse of medical devices marketed for single use only (SUDs) is safe, effective and cost-effective, and to consider the use and health services impact of this practice in Canada.

Methods:A systematic review was performed of studies that reported clinical or economic outcomes following reuse of SUDs in humans. Direct costs of adverse health events associated with SUD reuse and indications of budget impact were obtained using data for devices for laparoscopic cholecystectomy and coronary angioplasty. Legal and ethical issues were reviewed, drawing on material relevant to Canada. Data on current reuse of SUDs were obtained through a survey of Canadian acute care hospitals.

Results:Studies of variable quality suggested that SUD reuse could be safe and effective, and would give cost savings, if there were no adverse events. Eliminating reuse of SUDs for laparoscopic cholecystectomy and coronary angioplasty would add less than 0.1 percent to costs of the procedures over 1 year. Adverse health events associated with device reuse create liability risks; patients should be informed of any known or foreseeable risks of reuse. Most of the 28 percent (111/398) of acute hospitals that reprocess SUDs do so in-house. Some do not have a written policy or an incident reporting mechanism.

Conclusions:There is insufficient evidence to establish the safety, efficacy and cost-effectiveness of reusing SUDs. Legal and ethical issues require attention to minimize liability and maintain patient safety and trust. Some hospitals that reprocess SUDs do not have adequate documentation. These findings do not support the reuse of SUDs in Canadian hospitals.

Comparison of performance characteristics between new and reprocessed electrophysiology catheters

OBJECTIVE

Electrophysiology (EP) catheter reprocessing is widespread and previous studies have examined clinical performance, sterility and safety of these reprocessed devices. Here we compare the intrinsic engineering characteristics, electrical, mechanical and safety, between new and reprocessed devices.

MATERIALS AND METHODS

New (58 devices) and clinically used (five times)/reprocessed (165 devices) EP catheters from five manufacturers were employed to examine and compare catheter electrode continuity, electrode isolation, electrical leakage current, shaft torsion and stiffness characteristics as well as tip buckling and bond strengths.

RESULTS

Electrode continuity, isolation and leakage currents for both new and reprocessed EP catheters were within acceptance criteria for electrode continuity (<30 Omega) and shaft electrical leakage (<0.5 mA) as well as electrode isolation (>200 Omega). In addition, reprocessed catheters were equivalent when compared with their new counterparts. While catheter shaft torque forces varied five fold amongst manufacturers, comparison between new and reprocessed devices within a manufacturer showed no significant differences. Likewise shaft stiffness showed no significant difference between new and reprocessed devices. Average tip buckling forces for all catheters were substantially below the acceptance criteria of 0.45 lb (between 0.04 and 0.1 lb) with differences between new and reprocessed catheters not being significant. All bond strengths for both new and reprocessed catheters exceeded the acceptance criteria specified in ISO 10555-1.

CONCLUSIONS

This study found that reprocessed EP catheters which had undergone five actual clinical use/reprocessing cycles met and exceeded acceptance criteria specified by industry standards as well as individual manufacturer's criteria for both electrical and safety characteristics. We conclude that reprocessed EP catheters exhibit electrical, mechanical and safety characteristics which are equivalent to their new counterparts.

Change of the mechanical properties of two different balloon catheters with increasing numbers of cycles of resterilization

An increasing number of centers are reusing PTCA catheters even though manufacturers warrant single use only. This prospective bench laboratory trial addresses the quality of PTCA balloon catheters after up to three resterilization cycles in order to determine whether a larger trial is warranted to discern whether catheters should be reused. Forty PTCA catheters from two different manufacturers (nominal diameters 1.5 and 3.0 mm) were taken from the shelf. An independent institute tested mechanical properties such as burst pressure, nominal diameter, crossing profile, and balloon surface. The crossing profile increased by 22.5%-39.2% with no additional deterioration after repeated sterilizations. The nominal diameter either increased or decreased by a maximum of 47%. In all 1.5 mm balloons, the burst pressure remained above the manufacturers' values, whereas in the 3.0 mm balloons, the value dropped below the rated burst pressure in 40%-50% of the trials. In conclusion, in both catheter types analyzed, reuse was associated with a considerably worse quality, which puts in question their routine clinical use.

In vitro performance characteristics of reused ablation catheters

BACKGROUND

Prior studies have found that there is a widespread practice of catheter reprocessing in cardiac electrophysiology laboratories. Effects of reprocessing of ablation catheters on temperature sensing and mechanical deflection are not fully known.

METHODS

Twenty-four new and used ablation catheters were studied. Deviation of temperature sensing by catheters from the temperature of a heated saline bath was measured. The angle of deflection of digitally scanned catheters at 75% and 100% handle deflection was also measured. New and used catheters were compared with respect to their temperature sensing accuracy and deflection characteristics.

RESULTS

Overall, there was 0.7 +/- 0.1 degrees C (mean +/- standard error) deviation of the sensed temperature from the bath temperature, with no significant difference between new and used catheters. Similarly, there was no significant difference in the angle of deflection between new (66.7 degrees +/- 6.2 degrees and 24.3 degrees +/- 6.8 degrees at 75% and 100% deflections, respectively) and used (59.6 degrees +/- 5.6 degrees and 28.7 degrees +/- 9.9 degrees at 75% and 100% deflections, respectively) catheters. The difference in the angle of deflection between matched new and used catheters was 18.9 degrees +/- 4.2 degrees and 10.9 degrees +/- 2.4 degrees at 75% and 100% deflections, respectively, with a relatively broad range (5.0 degrees -35.6 degrees and 0.4 degrees -19.0 degrees at 75% and 100% deflections, respectively).

CONCLUSIONS

This study found no significant overall difference in temperature sensing accuracy and deflection angle of new and used ablation catheters. Nevertheless, individual differences in deflection characteristics between new and used catheters are occasionally seen and warrant screening of reprocessed catheters prior to their reuse.

Reuse of catheters for percutaneous transluminal coronary angioplasty: effects on procedure time and clinical outcomes

In July 1996, because of concern regarding the possible transmission of Creutzfeldt-Jakob disease, the province of Quebec stopped the reuse of percutaneous transluminal coronary angioplasty (PTCA) catheters. Prior to this time, PTCA balloon catheters were used a maximum of four times and guide catheters a maximum of two times in the cardiac catheterization laboratory at our institution. After this time, only new catheters were used. In order to examine the effects of catheter reuse on duration of PTCA procedures and clinical outcomes, we compared 53 consecutive patients undergoing PTCA prior to 21 July 1996 with 54 consecutive patients undergoing PTCA after that time. A total of 81 men and 26 women underwent PTCA (average age, 64 +/- 12 years). There were no significant differences between the single-use and reuse groups with respect to baseline characteristics. There were also no significant differences in the numbers of PTCA catheters used (97 vs. 103, P = NS) or angiographic success rates (88% vs. 83%, P = NS). There was a trend for total procedure time and fluoroscopy time to be slightly longer for single-use compared with reuse cases (49.2 vs. 45.7 min and 19.7 vs. 16.8 min, respectively; P = NS for both comparisons). However, after controlling for case severity and the use of stents, there were no significant differences in total procedure time or fluoroscopy time between the two groups. We found little evidence to suggest that the reuse of PTCA catheters is associated with longer total procedure time or fluoroscopy time. We conclude that if catheter reuse is not found to be associated with infectious disease transmission, its widespread use should be considered. Cathet. Cardiovasc. Intervent. 48:54-60, 1999.

Reuse of angioplasty catheters and risk of Creutzfeldt-Jakob disease

BACKGROUND

In 1996, the Quebec Ministry of Health and Social Services, concerned that reuse of devices contaminated with blood or blood products could cause the transmission of Creutzfeldt-Jakob disease (CJD), discontinued its practice of reusing angioplasty catheters despite the significant cost savings reuse had afforded the health care system for several years. The objective of this study was to establish whether the medical literature provides documentation of any cases in which CJD was transmitted by reused percutaneous transluminal coronary angioplasty (PTCA) equipment.

METHODS AND RESULTS

A Medline search was performed to identify previous studies that examined this issue. Key words for the search included PTCA, CJD, and material and equipment reuse. A substantial amount of effort has been spent on the study of PTCA catheter reuse in relation to the risk of infection, toxicity, and catheter breakage as well as cost. In Québec, studies by the Conseil d'Evaluation des Technologies de la Santé investigated the effectiveness of cleaning and sterilizing PTCA equipment and considered the possibility that reuse of single-use catheters, hemodialyzers, and cardiac pacemakers could spread CJD. A number of other studies found evidence that iatrogenic transmission was responsible for several cases of CJD by direct implantation in or adjacent to the central nervous system during neurosurgery. CJD was also transmitted to human beings by injection of pituitary growth hormone and to mice through cerebral inoculation of contaminated blood and urine. However, there were no documented cases of CJD occurring as a complication of PTCA equipment reuse.

CONCLUSIONS

The current literature indicates that there are no known cases of CJD attributable to the reuse of PTCA devices contaminated by blood or to the transfusion of blood or blood products. This practice is associated with a very low risk of CJD transmission. With the considerable cost savings made possible by reuse of PTCA equipment, reimplementation of this practice should be considered by health delivery systems, provided that stringent methods of cleaning and sterilization are observed.

Initial experience with reuse of coronary angioplasty catheters in the United States

OBJECTIVES

We sought to evaluate the performance of angioplasty catheters, restored under a strict manufacturing process, in patients with coronary artery disease.

BACKGROUND

Most countries outside the United States routinely reuse disposable medical equipment, resulting in significant cost savings. Because of quality and legal concerns, reuse in the United States has been limited. We investigated the reuse of percutaneous transluminal coronary angioplasty (PTCA) balloon catheters, restored by a process strictly controlled for bioburden and sterility, in patients undergoing PTCA.

METHODS

Used PTCA balloon catheters were shipped to a central facility and were decontaminated, cleaned and tested for endotoxin using the limulus amebocyte lystate (LAL) gel clot method. Physical testing and quality assurance were performed. The products were packaged and sterilized with ethylene oxide. Catheter performance was assessed in a pilot study powered to detect a 5% difference in the angiographic failure rates of new and reused balloons (beta 0.8).

RESULTS

The study enrolled 107 patients. The indication for PTCA was stable angina pectoris in 69 patients, unstable angina in 22 and acute myocardial infarction in 16. Of the 107 patients enrolled, 106 had a successful laboratory outcome, and 1 required coronary artery bypass graft surgery after failed rescue stenting. There were 122 lesions attempted (American College of Cardiology/American Heart Association classification A, n = 32; B1, n = 43; > or = B2, n = 35; C, n = 12). Of the 110 lesions initially approached with restored PTCA catheters, 108 were crossed and dilated. Sixty-four required no further procedures. Stenting was performed in 37 patients (29 planned, 8 rescue). Thus, the angiographic failure rate was 7% (10 of 108, 95% confidence interval 2% to 12%), comparable to the 10% rate seen with new balloons in other studies.

CONCLUSIONS

Restoration of disposable coronary angioplasty catheters using a highly controlled process appears to be safe and effective, with success rates similar to those of new products and no detectable sacrifice in performance. Cost analysis suggests that implementation of reuse technology for expensive disposable equipment may offer cost savings for U.S. hospitals, without sacrifice of quality.

Patient acceptance of reused angioplasty equipment

The reuse of percutaneous transluminal coronary angioplasty (PTCA) balloon catheters has recently been proposed as a way of containing costs. Our aim was to examine patient acceptability of this strategy. We asked 100 consecutive patients scheduled for potential or definite PTCA whether they would permit the use of sterilized, reused balloon catheters. We collected demographic, clinical, angiographic, and insurance-status data on all patients. Sixty-eight patients responded that they would have allowed reused equipment (group 1). Thirty-two patients would have refused (group 2). Only three group 2 patients could be enticed to change their opinions by appealing to their altruism or self-interest. The two groups of patients could not be distinguished by any variable, including insurance status. We conclude that a sufficient number of patients would be willing to permit reused PTCA equipment for such programs to be implemented successfully from a logistic standpoint. However, the disapproval by one third of patients raises the possibility of adverse publicity and litigation for institutions using such strategies.

Absence of increased in-hospital complications with reused balloon catheters

A reanalysis of data from a prospective Canadian study suggests that catheter reuse is not associated with an increased rate of in-hospital complications. However, these results should be replicated in clinical trials before catheter reuse becomes routinely established.