PICC Line Use Dropping Among Radiologists

Interventional radiologists have been at the forefront of the decreasing the number of peripherally inserted central catheters (PICC) thanks, in large part, to new evidence-based guidelines, a new study has found.

In an article published Aug. 26 in the American Journal of Roentgenology, a team of investigators from the University of Pittsburgh discussed the performance and success of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). These guidelines were first published in 2015, and they lay out a more restrictive use of PICC lines for physicians.

Even though PICC lines are widely used for venous access, using them can be problematic. In some cases, said the team led by Will Lindquester, M.D., an interventional radiology resident at the University of Pittsburgh Medical Center, PICC lines can open the door for bloodstream infections and deep vein thrombosis. Those negative outcomes led providers to work toward reduced PICC line use over the past decade. In fact, the team reported, PICC line placement has dropped by nearly 50 percent since 2010.

And, the publication of the MAGIC guidelines, the team pointed out, led to an even sharper decline from 2015 to 2016.

“The implementation of the MAGIC guidelines has been shown to decrease PICC placement on an individual institutional level, and the findings of this study demonstrate a sharper decline in physician and [advanced practice provider] placement for Medicare enrollees following the 2015 publication,” Lindquester said.

According to the MAGIC guidelines, he said, there are a significant number of inappropriate scenarios for PICC line placement, supporting the need for this substantial drop in volume. The recommendations call for more restricted indications for PICC use as awareness of PICC-related complications has increased.

To identify the size of the decrease, Lindquester’s team looked at Medicare Part B claims filed between 2010 and 2018. In their analysis, they found PICC procedures decreased by 46.5 percent during the eight-year period, falling from 243,837 in 2019 to 130,361 in 2018. During that time, the slope of the decrease grew from 3.4 per provider prior to 2015 to 7.3 per provider after, and the change was even more significant among radiologists. Their slope changed from 3.1 to 5.6 after the guidelines were introduced in 2015.

Alongside this change in usage, professional payments per procedure also declined, falling from $78.04 to $70.17. The drop in payment for advanced practice practitioners was similar, according to the study analysis.

Overall, the team determined, the reduction in PICC placements by interventional radiologists is most likely because the MAGIC guidelines specifically outline situations for which it would be appropriate:

•  A suitable target vein could not be identified by ultrasound at the bedside
•  The guidewire or catheter could not be easily advanced at the bedside
•  The patient requested sedation that could not be provided safely at bedside
•  Patients with bilateral mastectomy or altered chest wall anatomy
•  Patients with superior vena cava filters
•  Patients with pacemakers or defibrillators if the contralateral arm could not be used

 While the outcome of this study indicates these guidelines do have a clinical impact at the national level, the team concluded additional research is still necessary.

“Further study of changes in case complexity for interventional radiologists, given decrease volume of PICC placement by physicians, is warranted, especially in light of declining reimbursement for PICC placement,” they said.