Trends in Perioperative Catheter Utilization by Surgical Procedure Type in the United States, 2010 – 2017: Evidence from the Nationwide Inpatient Sample

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Anderton , Anthony C. Waddimba , Gerald O. Ogola , Michael A. Ramsay , Bryan Kim , Gregory R. Thoreson doi: https://doi.org/10.1101/2024.03.22.24304038 Priscilla D. Anderton 1 Texas A&M University, College of Medicine, College Station , Texas MS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Anthony C. Waddimba 1 Texas A&M University, College of Medicine, College Station , Texas 2 Baylor University Medical Center, Department of Surgery, Division of Surgical Research , Dallas, Texas 3 Baylor Scott and White Research Institute , Dallas, Texas MD, DSc Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gerald O. Ogola 2 Baylor University Medical Center, Department of Surgery, Division of Surgical Research , Dallas, Texas 3 Baylor Scott and White Research Institute , Dallas, Texas PhD, MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site Michael A. Ramsay 4 Baylor University Medical Center, Department of Anesthesiology and Pain Management , Dallas, Texas MD, FRCA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bryan Kim 1 Texas A&M University, College of Medicine, College Station , Texas MS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gregory R. Thoreson 2 Baylor University Medical Center, Department of Surgery, Division of Surgical Research , Dallas, Texas 5 Baylor of University Medical Center, Department of Surgery, Division of Urology , Dallas, Texas 6 Department of Clinical Research, Urology Clinics of North Texas , Dallas, Texas 7 Adjunct Assistant Professor, Department of Engineering, University of Texas , Dallas, TX MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: Gregory.Thoreson{at}BSWHealth.org thoreson{at}urologyclinics.com Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Background Indwelling urethral catheters are regularly used in the operative setting to monitor urinary output, decompress the bladder, or manage post-operative urinary retention. Indwelling urethral catheterization can be associated with significant complications, such as nosocomial infections and urethral trauma, hence the contemporary national and institutional efforts to reduce indwelling urethral catheter usage. Objectives The purpose of this study is to investigate national trends in perioperative catheter usage across surgical procedure categories. Methods This is a retrospective study of adults who received indwelling urethral catheters during elective surgical procedures performed in United States (U.S.) hospitals during 2010-2017. We utilized the National Inpatient Sample (NIS) procedure codes to identify surgical procedure types and insertions of indwelling urethral catheters. Yearly catheterization rates were utilized to assess significant differences in nationwide temporal trends. Results We sampled 81,128,725 perioperative catheterizations across twelve procedure categories. When specific categories were examined separately, the annual proportion of procedures utilizing catheterization decreased for eye (−0.05% [95% CI, -0.10%; -0.02%], p-value 0.013), musculoskeletal (−0.04% [95% CI, -0.09%; 0.003%] p-value 0.063), and urinary system surgeries (−0.54% [95% CI, -0.76%; -0.33%] p-value 0.001). The proportion that utilized urethral catheters increased annually for female reproductive (+0.05% [95% CI, 0.04%; 0.07%] p-value <0.001), male reproductive (+0.31% [95% CI, 0.18%; 0.44%] p-value 0.001), and respiratory system surgeries (0.08% [95% CI, 0.02%; 0.13%] p-value 0.015). When all operative procedures were examined together, the overall annual proportion involving urethral catheterization did not significantly vary during 2010-2017. Conclusion Despite wide dissemination of clinical guidelines and institutional efforts to reduce catheterizations, we observed no significant changes in the overall proportion of all surgical procedures (irrespective of procedure category) that utilized urethral catheters during our study period. Introduction The United States (U.S.) uses 30 million urinary catheters annually, with roughly $500 million spent on treating hospital-acquired urinary tract infections – a common complication of indwelling urethral catheter usage. 1 , 2 In 2009, the Centers for Disease Control (CDC) promulgated clinical guidelines for appropriate use of catheters in the perioperative setting in an attempt to reduce unwarranted catheterization, associated complications, and costs. 2 , 3 Little is known regarding nationwide trends in perioperative catheter usage, or how the proportion of surgical operations involving urethral catheterization has evolved since guideline dissemination. 4 , 5 The present study queried the Nationwide Inpatient Sample (NIS) database to identify national yearly trends and annual percentage changes in perioperative catheter usage across surgical procedure categories. Methods We analyzed elective surgical procedures performed with indwelling urethral catheters at U.S. hospitals during 2010-2017 and recorded in the NIS of the Agency for Health Research and Quality’s Healthcare Cost and Utilization Project ( eMethods in the Supplement). The NIS list of procedure codes was used to identify the specific type of surgical procedure and the insertion of an indwelling urethral catheter ( eTables in the Supplement). Only patients ≥ 18 years old were sampled. The primary outcome was the proportion of surgical procedures involving indwelling urethral catheters. This was derived by dividing the count of adults with both a primary code for a surgical procedure and a secondary code for indwelling catheterization by the overall count of adults with primary codes for surgical procedures in each calendar year. Preliminary assessments of variations in annual urethral catheter utilization were based on the Chi-square test of proportions. Significance was defined at P < .05. Yearly catheterization rates were then configured as time series data. The Mann-Kendall trend test was applied to assess statistically significant differences in nationwide temporal trends in the derived time series. Locally estimated scatterplot smoothing curves were fitted to assess time series relationships. Statistical analyses were conducted using SAS® software version 9.4. Results Between 2010 and 2017, a total of 81,128,725 perioperative catheterizations were performed in the U.S. Among twelve procedure groups, six demonstrated a significant change in proportion of catheters utilized annually. Annual catheter usage decreased at a rate of −0.05% ([95% CI, - 0.10%; -0.02%], p-value 0.013) for eye surgeries, −0.04% ([95% CI, -0.09%; 0.003%] p-value 0.063) for musculoskeletal system procedures, and −0.54% ([95% CI, -0.76%; -0.33%] p-value 0.001) for urinary system procedures (see Table 1 ; Figure 1A ). View this table: View inline View popup Download powerpoint Table 1. Trends in indwelling urethral catheterization, 2010-2017 Download figure Open in new tab Figure 1. Proportion of Indwelling Catheters Utilized Between 2010 – 2017 A . A: Proportion of indwelling catheters utilized overall B: Proportion of indwelling catheters utilized within individual procedure groups In contrast, catheter usage increased annually at a rate of +0.05% ([95% CI, 0.04%; 0.07%] p-value <0.001) for female reproductive procedures, +0.31% ([95% CI, 0.18%; 0.44%] p-value 0.001) for male reproductive procedures, and +0.08% ([95% CI, 0.02%; 0.13%] p-value 0.015) for respiratory system procedures ( Table 1 ; Figure 1A ). When all procedure groups were combined, there was no significant difference in the annual proportion of catheters used (annual trend, -0.0021% [95% CI, -0.032%; 0.028%]; p-value 0.873) ( Table 1 ; Figure 1B ). Discussion Between 2010 and 2017, three procedure categories demonstrated a significant decrease in the annual proportion of catheters used in the perioperative setting, while three other procedure categories demonstrated a significant increase. However, when all operative procedures are considered together, the overall proportion of catheterizations did not significantly change during this period, despite the dissemination of CDC guidelines and reports of successful initiatives to reduce urinary catheterizations within select institutions. 5 There are a few plausible explanations for this observation. This could be due to institution-level variation in guideline implementation or adherence. 4 , 5 Additionally, this could be explained by the lack of a standardized alternative method for the accurate measurement of intraoperative urinary output – a common indication for catheterization. 6 , 7 Thus, additional research studies are warranted to explore practical alternatives to indwelling urinary catheters that could be implemented in the ‘real world’ perioperative setting. The present study has notable limitations. First, this is a retrospective study limited to information available within the NIS database. Secondly, biases resulting from periodic changes in the sampling strategy utilized during NIS data collection ( eMethods in the Supplement) are possible. Data Availability All data produced in the present study are available upon reasonable request to the authors. References 1. ↵ Agatstein E , Aynehchi S. The Connected Catheter for management of Chronic Urinary Retention (CUR) in an adult male with Neurogenic Bladder - Case study . Urol Case Rep . 2019 Jun 15; 26 : 100947 . doi: 10.1016/j.eucr.2019.100947 . PMID: 31297331 ; PMCID: PMC6597782 . OpenUrl CrossRef PubMed 2. ↵ Jain P , Parada JP , David A , Smith LG . Overuse of the indwelling urinary tract catheter in hospitalized medical patients . Arch Intern Med . 1995 Jul 10; 155 ( 13 ): 1425 - 9 . PMID: 7794092 . OpenUrl CrossRef PubMed Web of Science 3. ↵ Gould CV , Umscheid CA , Agarwal RK , Kuntz G , Pegues DA ; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009 . Infect Control Hosp Epidemiol . 2010 Apr ; 31 ( 4 ): 319 – 26 . doi: 10.1086/651091 . PMID: 20156062 . OpenUrl CrossRef PubMed Web of Science 4. ↵ De Roo AC , Hendren S , Ameling JM , Meddings J. Using appropriateness criteria to identify opportunities to improve perioperative urinary catheter use . Am J Surg . 2020 ; 220 ( 3 ): 706 – 713 . doi: 10.1016/j.amjsurg.2020.01.008 OpenUrl CrossRef 5. ↵ Sadeghi M , Leis JA , Laflamme C , Sparkes D , Ditrani W , Watamaniuk A , Taggar R , Jinnah F , Avaness M , Vearncombe M , Nathens AB . Standardisation of perioperative urinary catheter use to reduce postsurgical urinary tract infection: an interrupted time series study . BMJ Qual Saf . 2019 Jan ; 28 ( 1 ): 32 – 38 . doi: 10.1136/bmjqs-2017-007458 . Epub 2018 May 29. PMID: 29844230 . OpenUrl Abstract / FREE Full Text 6. ↵ Nasrabadi MZ , Tabibi H , Salmani M , Torkashvand M , Zarepour E. A comprehensive survey on non-invasive wearable bladder volume monitoring systems . Med Biol Eng Comput . 2021 Aug ; 59 ( 7-8 ): 1373 – 1402 . doi: 10.1007/s11517-021-02395-x . Epub 2021 Jul 14. PMID: 34258707 . OpenUrl CrossRef PubMed 7. ↵ Møller T , Engedal MS , Plum LM , Aasvang EK . Reduced Need for Urinary Bladder Catheterization in the Postanesthesia Care Unit After Implementation of an Evidence-based Protocol: A Prospective Cohort Comparison Study . Eur Urol Open Sci . 2021 Feb 16; 26 : 27 – 34 . doi: 10.1016/j.euros.2021.01.013 . PMID: 34337505 ; PMCID: PMC8317857 . OpenUrl CrossRef PubMed View the discussion thread. Back to top Previous Next Posted March 24, 2024. Download PDF Supplementary Material Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. 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