{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T00:56:14Z","timestamp":1760057774780,"version":"build-2065373602"},"reference-count":40,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2025,2,19]],"date-time":"2025-02-19T00:00:00Z","timestamp":1739923200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>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 &lt; 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.<\/jats:p>","DOI":"10.3390\/jcm14041397","type":"journal-article","created":{"date-parts":[[2025,2,19]],"date-time":"2025-02-19T11:49:27Z","timestamp":1739965767000},"page":"1397","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cost-Effectiveness of Routine X-Rays After Central Venous Catheter Removal: A Value-Based Analysis of Post-Removal Complications"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-2338-6872","authenticated-orcid":false,"given":"Martin","family":"Breitwieser","sequence":"first","affiliation":[{"name":"Department for Orthopedic Surgery and Traumatology, Paracelsus Medical University, 5020 Salzburg, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Teresa","family":"Wiesner","sequence":"additional","affiliation":[{"name":"Department for Orthopedic Surgery and Traumatology, Paracelsus Medical University, 5020 Salzburg, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vanessa","family":"Moore","sequence":"additional","affiliation":[{"name":"Department for Orthopedic Surgery and Traumatology, Paracelsus Medical University, 5020 Salzburg, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Florian","family":"Wichlas","sequence":"additional","affiliation":[{"name":"Department for Orthopedic Surgery and Traumatology, Paracelsus Medical University, 5020 Salzburg, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christian","family":"Deininger","sequence":"additional","affiliation":[{"name":"Department for Orthopedic Surgery and Traumatology, Paracelsus Medical University, 5020 Salzburg, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,2,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"210","DOI":"10.51594\/imsrj.v4i2.819","article-title":"Healthcare management in a post-pandemic world: Lessons learned and future preparedness-a review","volume":"4","author":"Omaghomi","year":"2024","journal-title":"Int. Med. Sci. Res. J."},{"key":"ref_2","unstructured":"Porter, M. (2006). Redefining Health Care: Creating Value-Based Competition on Results, Harvard Business Press."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1007\/s40258-022-00785-2","article-title":"Analysing the efficiency of health systems: A systematic review of the literature","volume":"21","author":"Mbau","year":"2023","journal-title":"Appl. Health Econ. Health Policy"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1225","DOI":"10.1016\/j.jval.2023.04.004","article-title":"Developing criteria for health economic quality evaluation tool","volume":"26","author":"Kim","year":"2023","journal-title":"Value Health"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"3629","DOI":"10.1007\/s00330-015-3770-8","article-title":"Cost-effectiveness modelling in diagnostic imaging: A stepwise approach","volume":"25","author":"Sailer","year":"2015","journal-title":"Eur. Radiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1007\/s40258-024-00876-2","article-title":"Cost of low-value imaging worldwide: A systematic review","volume":"22","author":"Kjelle","year":"2024","journal-title":"Appl. Health Econ. Health Policy"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1186\/1752-2897-7-2","article-title":"Retrospective review of the use and costs of routine chest x rays in a trauma setting","volume":"7","author":"Ziegler","year":"2013","journal-title":"J. Trauma Manag. Outcomes"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1002\/jmri.23530","article-title":"Radiology\u2019s ethical responsibility for healthcare reform: Tempering the overutilization of medical imaging and trimming down a heavyweight","volume":"35","author":"Armao","year":"2012","journal-title":"J. Magn. Reson. Imaging"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Kjelle, E., Andersen, E.R., Krokeide, A.M., Soril, L.J., van Bodegom-Vos, L., Clement, F.M., and Hofmann, B.M. (2022). Characterizing and quantifying low-value diagnostic imaging internationally: A scoping review. BMC Med. Imaging, 22.","DOI":"10.1186\/s12880-022-00798-2"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1016\/j.ejim.2015.06.018","article-title":"Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis","volume":"26","author":"Karel","year":"2015","journal-title":"Eur. J. Intern. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"176","DOI":"10.4103\/IJCIIS.IJCIIS_14_18","article-title":"Massive air embolism while removing a central venous catheter","volume":"8","author":"Seong","year":"2018","journal-title":"Int. J. Crit. Illn. Inj. Sci."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1016\/j.nrl.2022.04.002","article-title":"Brain sagging syndrome, a potentially reversible cause of subacute ataxia and dementia. A case report","volume":"38","author":"Reinoso","year":"2023","journal-title":"Neurologia"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"17","DOI":"10.2739\/kurumemedj.MS651006","article-title":"A rare case of cerebral air embolism caused by pulmonary arteriovenous malformation after removal of a central venous catheter","volume":"65","author":"Kugiyama","year":"2018","journal-title":"Kurume Med. J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"309","DOI":"10.4103\/ija.ija_379_21","article-title":"Fragmentation of central venous catheter-A rare but dreaded complication","volume":"66","author":"Menon","year":"2022","journal-title":"Indian J. Anaesth."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"37","DOI":"10.38179\/ijcr.v3i1.123","article-title":"Hemothorax Occurring After Central Venous Catheter Removal: A Case Report","volume":"3","author":"Dib","year":"2023","journal-title":"Int. J. Clin. Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1177\/11297298221125965","article-title":"Should ultrasound evaluation for catheter-related thrombosis always be required before PICC removal?","volume":"25","author":"Pinelli","year":"2024","journal-title":"J. Vasc. Access"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1097\/NAN.0000000000000532","article-title":"Infusion therapy standards of practice","volume":"47","author":"Nickel","year":"2024","journal-title":"J. Infus. Nurs."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Breitwieser, M., Moore, V., Wiesner, T., Wichlas, F., and Deininger, C. (2024). NLP-Driven Analysis of Pneumothorax Incidence Following Central Venous Catheter Procedures: A Data-Driven Re-Evaluation of Routine Imaging in Value-Based Medicine. Diagnostics, 14.","DOI":"10.20944\/preprints202410.0740.v1"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Kjelle, E., Andersen, E.R., Soril, L.J., van Bodegom-Vos, L., and Hofmann, B.M. (2021). Interventions to reduce low-value imaging\u2013a systematic review of interventions and outcomes. BMC Health Serv. Res., 21.","DOI":"10.1186\/s12913-021-07004-z"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1148\/radiol.10100063","article-title":"Addressing overutilization in medical imaging","volume":"257","author":"Hendee","year":"2010","journal-title":"Radiology"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1080\/13814788.2017.1290795","article-title":"How to conduct research on overdiagnosis. A keynote paper from the EGPRN May 2016, Tel Aviv: \u2018Life can only be understood backwards; but it must be lived forwards\u2019 S\u00f8ren Kierkegaard (Danish philosopher 1813\u20131855)","volume":"23","author":"Brodersen","year":"2017","journal-title":"Eur. J. Gen. Pract."},{"key":"ref_22","first-page":"499","article-title":"Are chest x-rays mandatory following central venous recatheterization over a wire?\/Discussion","volume":"64","author":"Amshel","year":"1998","journal-title":"Am. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1016\/j.chest.2018.02.017","article-title":"Is routine chest x-ray after ultrasound-guided central venous catheter insertion choosing wisely?: A population-based retrospective study of 6875 patients","volume":"154","author":"Chui","year":"2018","journal-title":"Chest"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1458","DOI":"10.1002\/pbc.24568","article-title":"Relapse after treatment of pediatric Hodgkin lymphoma: Outcome and role of surveillance after end of therapy","volume":"60","author":"Friedmann","year":"2013","journal-title":"Pediatr. Blood Cancer"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1586\/14737167.2015.1051037","article-title":"The cost\u2013effectiveness of diagnostic cardiac imaging for stable coronary artery disease","volume":"15","author":"Turchetti","year":"2015","journal-title":"Expert Rev. Pharmacoeconomics Outcomes Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2635","DOI":"10.1200\/JCO.2011.40.7841","article-title":"Surveillance computed tomography imaging and detection of relapse in intermediate-and advanced-stage pediatric Hodgkin\u2019s lymphoma: A report from the Children\u2019s Oncology Group","volume":"30","author":"Voss","year":"2012","journal-title":"J. Clin. Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1312","DOI":"10.1001\/jama.2023.1792","article-title":"Cost-effectiveness thresholds used by study authors, 1990\u20132021","volume":"329","author":"Neumann","year":"2023","journal-title":"JAMA"},{"key":"ref_28","unstructured":"Vassall, A., Sweeney, S., Kahn, J., Gomez Guillen, G., Bollinger, L., Marseille, E., Herzel, B., DeCormier Plosky, W., Cunnama, L., and Sinanovic, E. (2025, February 17). Reference Case for Estimating the Costs of Global Health Services and Interventions. Available online: https:\/\/researchonline.lshtm.ac.uk\/id\/eprint\/4653001."},{"key":"ref_29","unstructured":"Akram, S., and Chowdhury, Y.S. (2020). Radiation Exposure of Medical Imaging, Statpearls Publishing."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1097\/00004032-200307000-00011","article-title":"Cancer risks from medical radiation","volume":"85","author":"Ron","year":"2003","journal-title":"Health Phys."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"5675","DOI":"10.1007\/s00330-023-09541-z","article-title":"Occupational exposure to ionizing radiation in medical staff: Trends during the 2009\u20132019 period in a multicentric study","volume":"33","author":"Baudin","year":"2023","journal-title":"Eur. Radiol."},{"key":"ref_32","first-page":"100459","article-title":"The carbon footprint of hospital diagnostic imaging in Australia","volume":"24","author":"McAlister","year":"2022","journal-title":"Lancet Reg. Health\u2013West. Pac."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1016\/j.jacr.2007.03.002","article-title":"American College of Radiology white paper on radiation dose in medicine","volume":"4","author":"Amis","year":"2007","journal-title":"J. Am. Coll. Radiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2304","DOI":"10.12968\/bjon.2000.9.22.5417","article-title":"Central venous catheter removal: Procedures and rationale","volume":"9","author":"Drewett","year":"2000","journal-title":"Br. J. Nurs."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Pinelli, F., Pittiruti, M., Annetta, M.G., Barbani, F., Bertoglio, S., Biasucci, D.G., Bolis, D., Brescia, F., Capozzoli, G., and D\u2019Arrigo, S. (2024). A GAVeCeLT consensus on the indication, insertion, and management of central venous access devices in the critically ill. J. Vasc. Access, 11297298241262932.","DOI":"10.1177\/11297298241262932"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1177\/17511437241227739","article-title":"Are routine chest radiographs still indicated after central line insertion? A scoping review","volume":"25","author":"Brindley","year":"2024","journal-title":"J. Intensive Care Soc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1378\/chest.11-0131","article-title":"Test characteristics of ultrasonography for the detection of pneumothorax: A systematic review and meta-analysis","volume":"141","author":"Alrajhi","year":"2012","journal-title":"Chest"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1186\/s13054-017-1814-y","article-title":"Ultrasound-guided central venous catheter placement: A structured review and recommendations for clinical practice","volume":"21","author":"Saugel","year":"2017","journal-title":"Crit. Care"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1186\/s13054-018-1989-x","article-title":"Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: A systematic review and meta-analysis","volume":"22","author":"Smit","year":"2018","journal-title":"Crit. Care"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1097\/CCM.0000000000002188","article-title":"Diagnostic accuracy of central venous catheter confirmation by bedside ultrasound versus chest radiography in critically ill patients: A systematic review and meta-analysis","volume":"45","author":"Ablordeppey","year":"2017","journal-title":"Crit. Care Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/4\/1397\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T16:38:13Z","timestamp":1760027893000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/4\/1397"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,19]]},"references-count":40,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2025,2]]}},"alternative-id":["jcm14041397"],"URL":"https:\/\/doi.org\/10.3390\/jcm14041397","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2025,2,19]]}}}