Michigan MAGIC

Background The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) provides evidence-based criteria for peripherally inserted central catheter (PICC) use. Whether implementing MAGIC improves PICC appropriateness and reduces complications is unknown. Methods A quasiexperimental study design to implement MAGIC in 52 Michigan hospitals was used. Data were collected from medical records by trained abstractors. Hospital performance on three appropriateness criteria was measured: short-term PICC use (≤5 days), use of multilumen PICCs and PICC placement in patients with chronic kidney disease. PICC appropriateness and device complications preintervention (January 2013 to December 2016) versus postintervention (January 2017 to January 2020) were compared. Change-point analysis was used to evaluate the effect of the intervention on device appropriateness. Logistic regression and Poisson models were fit to assess the association between appropriateness and complications (composite of catheter occlusion, venous thromboembolism (VTE) and central line-associated bloodstream infection (CLABSI)). Results Among 38 592 PICCs, median catheter dwell ranged from 8 to 56 days. During the preintervention period, the mean frequency of appropriate PICC use was 31.9% and the mean frequency of complications was 14.7%. Following the intervention, PICC appropriateness increased to 49.0% (absolute difference 17.1%, p<0.001) while complications decreased to 10.7% (absolute difference 4.0%, p=0.001). Compared with patients with inappropriate PICC placement, appropriate PICC use was associated with a significantly lower odds of complications (OR 0.29, 95% CI 0.25 to 0.34), including decreases in occlusion (OR 0.25, 95% CI 0.21 to 0.29), CLABSI (OR 0.61, 95% CI 0.46 to 0.81) and VTE (OR 0.40, 95% CI 0.33 to 0.47, all p<0.01). Patients with appropriate PICC placement had lower rate of complications than those with inappropriate PICC use (incidence rate ratio 0.987, 95% CI 0.98 to 0.99, p<0.001). Conclusions Implementation of MAGIC in Michigan hospitals was associated with improved PICC appropriateness and fewer complications. These findings have important quality, safety and policy implications for hospitals, patients and payors.

BACKGROUND. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was published in 2015, recommending more restricted indications for peripherally inserted central catheter (PICC) placement, particularly for those placed by physicians. Changes in PICC placement volume since the publication of MAGIC is largely unknown. OBJECTIVE. The purpose of this article was to study the trends in volume and reimbursement for PICC placement by physicians and advanced practice providers (APPs) for Medicare enrollees from 2010 to 2018 with specific attention to the changes in volume after the publication of MAGIC in 2015. METHODS. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010–2018 were extracted using the Current Procedural Terminology code for PICC placement. Total volume and payment amounts (for the professional component) were analyzed. Trendline slopes for volume per 100,000 Medicare beneficiaries before and after the 2015 publication of MAGIC were compared. RESULTS. Volume for PICC placement by physicians and APPs steadily declined from 243,837 in 2010 to 130,361 in 2018 (46.5%). The PICC placement volume decreased sharply after the 2015 publication of the MAGIC guidelines. The slope of the trendline for all providers from 2010 to 2015 was ?3.4 compared with ?7.3 from 2015 to 2018. The change in slope was more pronounced for radiologists (?3.1 to ?5.6) than for APPs (0.0 to ?1.1). Professional payment per procedure for radiologists decreased from $78.04 in 2010 to $70.17 in 2018, and reimbursement for APPs proportionally decreased from $65.76 to $60.66 during this time. The relative share of PICC placement by radiologists declined from 77.0% in 2010 to 70.6% in 2018, with a corresponding increase in relative share by APPs from 13.5% to 18.4%. The percentage placed in outpatient procedures increased from 15.1% to 18.2%. CONCLUSION. The volume of PICC placements has steadily decreased since 2010, with a sharper decline between 2015 and 2016 corresponding with the publication of the MAGIC evidence-based guidelines. The role of APPs in PICC placement has increased over this time period. CLINICAL IMPACT. The findings of this study suggest that evidence-based guidelines impact clinical practice on a national level.