Look at the instructions for any internal catheter and you will see “single use only,” a statement required by the Food and Drug Administration. But Medicare policy seems to say it’s fine to clean and re-use catheters, since it will only reimburse four catheters a month — unless you have two documented infections in a 12-month period. However, there are no accepted guidelines on the correct way to clean a single-use catheter.
How Medicare arrived at a “four catheter per month” policy remains a mystery. There are no studies that compare infection rates of single-use versus multi-use catheters. To make matters worse, more HMO and private insurance companies are following Medicare’s reimbursement guidelines. This may work fine for some, but for others, cleaning and re-using catheters puts them at risk for urinary tract infections and costly hospital stays, and could lead to permanent damage.
According to an article in The Arizona Republic titled “Medicare Challenged on Catheters,” the idea of re-using catheters started with the late Dr. Jack Lapides, a renowned urologist from the University of Michigan. In 1971 Lapides was successful in teaching people to catheterize at home, and part of the protocol included re-using catheters. Critics point out that it’s one thing to clean and re-use a catheter in your nice clean private bathroom, and quite another to do so in the real world of porta-potties and public restrooms. The article says that Lapides never tested the safety of re-using catheters. He simply declared re-use to be safe. Not only has there been no field (real-life) study that compares UTI rates in single-use vs. multi-use catheters, a number of improvements and options in catheters have become available since Lapides work. (See sidebar).
When it comes to re-using catheters, there is a myth that the bladder develops an immunity to bacteria over time. “People with frequent UTIs do not build up their immunity,” says Dr. Holly Zhao, assistant professor and attending physician of the department of physical medicine and rehabilitation at UC Davis Medical Center in Sacramento, Calif. “On the other hand,” she says, “those people with a history of frequent UTIs usually get ‘super-strains’ of bacteria that are hard to treat due to their resistance to multiple antibiotics. Getting a few mild UTIs a year puts a person at greater risk for kidney stones, more severe infections (upper urinary tract infections, such as kidney infection) autonomic dysreflexia, renal damage and renal failure.”
Zhao adds that with proper care, washing and re-using catheters can be done without significantly increased risk of UTIs. But as soon as problems such as chronic colonization of bacteria in the urinary system, a pressure ulcer close to the urethra or frequent UTIs enter the picture, a single-use system is recommended.
Dr. Rodney Anderson, professor of urology at Stanford Medical Center in Palo Alto, Calif., has a great deal of experience with SCI and is very practical when it comes to advice. His study of many years ago at Santa Clara Valley Medical Center in San Jose, Calif., demonstrated that “sterile intermittent catheterization was better in the hospital than the clean (washing your hands) technique, but it is not practical in the real world.” Anderson points out the difficulties doctors face when prescribing catheters, noting that insurance companies and the government have refused to underwrite the cost of sterile intermittent catheterization. “Most of us believe three catheters a week are adequate and you can wash and recycle,” he says, “but most federal government agencies only give four catheters a month.”
Is Single Use Better?
Current studies and guidelines may be leaning toward single-use catheters. A recent paper titled “Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Providers,” published in August 2006 by the Paralyzed Veterans of America, says, “If UTIs recur and no reason is found, a single-use catheter is recommended.” The guideline further states that “lower infection rates can be achieved with sterile techniques and pre-lubricated self-contained [touchless] catheters.”
Dr. Diana Cardenas, professor and chair of the University of Miami department of rehabilitation medicine, has conducted several studies dealing with SCI and UTIs. She says there hasn’t been hard proof that sterile technique alone necessarily makes a difference in hospital settings, but she agrees that, theoretically, less contamination should occur with touchless catheters. A bigger issue, she says, is the number of people handling a catheter, regardless of the setting. “Contamination can happen at home as well as in the hospital,” she says. “We showed clearly in a several-year study in caregiver situations where caregivers were doing the intermittent cathing, that this was the worst scenario, that infection was more likely than with an indwelling foley catheter.” In other words, the likelihood of contamination rises as the number of different people involved in cathing increases.
So wouldn’t it follow logically that those who must depend on others to cath intermittently would be better off using a touchless system? “Oh yes, I would agree,” she says. “They are definitely in a riskier category and need to have the best catheter system that we can provide — if they are having infections.”
There’s the disclaimer again — if they are having UTIs — which brings us back to the two documented infections per year Medicare policy. Wouldn’t it seem to make more sense to base a reimbursement policy on severity of infections rather than number? For instance, one hospitalization is usually more serious, and costly, than several mild UTIs treated at home. But Cardenas says it’s not that simple. “Most people are not hospitalized, even when they have a more serious infection in this day and age, because it’s not as easy to get hospitalized for any reason,” she says. “So hospitalization is not a very good outcome measure,” she concludes.
Cardenas’ most recent study, conducted with Jeanne Hoffman, Ph.D., while Cardenas was chief of rehabilitation medicine at University of Washington Medical Center (“Hydrophilic Catheters for Prevention of UTIs: A Randomized Clinical Trial in Chronic SCI”) compared UTI rates in two groups, one using hydrophilic catheters and a control group using their usual catheters. Both groups followed single-use protocol. A hydrophilic catheter is coated with a compound that becomes extremely slippery when water is added, the rationale being less friction causes less trauma to the urethra, reducing the chance of invasion by harmful bacteria. Of 44 subjects, 23 made up the control group while 21 were assigned to the treatment group, which used LoFric hydrophilic catheters. The study found that there was a significant reduction in UTIs requiring antibiotic treatment in the group using the hydrophilic catheters. But this only applied to men. In women there was no difference in infection rates.
Even though this study indicated that using hydrophilic catheters resulted in fewer UTIs, when asked if there is one best system, Cardenas says, “It’s so individualized. I have seen people who have no problem re-using catheters, even sticking it in their pocket. It’s still the host, we still don’t understand this about the person, and I’m hoping one day we’ll have some genetic information to help us, because some people can just do fine using clean technique and other people cannot. And for the life of me, some of the people who can’t do well are the cleanest people in the world.”
What About Real-World Scenarios?
Doctors’ recommendations and clinical studies are fine, but New Mobility readers give us a glimpse into real-life scenarios.
Jim Munson, 39, a sales rep for ROHO cushions and TiLite wheelchairs, is in his 20th year as a T10 para and has had his share of catheter difficulties. “I was using a straight catheter for a bunch of years with no problem, then started having trouble getting the catheter past my sphincter. It got so bad the urologist said my only option was to have surgery to open it up.” Then Munson ran into the local Coloplast rep, who gave him some sample “Speedy Cath” hydrophilic catheters with a coude tip (a smaller curved tip for easier passage). “The catheter worked great first time, I cancelled the surgery, and I’ve been using the Speedy Cath for years with no problem,” says Munson. But Munson’s insurance won’t pay for the catheters. Out of pocket costs can become prohibitive pretty quick without insurance coverage.
Jody Kemp, from Denver, Colo., works as a chef. Kemp, 35, in his 22nd year as a T3-4 para, says, “I reuse straight catheters. I’m anti-sanitary in my cath technique. I use one, shake it out and put it in my pocket — then reuse it again and again.” He can’t remember the last time he had a symptomatic UTI — a UTI where he actually felt bad — although he says he probably has a constant mild infection that doesn’t affect him. “I keep catheters all over the place, in my car, at home; whenever I do laundry I usually find a catheter in the wash along with loose change. I re-use a catheter for about a week and I don’t have any problems.”
Todd Boyer, 36, from Granite Bay, Calif., is a territory manager for A-Med Healthcare. Boyer, a T12 para for 13 years, has also had to fight for insurance coverage. “I’ve been using closed system catheters for eight years now and I haven’t had an infection. Before going to the closed system I was getting lots of UTIs.” At first Boyer’s insurance wouldn’t pay for his catheters, but an administrative law judge took one look at the case and told the insurance company they had to pay. “People need to fight for what they are entitled to and not take no for an answer,” he says.
Monica Bascio is an occupational therapist from Evergreen, Colo. Bascio, 37, is a world class handcycle racer and Paralympic cross country ski racer injured at T12 for 14 years. She is constantly getting UTIs. “I use a straight catheter, but I only get one catheter a day and I have to wash and re-use it. In fact, my doctor says he is doing me a favor for providing one a day. My HMO won’t pay for any more. It’s really frustrating and I’m tired of getting knocked out by UTIs all the time.”
David Moore, 45, is recently re-retired. Moore, from Portland, Ore., has been a T4 para for 26 years. “I was using closed system catheters for years with no problem, but I didn’t like the amount of garbage they created. So I switched to re-using a couple of straight catheters a week,” he says. He cleans his catheters in a solution of water and Urocare disinfectant, rinses them out, dries them on a paper towel and puts the clean ones in a Ziploc bag. He keeps two Ziploc bags in his pouch, one for clean catheters and one for used ones to be re-washed. “The system seems to work pretty good,” he says. “I only seem to get about one UTI a year and I feel much better about not creating so much trash.”
Todd Robinson, from Alpharetta, Ga., is a 36-year-old sales rep for At Home Medical and a T4 para for 25 years. “A long time back my insurance would only pay for one catheter a week. It was a total hassle trying to keep them clean, washing and drying them and trying to remember which ones were clean. I was already prone to infections, and with re-using them, I got even more infections,” he says. Since then, Robinson’s insurance has changed and he has switched to a closed system catheter and hasn’t had a UTI in five years. “I wheelchair race, and when I go to races and have to use the porta-potty, it’s gross,” he says. “I can’t imagine trying to re-use a catheter in there. With the closed system it doesn’t matter how dirty the bathroom is or how dirty my hands are. Where the catheter meets the urethra, it is still sterile.”
Re-use or single use, the bottom line is avoidance of UTIs. If you have a catheter system that is keeping you free of UTIs, stick with it. If you are having recurrent UTIs, go back to the basics. Cath often enough that your output volume is below 500 cubic centimeters and keep hands and body parts clean — antibacterial wipes are cheap and effective. Make sure you have any signs of a symptomatic UTI documented by your doctor, including providing a urine sample. Documentation is vital for insurance coverage.
And never overlook the basic rule: Stay hydrated. “I find more people getting into trouble by restricting their fluids because they’re trying to stay dry,” says Cardenas. “They end up hurting themselves because their bodies are going to pull fluid out anyway, and they’re more likely to get infected because of concentration [of more bacteria in less volume of fluid].”
Finally, with the various kinds of catheter systems available today, if your system isn’t working, try another. Catheter manufacturers and catheter suppliers are happy to provide free samples. We are all different — what works for one person may not work for another. The key is to find out which system works for you.
Tim Gilmer contributed to this story.
Rep. Rick Renzi of Arizona introduced a bill in Congress, H.R. 6302, on Sept. 29 to remove the frequency limitation on Medicare coverage for intermittent catheterization. To support this bill, send an e-mail to him at Rick.firstname.lastname@example.org, or call 202/225-2315.
What Are My Options?
PVA Publications’ “Bladder Management for Adults with Spinal Cord Injury” describes a variety of intermittent catheters available to meet individual needs:
- Single-use catheter. The basic straight catheter designed for single use.
- Single-use hydrophilic catheter. A catheter with a lubricious (slippery) coating activated by adding water.
- Antibacterial catheter. A single-use catheter impregnated with an antibacterial substance.
- Touchless catheter. A pre-lubricated catheter contained in a collection device, or sheath, that is inserted directly from the collection device/sheath into the urethra. Danger of contamination from bacteria is minimal even if hands or environment is unclean. The collection bag is a convenient way to monitor urine output.
Resources: Catheter Manufacturers
- Mentor, 800/525-0245, www.mentorcorp.com
- Astra Tech, 877/456-3742, www.astratechusa.com
- Coloplast, 800/788-0293, www.us.coloplast.com
- Bard, 800/526-4455 , www.bardmedical.com
- Apogee Medical, 800/572-6461, www.apogeemed.com
- Rusch (Teleflex), 866/383-5124, www.myrusch.com
- Hollister, 800/323-4060, www.hollister.com
- Rochester, 800/243-3315, www.rocm.com