In the continuing effort to foster innovation and cost savings in cardiovascular programs, CFA was reminded of two interrelated clinical pathway issues by recently published research.  

In looking for ways to improve outcomes and decrease the cost of interventional cardiology procedures, the concept of transradial versus transfemoral arterial access has received considerable attention in recent years.  Additionally, the transition of select PCI procedures[1] from inpatient status to same-day discharge has also grown considerably.  Combined, utilizing the transradial approach for select PCI procedures, allowing patients to achieve same-day discharge, is growing steadily, although at a slow rate.

The first study was published in JACC:  Cardiovascular Innovations:

The second, supporting piece of research comes from the updated ACC National Cardiovascular Data Registry (NCDR) CathPCI data released in February:

While national data on SDD is difficult to obtain, it is believed that the typical average SDD rate is about 35% (and varies by diagnosis, procedure and presence/absence of complications and comorbidities).  There is considerable anecdotal information from progressive hospitals suggesting that, depending upon the inclusion/exclusion criteria used, and ultimately the mix of patients, rates approaching the 50% to 75% range can be reached.  While TRI and SDD are somewhat dependent variables in the above referenced studies, they are not completely dependent.  SDD can occur with patients who experience a transfemoral approach procedure.  

Further supporting documentation from a joint consensus document on transradial PCI, published in January 2013 by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the Acute Cardiovascular Care Association (ACCA) and the Working Group (WG) on Thrombosis of the European Society of Cardiology (ESC), the European Society of Cardiology in a press release stated:

“The radial approach for percutaneous coronary interventions (PCI) was developed 20 years ago and is used for more than 50% of procedures in France, Scandinavian countries, the UK, Spain and Italy. Despite the advantages of radial access some countries in Europe such as Germany use radial access for fewer than 10% of PCI….

“Evidence has accumulated in the literature showing the benefits of radial over femoral access for PCI including reduced bleeding and improved survival. In addition, the development of smaller and thinner devices has made the radial approach increasingly practical.”[2}

Implications

Both TRI and SDD represent significant departures from traditional pathways of care utilized by most interventional cardiologists in the U.S.[3]  Progressive hospitals and their medical staffs have adopted these two major changes as continuing research has documented better outcomes, lower costs and enhanced patient experience.

As is typical, actual practice has moved beyond the “official” stance on these issues, as the guidance from professional societies is believed to be “too strict” by some cardiologists and not specific enough by others in the field.  The early adopters are reaping the benefits of these changes in pathways of care.  The problem for most hospitals in making changes such as these in daily practice is physician inertia.  These changes mandate physician education and adoption of new techniques and approaches; careful patient selection, risk stratification, and care management; and procedures in place to be able to successfully manage the new care processes with carefully trained staff.

For several years, cardiology fellows in training have been receiving specific experience and education in the use of transradial techniques.  This has left interventional cardiologists who received their training prior to the inclusion of transradial access in their training programs to seek out other training programs and methods to learn to use this technique competently.  Many vendors of transradial access devices arrange for and provide educational opportunities for interventional cardiologists and cardiac cath lab staff to receive education and training in this technique.

Conclusion

All hospitals should actively seek to improve quality, lower costs and enhance patient experience.  Adapting new, well documented care pathways, such as TRI and SDI, are important strategies in the continuing quest for clinical excellence and the delivery of value-based care.

There are consensus guideline documents available through the SCAI, ACCF and AHA and training programs offered throughout the country by the PCI product vendor community.  Planning, implementing or expanding a transradial access PCI program in your hospital will require some research and education, but the potential benefits in outcomes, patient satisfaction and cost savings are well worth the investment.

If you are interested in learning more about strategies to deal with cost reduction and quality enhancement programs for cardiovascular or other services, please contact CFA at (949) 443-4005 or by e-mail at cfa@charlesfrancassociates.com.  

Footnotes

[1] Inclusive of low-risk patients who generally have preserved EF (>30%), no N-STEMI, controlled BP, normal mental status, creatinine <2.5 mg/dl, INR <1.8, does not require prolonged anti-coagulation post-procedure, hemodynamically stable, no allergies to ASA, has not received LMWH or thrombolytic therapy in the past 48-hours.

[2] Accessed through the website http://www.ptca.org/radial/ a resource for CV management staff and cardiologists seeking up-to-date information on TRI.

[3] Because same-day PCI discharge is not currently the standard of care in the U.S., each hospital program should have detailed inclusion/exclusion criteria in place.  Determining the definition of an appropriate patient requires a combination of what is defined in the literature and what is most appropriate for the individual needs of the specific patient.