Elective percutaneous coronary intervention (PCI) is a commonly performed procedure in the United States, with roughly 600,000 PCI procedures conducted annually. These procedures have the highest aggregate costs of all cardiovascular procedures (including cardiac surgery), and PCI also has the third-highest aggregate cost of any surgical procedure, estimated at about $10 billion annually.
And the costs of PCI for the United States exceed those for any other country, with the nation’s cost being almost twice as high as the average for Europe. There is increasing pressure on hospitals to improve the quality and value of their services, and in this environment, reducing the costs of elective PCI is an important opportunity to explore. In fact, alternative payment models, such as CMS’s episode payment models, commonly known as bundled payments, are influencing hospitals to prepare for the shift in payments from volume-based to value-based payment.
A relatively new approach to PCI that has been shown to improve patient outcomes, increase patient satisfaction and reduce costs involves transradial intervention (TRI), where vascular access is through the wrist rather than though the groin (i.e, transfemoral intervention), which was previously the default approach.
Impact of TRI on patient safety and bleeding risk
Use of TRI has demonstrated lower rates of mortality, bleeding, vascular access site complications (VASCs) and composite outcomes of major adverse cardiovascular events (MACE) and net adverse clinical events (NACE). In particular, data show safety benefits in the setting of acute coronary syndrome (ACS), when patients are at risk for bleeding complications related to receiving anticoagulation and antiplatelet agents. In targeted analyses of populations at high risk for procedural complications, including women, the elderly and the severely obese, radial access was shown to improve clinical outcomes.
Impact of TRI on patient satisfaction
Multiple randomized clinical trials comparing radial versus femoral access for angiography or PCI have shown consistent patient preference for radial over femoral access.
In a trial involving more than 7,000 patients (called the RIVAL trial), radial was preferred over femoral access for their next procedure by more than 70% of those surveyed. And in another trial, SAFE-PCI, women undergoing radial access for diagnostic angiography or PCI were more likely to prefer the same access route for their next procedure than women who underwent femoral access, though assessments with validated instruments showed no measurable difference in quality of life in radial versus femoral groups.
In yet another trial, conducted by Cooper et al, the vast majority of the trial’s 200 patients strongly preferred radial access. Patients rated radial access as being more comfortable than femoral access, and patients undergoing femoral access reported greater associated back pain and difficulty walking. Survey data investigating patient preference related to vascular access during cardiac catheterization showed that decreased risk of major bleeding was the top priority for satisfaction, followed by desires for decreased length of stay (LOS) and maximized post-procedural mobilization.
Impact of TRI on care pathways and SDD
SDD after elective PCI is a potential strategy for improving the value of PCI because it is associated with greater patient satisfaction and reduced costs. Despite observational and randomized data that demonstrate the safety of SDD, studies from 2004 to 2008 and 2009 to 2013 suggest a relatively modest uptake of this practice in the United States. These results are not surprising, as, to our knowledge, there have been few systematic efforts made toward implementing SDD after elective PCI, although emerging payment models may create an urgency to adopt this practice if it is safe and financially beneficial to hospitals.
6 trends requiring hospital leaders’ attention
However, revenue growth in the cardiac cath lab has declined, and margins are lower than previously. There are six reasons for this trend:
- The payment rate increases are generally below inflation rate and continue to decline.
- There is continued upsurge in staffing and technology expenses hospitals incur.
- As the aging population increases, government payers with low payment rate are growing and account for a larger proportion of overall business. Government payers comprised 55% of gross patient revenue in 2006, but that percentage increased to 61% in 2016.
- Private insurance carriers are gradually lowering their coverage or changing policies and practices around coverage for services such as outpatient imaging.
- Hospitals are also seeing contracting with insurers become more difficult, as these payers want to continually reduce payment rates.
- There is an ongoing movement of care away from traditional acute care hospitals (ACH) to ambulatory surgery centers (ASC) and office-based labs. The current administration has recommended that states consider scaling back or repealing Certificate of Need laws. If the states were to do so, it would become even easier for non-acute care facilities to perform cardiac procedures and further shift cardiac catheterization and PCI from ACH to ASC and office-based labs.
For all these reasons, hospital margins with both governmental and private payers are continuously declining. In this setting of declining payment rates, the shift toward outpatient care and an increased percentage of payment from government sources, the hospital cath lab faces serious revenue challenges that require the attention of hospital leaders. And how efficiently a cath lab is run could make a big difference to the overall cardiovascular service line and the hospital.
(See also the sidebar describing the broad trends driving the imperative for hospitals to revisit cardiac care.)
Benefits of TRI and SDD
Transradial intervention (TRI) and single-day discharge (SDD) after percutaneous coronary intervention (PCI) offer an important means for hospitals to address challenges posed by declining revenue growth in the cardiac cath lab. Through lower risk of bleeding and vascular access site complications (VASCs), earlier ambulation, and decreased length of stay (LOS), TRI results in cost savings and safety benefits for patients, payers, hospitals and the entire healthcare system. Using TRI to facilitate efficient peri-procedural care and SDD has resulted in enhanced patient satisfaction and cost savings. These benefits are well supported by findings of clinical trials.
Benefit in patients with high bleeding risk. Evidence points to the benefits of a TRI approach in patients at higher bleeding risk, as bleeding is a costly complication associated with longer LOS. In one analysis of internal admission cost data compiled from five PCI centers, the approach was performed in 17% of cases and was associated with decreased LOS, less bleeding and a total cost savings of $830 per admission when compared with transfemoral intervention. There was no significant difference in procedural cost. Further, 20% of the savings was attributed to decreased bleeding complications, and as a result, it was proposed that cost savings of utilizing TRI would be maximized in those with the highest risk of bleeding.
Benefit of cost savings. Institutional-level savings were confirmed in a nationally representative analysis of 672,470 elective PCIs across 493 U.S. hospitals in the Premier Healthcare Database. In this analysis, SDD was significantly more likely in institutions performing TRI approach 20.6% of the time (incidence rate ratio 1.45; 95% CI 1.40-1.50; p < 0.001). In the cost analysis, SDD was associated with an adjusted savings of $5,128 (95% CI $5,006-$5,248) per procedure with highest savings in the areas of central supply and reduced room and board costs. These savings came without consequence to clinical outcomes, as SDD was not associated with a higher rate of rehospitalization for bleeding, acute kidney injury (AKI) or myocardial infarction (MI), and there was no difference in post-discharge mortality. The high rates of inter-hospital variation illustrated that institutional practices, rather than solely patient attributes, may influence the treatment one receives. This variation decreased over the nine-year study period, but during this time, there was a range of SDD rate that varied from as low as 0% to as high as 83%, and practice variability was still high at the conclusion of the study. These variations emphasize the importance of deliberate, data-driven implementations for successful and safe SDD programs. Nationwide utilization of such a program with SDD rates as observed in the top decile were projected to save the healthcare system approximately $577 million annually based on National Cardiovascular Data Registry elective catheterization procedure volumes.
Benefit of improved patient satisfaction. Systematic implementation of SDD for elective PCI has been described as a potential strategy not only for improving fiscal value but also for improving patient satisfaction. In an observational analysis of patients undergoing elective PCI from Barnes Jewish Hospital in St. Louis, 99.3% of SDD patients were “extremely satisfied” with being discharged same day, and all these patients rated their overall care as “excellent care.” At follow-up, these SDD patients had zero adverse outcome events of mortality, bleeding, or VASC requiring treatment, and there was no difference in AKI. Implementation of the patient-centered SDD program was projected to result in single-institutional savings of $1.8 million annually based on end-of-study SDD and PCI rate and volume estimates. Cost savings were realized across all categories of medical costs, but the bulk of the saved costs were owed to decreases in variable direct costs including complications, lab tests, medications, medical and surgical supplies, and physician and nursing expenses.
Change needed for cath labs
In this environment, hospital leaders should seek to persuade physicians to adopt the new protocol, and urge them to move toward SDD. The body of published clinical evidence of its feasibility and safety is growing. Recently, the Society of Coronary Angiography and Intervention formulated an expert consensus document outlining the safety and effectiveness of SDD. Its combination of clinical and economic data provides the most effective means to encourage physicians to adopt and tailor new best practices to the appropriate patient population.
In conclusion, as hospital leaders contend with spiraling costs and declining payments, they also need to be mindful of the need for patient-centered care, reducing complications and achieving greater patient satisfaction in the cath lab. Acute care facilities have no choice but to prepare strategically for such a development. Redefining the care pathways in the cath lab is not optional; it is imperative. A patient-centered approach that mitigates risks, expedites safe and effective discharge and yields high-quality outcomes and patient satisfaction via coordinated care pathways needs to become the norm.
 Amin, A.P., Baklanov, D.V., Chhatriwalla, A.K., Safley, D.M., et al., “Costs associated with access site and same-day discharge among Medicare beneficiaries undergoing percutaneous coronary intervention: An evaluation of the current percutaneous coronary intervention care pathways in the United States,” JACC: Cardia Interventions, February 2017.
 Peterson, C.L., Burton, R., U.S. health care spending: Comparison with other OECD countries, Cornell University ILR School DigitalCommons@ILR, 2007.
 Valgimigli, M., Frigoli, E., Leonardi, S., Vranckx, P., et al., “Radial versus femoral access and bivalirudin versus unfractionated heparin in invasively managed patients with acute coronary syndrome (MATRIX): final 1-year results of a multicentre, randomised controlled trial,” The Lancet, Sept. 8, 2018.
 See Shroff, Adhir, “Review of the RIVAL trial,” Diagnostic and Interventional Cardiology, May 18, 2011; Rao, S.V., Hess, C.N., Barham, B, Aberle, L.H., et al., “A registry-based randomized trial comparing radial and femoral approaches in women undergoing percutaneous coronary intervention: the SAFE-PCI for Women (Study of Access Site for Enhancement of PCI for Women) trial,” JACC: Cardiological Interventions, Aug. 2014.
 Cooper, C.J.1, El-Shiekh, R.A., Cohen, D.J., Blaesing L., “Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison,” American Heart Journal, September 1999.
 U.S. Departments of Health and Human Services, Treasury and Labor, Reforming America’s Healthcare System Through Choice and Competition, Dec. 3, 2018.
 Amin, A.P., House, J.A., Safley, D.M., Chhatriwalla, A.K., et al., “Costs of transradial percutaneous coronary intervention,” JACC: Cardiovascular Interventions, August 2013.
 Amin, A.P., Pinto, D., House, M.S., Rao, S.V., et al., “Association of Same-Day Discharge After Elective Percutaneous Coronary Intervention in the United States with Costs and Outcomes,” JAMA Cardiology, November 2018.
 Amin, A.P., Crimmons-Reda, P., Miller, S., Rahn, B., et al., “Novel Patient‐Centered Approach to Facilitate Same‐Day Discharge in Patients Undergoing Elective Percutaneous Coronary Intervention,” Journal of the American Heart Association, Feb. 20, 2018.
 Seto, A.H., Shroff, A., Abu‐Fadel, M., et al., “Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheterization and Cardiovascular Interventions,” Wiley Online Library, April 24, 2018.