Transradial PCI: A Handy Way to Reduce Costs
If you want to increase the bottom line for your practice or hospital, think twice about instituting a transradial PCI program. But if you want to lower costs, free up resources and position yourself for a possible shift in reimbursement toward outpatient care and quality incentives, then developing expertise in transradial access will pay dividends, proponents of the procedure say.
Transradial PCI offers a number of economic advantages, but in the U.S., reimbursement is not one of them, says Sunil V. Rao, MD, an interventional cardiologist at Duke University Medical Center and director of the cardiac catheterization laboratories at the Durham Veterans Affairs Medical Center, both in Durham, N.C. "The reimbursement scheme does not discriminate by access site," explains Rao, whose preferred method for PCI is the radial approach. "But there is an indirect benefit."
Transradial PCI uses a vascular access technique that requires a steeper learning curve than the femoral approach favored in the U.S. But anatomically, the radial artery is an attractive access site because it runs closer to the skin than does the femoral artery, and is well separated from major veins and nerves. As a consequence, transradial PCI in some studies is associated with fewer bleeding and vascular complications, allowing patients to be ambulatory more quickly. That, in turn, may lead to lower hospital costs and shorter hospital lengths of stay.
"From an economic standpoint, the two most helpful patient categories for transradial are patients at high risk for bleeding and patients who will go home the same day as the PCI," says Ronald P. Caputo, MD, director of interventional cardiology research at St. Joseph's Hospital in Syracuse, N.Y. "Patients who are most at risk for bleeding are patients with an acute coronary syndrome [ACS], especially after an acute MI."
An analysis by Kugelmass et al found that vascular access complications in Medicare patients who underwent PCI contributed to $4,278 in adjusted incremental hospital costs (Am J Cardiol 2006;97:322-327). A study by Chase et al concluded that patients who underwent the femoral approach were twice as likely to need a transfusion than were patients who received a radial procedure (Heart 2008;94:1019-1025).
And transfusions carry a big price tag. In an analysis of two medical centers, Maloney and colleagues calculated that a post-PCI transfusion event adds on average 9.1 hospital days and associated hospital costs of $25,094 onto the PCI admission.
To put those costs in another context, Caputo estimates that charges for interventions might include $473 for a unit of blood in a transfusion or $1,680 for a half hour in an operating room.
With the radial approach, hemostasis can be achieved using bandages and pressure, which is easier, quicker and more comfortable for the patient than with the femoral approach, Caputo and Rao say. The use of vascular closure devices with the femoral approach may speed up recovery, but with an added cost of the device.
"The reduction in complications ultimately translates into a more cost-effective and sometimes cost-saving procedure because you reduce the amount of time the patient is in the hospital," argues Rao. "At a large population level, when you reduce the complications, then you reduce the number of tests and the number of days in the hospital."
Currently, inpatient PCI—where a patient remains in the hospital for more than 23 hours after admission—is reimbursed under Medicare at a higher rate than outpatient PCI—where the patient is discharged within 24 hours. But Caputo and Rao say federal efforts to lower costs while improving efficiencies and outcomes make outpatient PCI for treating less complicated patients a compelling option for payors.
"If you have bundled payment coupled with quality metrics such as pay for performance, physicians will have an economic incentive to provide efficient and high-quality care," Caputo notes. "That is where transradial will impact physician reimbursement. We were concerned before, but not from an economic standpoint. Now there will be an economic concern associated with our performance."
Transradial PCI offers a number of economic advantages, but in the U.S., reimbursement is not one of them, says Sunil V. Rao, MD, an interventional cardiologist at Duke University Medical Center and director of the cardiac catheterization laboratories at the Durham Veterans Affairs Medical Center, both in Durham, N.C. "The reimbursement scheme does not discriminate by access site," explains Rao, whose preferred method for PCI is the radial approach. "But there is an indirect benefit."
Transradial PCI uses a vascular access technique that requires a steeper learning curve than the femoral approach favored in the U.S. But anatomically, the radial artery is an attractive access site because it runs closer to the skin than does the femoral artery, and is well separated from major veins and nerves. As a consequence, transradial PCI in some studies is associated with fewer bleeding and vascular complications, allowing patients to be ambulatory more quickly. That, in turn, may lead to lower hospital costs and shorter hospital lengths of stay.
"From an economic standpoint, the two most helpful patient categories for transradial are patients at high risk for bleeding and patients who will go home the same day as the PCI," says Ronald P. Caputo, MD, director of interventional cardiology research at St. Joseph's Hospital in Syracuse, N.Y. "Patients who are most at risk for bleeding are patients with an acute coronary syndrome [ACS], especially after an acute MI."
Costs and complications
In an analysis of data on 593,094 radial and femoral PCI procedures in the National Cardiovascular Data Registry, Rao and colleagues found that 0.19 percent of the radial group developed vascular complications, compared with 0.70 percent in the femoral access group, and 0.79 percent had bleeding complications compared with 1.83 percent in the femoral group. Both groups had similar procedural success rates. The results held up if the patients were elderly, women or had ACS (J Am Coll Cardiol Intv 2008;1;379-386). More recently, results from the RIVAL study, presented at ACC.11, showed a 60 percent reduction in vascular complications in the radial group, but no significant difference in major non-CABG bleeding.An analysis by Kugelmass et al found that vascular access complications in Medicare patients who underwent PCI contributed to $4,278 in adjusted incremental hospital costs (Am J Cardiol 2006;97:322-327). A study by Chase et al concluded that patients who underwent the femoral approach were twice as likely to need a transfusion than were patients who received a radial procedure (Heart 2008;94:1019-1025).
And transfusions carry a big price tag. In an analysis of two medical centers, Maloney and colleagues calculated that a post-PCI transfusion event adds on average 9.1 hospital days and associated hospital costs of $25,094 onto the PCI admission.
| Vascular Complications: Sample of Associated Costs (Exclusive of Length of Stay) | |
| Femoral duplex ultrasound | $243 |
| CT abdomen w/o contrast | $586 |
| CT pelvis w/o contrast | $586 |
| Hemoglobin/Hematocrit x 3 | $138 |
| 1 unit PRBC transfusion cost | $473 |
| Thrombin injection for femoral artery | $667 |
| Operating room charge per 30 minutes | $1,680 |
| PRBC=Packed red blood cell. Representative Hospital Charges: N.E. United States Source: Ronald P. Caputo, MD |
To put those costs in another context, Caputo estimates that charges for interventions might include $473 for a unit of blood in a transfusion or $1,680 for a half hour in an operating room.
With the radial approach, hemostasis can be achieved using bandages and pressure, which is easier, quicker and more comfortable for the patient than with the femoral approach, Caputo and Rao say. The use of vascular closure devices with the femoral approach may speed up recovery, but with an added cost of the device.
Efficient use of resources
Faster recovery means patients may be on their feet sooner, freeing up resources such as staff and hospital beds. One study from Italy, for instance, showed that the workload for nurses was lighter when patients underwent a radial PCI, with cath lab and ward nurses putting in 88 fewer minutes and 334 fewer minutes, respectively, for a radial case (Euro J Cardiovasc Nursing 2005;4:234-241). A study based on transradial PCI patients in Quebec who were randomized to either a same-day discharge and no infusion or an overnight hospital stay and a 12-hour infusion of abciximab (ReoPro, Eli Lilly) therapy pegged outpatient savings at $1,141 Canadian ($1,127 U.S.) per patient (Eur J of Cardiovasc Nurs 2005;4:234-241)."The reduction in complications ultimately translates into a more cost-effective and sometimes cost-saving procedure because you reduce the amount of time the patient is in the hospital," argues Rao. "At a large population level, when you reduce the complications, then you reduce the number of tests and the number of days in the hospital."
Currently, inpatient PCI—where a patient remains in the hospital for more than 23 hours after admission—is reimbursed under Medicare at a higher rate than outpatient PCI—where the patient is discharged within 24 hours. But Caputo and Rao say federal efforts to lower costs while improving efficiencies and outcomes make outpatient PCI for treating less complicated patients a compelling option for payors.
"If you have bundled payment coupled with quality metrics such as pay for performance, physicians will have an economic incentive to provide efficient and high-quality care," Caputo notes. "That is where transradial will impact physician reimbursement. We were concerned before, but not from an economic standpoint. Now there will be an economic concern associated with our performance."
| Radial PCI Ramps Up in U.S. |
| Transradial PCI is prevalent in Europe and other regions, but use of the procedure has been slow to gain traction in the U.S. Two oft-cited reasons for the lag in the U.S. are challenges in becoming proficient in the technique and operator concerns that data supporting its use may not represent practices and patients in the U.S. The learning curve is steep. Estimates of the number of cases needed to be efficient and competent range from 50 to 150 (Circ Cardiovasc Interv 2011;4;336-341 and J Am Coll Cardiol 2011;58;B141). Ronald P. Caputo, MD, director of interventional cardiology research at St. Joseph's Hospital in Syracuse, N.Y., argues that in the past, lack of U.S. training programs hampered both interest and capabilities, but in recent years, access to training venues has grown, creating a snowball effect. "For transradial PCI, we have seen utilization go from 1 to 1.5 percent to 15 percent in three years," Caputo says, citing unpublished trends tracked through the National Cardiovascular Data Registry database. "We may end up being 30 to 40 percent transradial utilization, similar to what you see in Canada." Greater utilization is helping to provide the volume needed to conduct a U.S.-based trial. Sunil V. Rao, MD, an interventional cardiologist at Duke University Medical Center and director of the cardiac cath labs at Durham VA Medical Center, both in Durham, N.C., is leading the SAFE PCI for Women trial. The multi-center study will randomize up to 3,000 women undergoing elective or urgent PCI to the transfemoral or transradial approach to compare the efficacy and feasibility of transradial PCI. Women have smaller radial arteries, making them potentially more vulnerable to procedural failures. But they also have higher rates of bleeding complications and may have better outcomes with the radial approach. "Females turned out to be an open question," explains Rao. "We don't know if we can substantially reduce bleeding, and if we can get the procedure appropriately done in women. Heart disease is the number one killer of women, but we don't do a lot of clinical trials in women." Evaluating the procedure in patient populations, such as women, may also serve to increase adoption if it proves that the approach is safe and efficacious. |