TCT 2017: Physicians explore economic merits of minimalist approach to TAVR, ‘prehab’ programs

Transcatheter aortic valve replacement (TAVR) scored a massive victory Oct. 31 when a cost-effectiveness analysis revealed it was the “economically dominant” strategy compared to surgical aortic valve replacement (SAVR) for patients at intermediate surgical risk.

However, that analysis focused on the societal costs of the procedures. Hospitals are still struggling to make money off TAVR, which is exploding in popularity but has higher procedural costs than SAVR—mostly due to more expensive valves.

During the Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium, Michael J. Rinaldi, MD, showed a survey of 92 health systems in which 52 percent reported an average negative margin on TAVR procedures. In an hour-long session, Rinaldi and other experts agreed shortening hospital stays and reducing the number of days spent in the intensive care unit (ICU) are key aspects in making TAVR more profitable for hospitals.

In the cost-effectiveness analysis presented by David J. Cohen, MD, MSc, for example, TAVR was associated with a 4.6-day length of stay versus SAVR’s 10.9 days.

“Because length of stay has dropped dramatically, that does a couple of things,” said Rinaldi, with Carolinas Medical Center in Charlotte, North Carolina. “It doesn’t just reduce your costs, but it also increases your access. My hospital is always at 120 percent capacity, so we’re always fighting for beds. If you’re increasing volume in the hospital, unless you figure out a way to get patients out quicker, you’re not going to be able to accommodate that volume.”

Rinaldi said even though upfront costs are higher with TAVR, administrators should be reassured by downstream revenue opportunities associated with the procedure. CT scans, heart catheterizations and echocardiographies are commonly required during follow-up care, “all the kinds of things that traditionally come with significant margin for the hospital,” Rinaldi said.

Minimalist approach

Cardiologist J. Bradley Oldemeyer, MD, followed Rinaldi’s presentation by detailing his experience with a minimalist approach to TAVR.

Adopted in June 2015 at Medical Center of the Rockies in Loveland, Colorado, the approach resulted in an average procedural time reduction of 20 minutes and an average cost savings of $6,200 per case ($51,800 for the standard approach vs. $45,600 for minimalist approach).

“We describe the minimalist best practice as the treatment of patients utilizing only those adjuncts required to safely and expeditiously complete the intervention and provide optimal post-procedural care,” Oldemeyer said. “So, we look at each aspect of each procedure and say is it necessary, what does it add and can we get rid of it?”

Some of the procedural changes, Oldemeyer said, were the use of moderate sedation rather than general anesthesia, the elimination of transesophageal echocardiography (ECG) and the removal of internal jugular lines and radial artery lines in most cases.

In addition, the patients recovered in the post-anesthesia care unit (PACU) rather than the ICU and were quickly transferred to a step-down unit. Hospital employees attempted to get the patients up and walking six to eight hours after the procedure.

Discharge planning was handled the day of the procedure and all labwork, ECGs and physical therapy (PT)/occupational therapy (OT) was completed before noon the following day, with a follow-up appointment scheduled within a week. Oldemeyer reported hospital length of stays were cut from 6.8 days with the standard approach to 1.7 days with the minimalist approach.

“It takes a lot of physician oversight to do this. Between subsequent TAVRs we go and we make sure they’re out of bed and they’re moving,” he said.

But it’s worth the extra work.

“If the patient is up and walking in six hours they really don’t need extensive PT and OT and that gets them home earlier,” he said.

Can ‘prehab’ further improve outcomes and reduce length of stay?

James E. Harvey, MD, a cardiologist based in York, Pennsylvania, is testing another way to potentially improve patients’ post-TAVR recovery.

He is part of a team that has enrolled 50 percent of patients into a clinical trial evaluating whether pre-TAVR physical therapy can improve outcomes—which could, in turn, reduce associated complications and hospital length of stays.

The idea came when Harvey spoke with a physical therapist who argued against sending a patient home because of abnormalities in his gait.

“You should’ve seen him three weeks ago! This is the best he’s ever looked,” Harvey recalled saying.

“It was very clear that there was a disconnect between the preprocedural baseline function at home and the physical therapy and occupational assessment of function,” he continued. “We started chewing on this and we came up with this idea: Can preprocedural physical therapy result in improved TAVR outcomes? … Can you change their frailty or somehow augment the patient ahead of time to result in improved outcomes afterwards?”

Harvey pointed to a previous trial that showed preprocedural physical therapy decreased ICU and hospital stays in coronary artery bypass graft patients, improved their physical functioning after surgery and reduced post-operative complications. He noted monitored exercise testing is safe even for patients with aortic stenosis who may be candidates for TAVR.

And while it’s too early to say whether the ‘prehab’ method leads to better outcomes, Harvey said the patients already enrolled in the trial love the concept. Some reported feeling empowered.

“It’s an incredibly vulnerable feeling to walk into surgery,” he said. “You feel powerless and you feel completely out of control. We gave them something to do that they were working towards their own health, they were part of the team. They were charged up and ready to go. … We obviously have to look at the clinical outcomes and the economic outcomes, but I can tell you that it made a dramatic difference in that patient’s life going into the procedure and afterward.”