Radial-Access, Same-Day-Discharge PCI Could Save US Millions

Patrice Wendling

February 23, 2017

ST LOUIS, MO — A modest 30% shift shift from femoral-access PCI to transradial-access with same-day discharge for stable patients undergoing elective PCI could save US hospitals about $332 million annually, a new study indicates[1].

Consistent with prior randomized and observational data, transradial-access PCI was was also associated with fewer complications than a transfemoral approach.

"I believe this is a remarkable paper that has the potentially to fundamentally transform how we practice and change the delivery of PCI care in this country," lead author Dr Amit P Amin (Washington University School of Medicine, St Louis, MO) told heartwire from Medscape in an email.

Commenting to heartwire , Dr Robert Harrington (Stanford University, CA), who was not involved in the study, said in an email the data are consistent with prior reports, but the nonrandomized nature of the analyses and cost data based on modeling exercises are limitations. Still, a reasonable assumption is that at least some cost saving should occur with a practice switch.

He added, "Overall, we should be moving more aggressively toward a transradial approach in cath and PCI. The continuing accumulation of clinical and now cost data support this."

The analysis also demonstrates just how far contemporary US practice is from realizing the potential cost savings foreseen with transradial  same-day-discharge PCI. Among the 279,987 Medicare beneficiaries eligible for same-day discharge in the analysis, only 9% underwent transradial PCI, and just 5.3% were sent home the same day.

Amin said there's a perception that transradial PCI is more technically challenging but that these challenges may be easily overcome given the technological and engineering advances made over the past decade.

Higher radiation exposure to cath-lab staff is seen as another barrier, and "there is some truth to this," he said, noting that prior studies have shown slightly longer procedure and fluoroscopy time and radiation dose. This occurs mostly in the initial phase of the learning curve, however, and as operators become more proficient, radiation dose is equivalent between the transradial and transfemoral approaches.

"We certainly hope that professional societies and guidelines will reassess the accumulating body of literature on the safety of transradial and same-day discharge and provide guidance and direction to physicians, hospitals, and healthcare systems on how to deliver 'high-value care' of superior outcomes at lower healthcare costs," Amin said.

The study was published in the February 27, 2017 issue of JACC: Cardiovascular Interventions.

The investigators linked Medicare claims data to the nearly 280,000 patients who underwent PCI between July 2009 and December 2012 in the US NCDR CathPCI Registry. Propensity-score matching and inverse probability weighting were used to estimate hospital costs, inflated to 2014 dollars.

They found that using transradial rather than transfemoral access saved $916 per patient after risk adjustment ($15,786 vs $16,701; P<0.001).

Similarly, adjusted costs were $3502 lower with same-day discharge than when patients were kept overnight ($13,256 vs $16,753; P<0.001).

Combining the two strategies resulted in an adjusted cost saving of $3689 for hospitals when compared with a transfemoral approach without same-day discharge, the current most common pathway.

The investigators calculated that for a hospital performing 1000 elective PCI procedures each year, a 30% conversion from the current pathway to transradial same-day discharge could potentially save the hospital $1 million annually.

Harrington said moving the US to a 30% conversion "will require a major educational effort for US interventionalists" given low current uptake.

Some of this is generational and so should increase over time as more recently trained interventionalists enter practice, but, he added, "These costs of a temporary decrease in efficiency need to be considered as well."

As regards to safety, transradial compared with transfemoral interventions were associated with less in-hospital bleeding (1.4% vs 3.0%), transfusions (0.5% vs 1.2%), and vascular complications (0.2% vs 0.4%; P<0.0001 for all).

The authors note that the reduction in bleeding with transradial PCI was achieved despite frequent use of other bleeding-avoidance strategies such as bivalirudin (51%) and closure devices (58%) in the transfemoral group.

In an accompanying editorial[2], Dr Joseph Ladapo (David Geffen School of Medicine, University of Los Angeles, CA) cautions about selection bias in the analysis, noting that patients most likely to undergo transradial PCI and same-day discharge are the least complicated, lowest-risk patients.

He suggests the cost savings are "perhaps smaller in magnitude" than estimated by the authors and notes that in the postelection landscape of payment-targeted healthcare reform, PCI is "a prime example of the type of procedure that should be sensitive to policy changes that affect costs."

PCI is performed some 954,000 times annually in the US and leads national expenditures for cardiovascular procedures, with several billion dollars in direct expenditures.

Ladapo concludes, "To the extent that accountable-care organizations and bundled-payment reforms increase cost awareness among physicians and hospitals, studies like Amin et al's are critical to informing professional society guidelines and helping physicians, hospitals, and health systems provide high-quality care while constraining growth in healthcare costs."

The study was supported by a research grant from Vita Solutions, a subsidiary of the Medicines Company. Amin reports funding from the Clinical and Translational Science Award program of the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) and the National Cancer Institute of the NIH; receiving a research grant from Volcano Corporation; and consultancy for the Medicines Company, Terumo, and AstraZeneca. Disclosures for the coauthors are listed in the paper. Ladapo reports receiving support for his work from the National Heart, Lung, and Blood Institute and the Robert Wood Johnson Foundation.

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