Effects on Cost and Resource Use

1. Transradial Angiography and Intervention
EFFECTS ON COST
AND RESOURCE USE
Adhir Shroff, MD, MPH, FACC, FSCAI
Associate Professor of Medicine
University of Illinois-Chicago

2. TR Angiography and Intervention: Effects on Cost and Resource Use
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Disclosures
• I have received unrestricted educational grants
from:
▫ Cook Medical
▫ St. Jude Medical, Inc
▫ Terumo Medical
▫ Medical Concepts Development
▫ Boston Scientific Corporation
▫ Teleflex
• I serve as a consultant to Terumo, the Medicines
Company, and Abiomed
Adhir Shroff, MD, MPH
Associate Professor of Medicine

3. TR Angiography and Intervention: Effects on Cost and Resource Use
3
Agenda
• Economic stakeholders
• Impact of TR on resource utilization
▫ Bleeding
▫ Staff workload
▫ Improved efficiency
• Same-day PCI discharge program: Economic
implications
Adhir Shroff, MD, MPH
Associate Professor of Medicine

4. TR Angiography and Intervention: Effects on Cost and Resource Use
4
Missed Opportunities to Realize Cost Savings and
Efficiencies: Key Considerations in Adapting Care Delivery for OP s
Suboptimal Operations Overlooked Clinical Solutions
Ad-hoc Scheduling Bleeding, Access Site
Outpatients scheduled throughout Complications
day, leading to lengthy LOS Bleeding complications contribute
to excess costs and extended stay
Untailored Care Protocols
Identical inpatient and outpatient
care fails to account for lower acuity Missed Clinical Advancements
of outpatients Radial access and closure devices
have made significant advances in
expediting ambulation
Undefined Inclusion/Exclusion
Criteria
No hardwired criteria to determine Unaccommodated
patient status Comorbidities
Obesity and diabetes require
Inefficient Discharge extended care and often are not
Outpatients often occupy beds accounted for during pre-procedure
longer than clinically necessary, planning
adding to overhead costs Slide courtesy of Terumo
Adhir Shroff, MD, MPH
Associate Professor of Medicine

5. TR Angiography and Intervention: Effects on Cost and Resource Use
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Here is what we know…
• Access site closure is very reliable
• Less bleeding complications with TR procedures
• Earlier mobilization of the patient following the
procedure
How do these facts impact resource
utilization?
Adhir Shroff, MD, MPH
Associate Professor of Medicine

6. TR Angiography and Intervention: Effects on Cost and Resource Use
6
Economic Stakeholders
• Shorter recovery time
Patient • Return to work
• Less complications
• Potential to increase referral
Physician base
• Improve case turnover
• Improved through-put
Cath lab/Medical • Less staff utilization
Center • +/- Complications
• Less complications
Payor/Society • Return to work
Adhir Shroff, MD, MPH
Associate Professor of Medicine

7. TR Angiography and Intervention: Effects on Cost and Resource Use
7
Choice of Vascular Access:
Cost of Post-PCI Complications
• Transradial catheterization decreases bleeding
complications
• Bleeding complications have a profound
economic impact on the medical center and
payors (and of course the patient and physician)
Adhir Shroff, MD, MPH
Associate Professor of Medicine

8. TR Angiography and Intervention: Effects on Cost and Resource Use
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Choice of Vascular Access:
Cost of Post-PCI Complications
Medicare beneficiaries (2002)
90.5%
Am J Cardiol 2006;97: 322-327
Adhir Shroff, MD, MPH
Associate Professor of Medicine

9. TR Angiography and Intervention: Effects on Cost and Resource Use
9
Choice of Vascular Access:
Cost of Post-PCI Complications
Length of Stay
Am J Cardiol 2006;97: 322-327
Adhir Shroff, MD, MPH
Associate Professor of Medicine

10. TR Angiography and Intervention: Effects on Cost and Resource Use
10
Cost of Post-PCI Bleeding
GUSTO Trial (IIb)
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
Mild Moderate Severe
Bleeding Bleeding Bleeding
Qual Saf Health Care 2007;16:154–159 J Am Coll Cardiol 2008;52:1758–68 Am Heart J 2008;155:369-74
Adhir Shroff, MD, MPH
Associate Professor of Medicine

11. TR Angiography and Intervention: Effects on Cost and Resource Use
11
Impact of Bleeding on Survival post-PCI
HR: 1.6
HR: 2.7
HR: 10.6
Am J Cardiol 2005;96:1200 –1206
Adhir Shroff, MD, MPH
Associate Professor of Medicine

12. TR Angiography and Intervention: Effects on Cost and Resource Use
12
Choice of Vascular Access:
Resource Utilization
• Nurse staffing represents an • 200 consecutive patients
important component of • Dx and PCI cases
resourse consumption • Cath lab nursing work load:
• Small shifts in nurse staffing ▫ Mean: 103 min
can account for large shifts in ▫ TR: 86 min
expenses ▫ TF: 174 min
• Non-randomized study from
174
Italy
103
• Diagnostic and/or 86
interventional procedures
Eur J Card Nursing 4(2005) 234-241
Adhir Shroff, MD, MPH
Associate Professor of Medicine

13. TR Angiography and Intervention: Effects on Cost and Resource Use
13
Choice of Vascular Access:
Resource Utilization
• 200 consecutive patients
• Dx and PCI cases
• Ward-staff work load for
generic tasks :
▫ TR: 86 min
▫ TF: 174 min
• For generic + medical
care tasks:
174 ▫ TR: 386 min
86 ▫ TF: 720 min
Eur J Card Nursing 4(2005) 234-241
Adhir Shroff, MD, MPH
Associate Professor of Medicine

14. TR Angiography and Intervention: Effects on Cost and Resource Use
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Choice of Vascular Access:
Resource Utilization
p<0.01
100
p<0.01 91.7 • At UIC/JBVA, we do
90
TF ~2000 diagnostics
80 72.5 TR and 500 PCI
70
• TR access will save:
60 54.6
Minutes
▫ 596 hrs (dx)
50 47.2
▫ 393 hrs (PCI)
40 • Total 989 hrs x $48.50
30 • ~$50,000/yr
20
10
0
Diagnostic PCI
Schaufele TG. RAPTOR. AHA 2009
Adhir Shroff, MD, MPH
Associate Professor of Medicine

15. TR Angiography and Intervention: Effects on Cost and Resource Use
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Choice of Vascular Access:
Costs of Diagnostic Catheterization
p<0.05
$370 $447 $553
J Inv Cardio 2007; 19: 349-353
Adhir Shroff, MD, MPH
Associate Professor of Medicine

16. TR Angiography and Intervention: Effects on Cost and Resource Use
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Economic Impact and Marketing Opportunities
Adhir Shroff, MD, MPH
Associate Professor of Medicine

17. TR Angiography and Intervention: Effects on Cost and Resource Use
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Finding the Balance Between IP and OP PCI
• Patient Acuity a Major Factor in Determining Outpatient Shift
Outpatient shift potential
Case distribution
TRI has tremendous
Percentage of future growth
Cases Eligible potential
to Move
Outpatient
Shaded region represents
outpatient cases
Low Relative Patient High
Acuity
Relationship Between Acuity, Case Distribution, and Outpatient Shift
Source: Cardiovascular Roundtable interviews and analysis.
Adhir Shroff, MD, MPH
Associate Professor of Medicine

18. TR Angiography and Intervention: Effects on Cost and Resource Use
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Choice of Vascular Access:
Same-Day PCI Discharge Program
EASY Trial
Same-day 8.9hrs
discharge DC C$1004
(No infusion)
Uncomplicated
TR-PCI with
abciximab ®
bolus
26.5 hrs
Overnight
stay DC C$3117
(+ infusion)
Average savings of C$2,113 per patient with same-day d/c
Circulation. 2008;118:S_1119
Adhir Shroff, MD, MPH
Associate Professor of Medicine

19. TR Angiography and Intervention: Effects on Cost and Resource Use
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Cost Analysis: MSDRG 247
• PCI with DES w/o MCC (low acuity case)
• Most comparable to OP case
• DIRECT costs: $1434 difference btwn 1d and 2d
LOS (Medicare 2008)
▫ ~$60/hr/patient in savings
• TOTAL Costs: $2428 difference between 1d and
2d LOS
▫ ~$101/hr/patient in savings
Analysis by the Cardiovascular Roundtable
Adhir Shroff, MD, MPH
Associate Professor of Medicine

20. TR Angiography and Intervention: Effects on Cost and Resource Use
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Choice of Vascular Access:
Our Economic Basis for Same-Day PCI Discharge
• In the VA system, there is an economic cost to
keeping patient in the hospital
• At the University, we found:
▫ Medicare/aid does not reimburse for observation
costs therefore no difference in reimbursement
for 23hr obs vs. 8hr obs
▫ Among private insurers, only a 6% difference in
total payment to UICMC for a 23hr obs vs. 8hr
obs stay
▫ Clearing the bed for other patients was the priority
Adhir Shroff, MD, MPH
Associate Professor of Medicine

21. TR Angiography and Intervention: Effects on Cost and Resource Use
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Impact of Same Day PCI Discharge at UIC
–Financial Model
Total Observatio Payment Payment Change
Charges n Charges for 23hr for 8hr
Commercial $134,140 $7,592 $70,468 $67,176 $3292
Payer (n=4) (5%)
Government $105,685 $5,504 $18,577 $18,577 0
Payer (n=4) (0%)
Adhir Shroff, MD, MPH
Associate Professor of Medicine

22. TR Angiography and Intervention: Effects on Cost and Resource Use
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Building and Marketing a Same Day DC Program
Designing Around the Attracting Savvy Consumers
Ambulatory Experience
Staffed by dedicated RNs familiar Building off of word-of-
with radial access, focused on mouth marketing
expedited discharge through patients
Fast and
Efficient
Heart
Care
Lounge equipped Direct-to-consumer
Patients recover marketing materials
sitting upright in with WiFi, TV,
reading materials emphasize efficiency of
lounge chairs care
Source: St. Joseph s Health System, Atlanta, GA
Cardiovascular Roundtable interviews and analysis.
Adhir Shroff, MD, MPH
Associate Professor of Medicine

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Photo courtesy of Chris Savas
Radial Lounge
St Joseph s Hospital (Atlanta, GA)
Adhir Shroff, MD, MPH
Associate Professor of Medicine

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Conclusions
• Primary economic driving force for TR is a
decrease in bleeding events
• Decreased nursing/staff workload will
contribute to decreasing costs
• Improved efficiency (including same-day PCI
programs) may also yield important savings
Adhir Shroff, MD, MPH
Associate Professor of Medicine

25. TR Angiography and Intervention: Effects on Cost and Resource Use
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Thank you…
Adhir Shroff, MD, MPH
Associate Professor of Medicine