1.
Value Driven Care for the Cardiac Cathlab
with Transradial PCI
Amit Amin MD MS,
Washington University School of Medicine, St. Louis, MO

2.
Conflicts of Interest
• I have no conflict of interest to declare

3.
Transradial PCI is Rapidly Increasing in
the United States

4.
Exorbitant Costs of Coronary Disease Care
in the United States
$10 Billion
$6.4 Billion
0
2
4
6
8
10
12
PCI Cost CAD hospitalization
US$(Billions)
Annual Costs
Centers for Medicare and Medicaid, CAD white paper, version date 5/20/16

5.
From CMS…
• “This lack of incentives for delivering high-
value care across the continuum of CAD too
often results in higher than necessary rates of
adverse events, hospital admissions and re-
admissions, and lack of appropriate preventive
services and follow-up for patients with CAD.”

6.
CMS’s Aggressive Goal of Alternative
Payment Models (APMs)

7.
• Time critical change

8.
Newer payment changes on the
horizon…
• Will transform the delivery of PCI
• Requires physicians and administrators to
engage and understand what drives outcomes
AND costs !!

9.
Risk and Complexity of PCI Patients is
Increasing
• Comorbidities are on the rise

10.
Risk and Complexity of PCI Patients is Increasing

11.
Outcomes
• Persistently poor
• Large degree of variation in practices
• Large variation in outcomes
• Large variation in costs

12.
Large Variation in Costs of PCI across US Hospitals
$0
$10,000
$20,000
$30,000
$40,000
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100103106109112115118121124127130133136139142145148151154157160163166169172175178181184187190193196199202205208211214217220223226229232235238241244247250253256
MeanhospitalPCIcosts($)
Hospitals ranked in ascending order of their PCI costs
Variation in Hospital Costs of PCI
32% of the variation in PCI costs was explained
by ‘hospitals’ alone, despite extensive
adjustment of patient level factors
Amin AP et al. AHA QCOR conference 2015

13.
Hospitals are struggling
-20%
-15%
-10%
-5%
0%
5%
10%
15%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Hospital Medicare Margins
IP OP Overall
Source: MedPAC report March 2015

14.
Very Challenging to Provide “High
Value Care” when Risk is High

15.
Methods
Amin AP et al. JACC Cardiovasc Interv. 2013 Aug;6(8):827-34.

16.
Adjusted Costs of Radial PCI:
From 5 US Hospitals
$14,954
$15,784
$14,000
$14,500
$15,000
$15,500
$16,000
Radial Femoral
P < 0.001
Δ $ 830 favoring radial PCI
Amin AP et al. JACC Cardiovasc Interv. 2013 Aug;6(8):827-34.

17.
Current Hospital Costs of PCI:
the PCI Care Pathway
Amin AP et al. Accepted for Publication JACC Intv. 2016

18.
Δ $ 3,600 favoring radial SDD PCI
Current Hospital Costs of PCI:
the PCI Care Pathway
Amin AP et al. Accepted for Publication JACC Intv. 2016

19.
Cost savings to a hospital performing 1,000 elective PCI procedures
annually, when converting from the current pathway of TFI NSDD to
TRI SDD
Amin AP et al. Accepted for Publication JACC Intv. 2016

20.
What we did at Barnes Jewish Hospital

21.
Market Leader in St. Louis Metropolitan Area
U.S. News & World Report “Best Hospitals in
America” Honor Roll for 22 Consecutive Years
During 2014:
• 955,986 OP visits
• 1,167 Staffed Beds
• 57,718 Inpatient Admissions
• 47,299 Surgeries
Heart & Vascular Program Ranked #15 via U.S.
News & World Report

22.
PCI Outcomes at BJH before we
started….
• Excellent Mortality
• Excellent STEMI D2B
• However, a high rate of
bleeding complications
10.37%
8.87%
7.13%
8.96%
8.23%
7.79%
8.20%
0%
2%
4%
6%
8%
10%
12%
Q1 Q2 Q3 Q3 Q1 Q2 Q3
2011 2011 2011 2011 2012 2012 2012
PCI related Bleeding Events (%)
NCDR Avg 4.43%

23.
Patient Centered Approach in the
Cathlab
• We predict patient-specific risk via a software
solution (ePRISM)
• We target those at the highest risk with
evidence based safe therapies – the goal is to
achieve high reliability

24.
Consistent attention to patient specific
risks, each case, each time

25.
Impact on Hospital Efficiency and
Costs

26.
Rapid Uptake of Radial Access for PCI
0%
10%20%30%40%
2013 2014 2015
1 2 3 4 5 6 7 8 9101112 1 2 3 4 5 6 7 8 9101112 1 2 3 4 5 6 7 8 9101112

27.
Bleeding Events Have Reduced

28.
Mortality Has reduced

29.
BJH Same Day Discharge Program

30.
Same Day Discharge (~80%) has reduced
LOS and Cost
• Our unique “patient-centered approach” to SDD:
• Provides us the ability to perform SDD even when
PCI complexity is high

31.
68%
63%
26%
36%
67%
20%
28%
18%
0%
20%
40%
60%
80%
Type C
lesion
Long
lesion >
20 mm
SVG graft Diabetes CHF CVD PVD COPD
Prevalence of Comorbidities and Lesion
Complexity among Same Day Discharges

32.
Predicted Risks of Bleeding, Mortality
and AKI

33.
Patient Satisfaction is High with SDD
19%
82%
12%
88%
0%
25%
50%
75%
100%
Excellent
Care - No
Excellent
Care - Yes
Extremely
Satisfied - No
Extremely
Satisfied -
Yes

34.
Lower Spend with SDD

35.
PCI Cost Per Case by DRG (Medicare Pts Only):
BJH has lower spend than most hospitals
BJH Hospital National Avg

36.
Total Cost Savings Annually ~ $5 Million
Savings from a reduction in PCI complications $1,235,000
Increased revenue from improved outcomes (QHIP) $884,000
Increased revenue from Medicare (VBP) program $600,000
Savings from Same Day Discharge (SDD) program $452,000
Savings on PCI medications / Pharmacy savings $494,000
Estimated total savings $3,665,000

37.
Post-Implementation
Case example

38.
78 yr male with ESRD, calcified vessels, PVD, CHF,
COPD (FEV1 32%), CTS refused CABG

39.
78 yr male with ESRD, calcified vessels, PVD,
CHF, COPD (FEV1 32%), CTS refused CABG

40.
78 yr male with ESRD, calcified vessels, PVD,
CHF, COPD (FEV1 32%), CTS refused CABG

41.
65 yr old male, returns 3 weeks after CABG with
chest pain, drop in EF and EKG changes

42.
CTO of OM

43.
Case Example
• 86 yr old female, 46 kg, frail, severe COPD/asthma, FEV1
41%, steroids for 45 yrs, thin skin, bruised all over, CKD,
eGFR 30, HTN, PVD, CVD, Afib, on coumadin, CHF EF 35%,
RWMA, restrictive physiology, porcelain aorta on CXR,
extensive coronary calcium
• Presents with crescendo unstable angina, she thinks its
“asthma”
• EKG changes of ST–depression V1-V6 at baseline
• Refusing CABG

44.
Formal Pre-procedure Risk Assessment
Maximum tolerated safe contrast limit = 124 ml
Images from ePRISM©

45.
Case Example

46.
Case Example

47.
• 100 cc dye use, no bleeding, no AKI
• Angina Resolved
• Underwent cardiac rehab 30 mins daily
• Walking 2-3 flights of stairs

48.
Thank you!

49.
Thank you!

50.
What will the Episode of Bundled Care
include?

51.
Episode Definition

52.
CAD Episode Timeline

53.
Goals of Bundled Payments for PCI

54.
“..mistakes will occur, and it is
not reasonable to ask for
perfection, but it is
reasonable to ask that we
never cease to aim for it…”