|The GE Innova digital cardiac cath lab is coupled with the Mac-Lab hemodynamic monitoring system and the Centricity Cardiology image and data management system.|
Cardiac catheterization labs across the country are evolving. Changes in types and volumes of procedures combined with an increasingly competitive environment and reimbursement cuts are forcing cath labs to adapt and fine-tune their management strategies. What brings success? Diversifying into EP and peripheral vascular procedures, tightly managing and even consigning pricey inventory such as drug-eluting stents, cross-training staff, and ensuring high flexibility.
The cath lab then and now
The initial purpose of the cath lab—evaluation and diagnosis of coronary artery disease—has been supplanted by interventional procedures since the onset of drug-eluting stents and statins. Since the advent of coronary stenting, a greater percentage of patients’ coronaries are remaining open, translating into fewer repeat procedures. What’s more, cardiologists are getting into the cardiac cath business on their own and launching joint-venture operations. The upshot for many sites, says Katrina Dunn, cath lab manager at Methodist-DeBakey Heart Center in Houston, is that the bread-and-butter business of the cardiac cath lab is in a state of decline. Plus, regulations and declining reimbursement are taking their tolls in the cath lab. “Our margins are much narrower than they used to be. We have to stay on top of the cath lab from the business perspective,” says Eileen Wimsatt, director of cardiac cath lab and electrophysiology (EP) lab at Inova Heart and Vascular Institute in Falls Church, Va.
If you take a closer look at the cath lab in terms of procedure volume, in 2006, about 4.21 million studies were performed in 1,970 sites, reflecting growth of just 2 percent annually, according to market research firm IMV. Of these cath lab cases, 89 percent were cardiac-related and 11 percent were non-cardiac applications. But despite the flattening in the number of procedures, capital budgets are increasing at a faster pace. From 2003 to 2006, the average device budget per cath lab surged about 18 percent per year to $1.8 million. Also, the proportion of sites with capital budgets of more than $1.5 million has increased from 14 percent in 2000 to 30 percent in 2006, as hospitals invest in new technology such as flat-panel digital detectors, according to IMV. The typical cath lab is used by an average of 10.8 cardiologists and 3.6 cardiology groups.
So how are smart cath labs handling these changes? They’re employing a variety of strategies from investing in a broader array of imaging equipment to facilitate EP and peripheral vascular work and optimizing IT solutions to cross-training staff as well as exploring high-tech inventory management tools like radiofrequency identification technology (RFID).
A complicated arena
The cath lab at Methodist-DeBakey Heart Center is a microcosm of its peers nationwide. Its procedure mix has changed from 75 percent coronary evaluations, 20 percent EP studies and 5 percent peripheral vascular work to 45 percent coronary exams, 40 percent EP work and 15 percent peripheral vascular over the course of a few years. One hitch associated with EP procedures is time. EP cases take much longer than standard coronary cases—often by a factor of two. A diagnostic EP case is a two-hour procedure, and a complex interventional procedure can last between three and five hours. In comparison, a diagnostic coronary case is a 30- to 45-minute procedure, and interventional cases last between 60 and 90 minutes.
But the challenges of EP aren’t the only factor complicating the cath business. Two satellite hospitals have opened cardiac cath labs and usually retain the straightforward, non-complex cases, so Methodist-DeBakey patients tend to be more complex with greater co-morbidity than in the past. Patient length of stay is longer. Ultimately, the volume of EP and peripheral vascular work has not offset the loss of coronary procedures, says Dunn, and it requires more resources to complete fewer cases.
One survival mechanism for the cath lab is to change its imaging arsenal. “We used to take a cookie cutter approach to imaging equipment, with each lab a clone of the others. Now, we need equipment that supports peripheral vascular, EP and coronary procedures,” explains Dunn. The center’s eight cath labs are outfitted with a variety of Siemens Medical Solutions imaging equipment.