Roundtable: Cost-Control Strategies in the Cath Lab

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Due to the current economic recession and decreasing reimbursement to cardiology, cath labs across the U.S. are being pressured to implement cost-control strategies to remain solvent.  Five cath lab practitioners and administrators came together to discuss their institutions’ tactics for maintaining economic viability, including competitive bidding and reducing the number of vendor products, while providing superior patient care.

Roundtable Speakers include:

  • Peter L. Duffy, MD, Interventional Cardiologist, FirstHealth of the Carolinas in Pinehurst, N.C.
  • Joseph D. Babb, MD, Interventional Cardiologist, East Carolina Heart Institute in Greenville, N.C.
  • Michael J. Lim, MD, Interim Director, Division of Cardiology, St. Louis University in St. Louis
  • J. Jeffrey Marshall, MD, Interventional Cardiologist and Director of the Cardiac Cath Lab, Northeast Georgia Medical Center in Gainesville, Ga.
  • Cathy (CJ) Hosea, RT, BS, Cath Lab Manager, Citrus Memorial Heart Center in Inverness, Fla.

Could you provide a cath lab strategy that resulted in cost savings?

Duffy: It was our transition from a mostly femoral lab for diagnostic and interventional cases to the transradial approach. Two years ago, 2 percent of our cases were transradial, now it represents 15 percent of our interventions. About 80 to 85 percent of my cases are transradial. This shift has facilitated faster turnover times, as we have the capability of same-day discharges for cases performed earlier in the day.  

Babb: Our facility is probably doing 2 to 3 percent of our cases radially, which represents the tension of evolving technologies. While radial access has many advantages, including lower complication rates, it has some disadvantages, including more radiation exposure to the operator and a higher failure rate to engage the vessel. Also, the learning curve for radial can turn off conventional interventionalists. Some have suggested that even seasoned interventionalists need about 150 to 200 cases to feel really comfortable. It could be a cost-savings strategy, but even if we performed radial procedures, we couldn’t discharge patients the same day because of our rural location, as many patients drive an hour-and-a-half to two hours.  

It’s hard to measure the cost savings of a radial program because very few radial programs have hit that magic number to realize savings. Decreasing complications in patients who you catheterize—either diagnostic or intervention—will decrease costs, but when you’re only using the approach on 15 percent of your cases, you might not recognize savings yet. 

Our system has adopted a systematic approach. Last year, we used the radial approach on all of our elective outpatient caths that could be cathed radially. This year, we’ve moved to all of our outpatients and inpatients who could be cathed radially. Then, our last step will be to transition the emergent cases to radial access. However, the learning curve is a lot higher in our institution because we’re training fellows to perform them as well.     

Babb: It depends a great deal on the practice setting. Cost savings are not going to be as easily recognizable in a structured teaching environment, as it would be when you are in control of your own practice and you are personally performing these cases.  

Has the dawn of the drug-eluting stent (DES) era resulted in a decrease in readmissions? If so, how are you compensating for those revenue losses?  

Marshall: The use of DES has reduced restenosis, and everybody has seen that in their lab. However, our lab is located in an area where the population is growing. Our cath lab numbers for the last three years are up about 6 percent per year. In fact, we’re building a new cath lab. Also, we’ve been involved with peripheral and carotid and other types of intervention for a while. As the cath volume has grown, so too has the peripheral intervention work. We now have a hybrid OR where the vascular surgeons are performing stent graphs instead of in the cath lab. Fortunately, we have been somewhat insulated from the drop-off.

Hosea: It’s a little different here. We have one of the oldest populations in the U.S. and the second oldest in Florida. Our physicians thoroughly evaluate the patients, along with their ability to be compliant with post-stent implantation prescriptions. Unlike most facilities, we stayed at a 50/50 mix of DES and bare-metal stents [BMS]. Even if the companies are going to give them a