Transradial Interventions: Helping Cath Labs Stay Cost Savvy

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 - Transradial recovery cath lounge
Transradial recovery cath lounge at St. Joseph's Hospital in Atlanta.
Source: St. Joseph's Hospital

While a plethora of research has reinforced the clinical benefits of performing catheter-based procedures—diagnostic and PCI—via the radial artery compared with the femoral artery, some hospital executives question whether the fiscal and workflow benefits of employing this technique will be equally beneficial. Four providers speak to their reasons for adopting a transradial program, along with the economic and practice management considerations.

St. Luke’s South 

St. Luke’s South in Overland Park, Kan., began using the transradial technique more frequently in June 2009 after Dmitri V. Baklanov, MD, joined its cath lab team. Now, four out of the 10 interventionalists throughout St. Luke’s Mid America Heart Institute have adopted the approach.

As a physician champion, Baklanov took it upon himself to train his colleagues at no cost to the hospital system. “The physicians were willing to get trained because it is a beneficial therapeutic means to prevent bleeding risks and avoid transfusions, especially with appropriate patient selection,” says Kathy Howell, CEO of St. Luke’s South.

In fact, Jolly et al found that the transradial approach was associated with a 73 percent reduction in major bleeding compared with the transfemoral approach (Am Heart J 2009;157:132-140). The authors noted the radial approach may offer advantages for patients with peripheral arterial disease and/or obesity.

Howell advocates for the physician champion strategy for introducing the technique to staff. “Training was not a big undertaking,” she explains. “In a one-to-one approach, Dmitri went to the staff meetings of the cath lab managers, cardiovascular recovery nurses and the ICU nurses to provide in-services education, resulting in a very smooth transition. Therefore, the administrative effort was minimal.”

However, physicians require about 200 procedures to become truly proficient, Howell says.

“Our board and administrators were not resistant to the transition, but we were curious about the impact to workflow and patient outcomes,” Howell says. “Within a couple weeks, the nursing staff was ‘sold,’ due to the time efficiencies and improved patient outcomes.” Also, the use of the new technique did not require a “huge change” to the cath lab’s inventory shelves, she says.

While St. Luke’s still maintains a three-to-one ratio for both types of procedures in the CV recovery unit, they were able to decrease personnel during certain hours of transradial procedures. A second staff member is required to be present during the ‘groin pull’ of femoral procedures, the necessity of which has been eliminated with transradial procedures.

During the first five months of 2010, 48 percent of the patients underwent the transradial approach at St. Luke’s South. For diagnostic caths, 44 patients underwent the transfemoral approach and 43 underwent transradial. For PCI, 35 patients underwent transfemoral and 33 patients transradial. The current complication rate is less than 2 percent for transfemoral patients and zero for transradial patients. St. Luke’s interventionalists rotate in all four Metro Kansas City hospitals and they tend to be predominantly femoralists or radialists, resulting in these averages at St. Luke’s South.

Length of stay for cardiac caths has come to the forefront recently in the U.S., as CMS recommended that 20 percent of PCI procedures be reimbursed as outpatient procedures. As a result, St. Luke’s South has begun assessing length of stay and comparing the transradial and transfemoral techniques, discovering a “substantial” length of stay reduction for the radial approach—from 0.7 days to as much as a full-day for therapeutic catheterizations, says Howell.

This finding is in line with other research. Cooper et al found that transradial catheterization significantly reduced median length of stay (3.6 vs. 10.4 hours), which led to significant reductions in bed, pharmacy and total hospital costs ($2,010 vs. $2,299) in 101 patients who underwent transradial diagnostic cardiac cath and 99 patients who underwent transfemoral (Am Heart J 1999;138:430-436). When a subgroup of 171 outpatients was analyzed, they found a similar reduction in total cost ($1,974 vs. $2,223).

In another study that further broke down the price points, Roussanov et al found that total procedural costs including access, catheters, contrast, closure device and recovery costs were significantly lower in the radial group, at $369.50, compared with the femoral group without closure device, at $446.90, and the femoral group with closure device, at $553.40, (J Invasive Cardiol 2007;19(8):349-53).

Finally, St. Luke’s closely tracks its inpatient satisfaction, and Howell attributes the use of the transradial technique as partly responsible for a jump of three points during the past quarter because “these patients are thrilled about their outcomes.”

University of Illinois at Chicago (UIC)/Jesse Brown VA Medical Center 

Some interventionalists have adopted the transradial technique through an exposure to European outcomes. Adhir Shroff, MD, director of the cardiac cath lab at UIC, explains that his partner, Mladen Vidovich, MD, chief of cardiology at Jesse Brown, attended EuroPCR, where he learned various data on the benefits of radial access for bleeding complications.

While transradial catheterizations are much more common in Europe—most notably in France where it was used for 36 percent of coronary catheterizations in 2003—transradial usage currently is estimated at 3 to 5 percent in the U.S.

When Shroff and Vidovich sought to launch the program—as the only two interventionalists in their labs—they spoke with the cath lab manager, who first resisted the idea due to the perception that it increased procedure times. After some debate, they undertook the program for a month test-run, during which they treated every appropriate case using the transradial approach.

Despite the perception about increased procedure times, a recent study of 489 nonrandomized STEMI patients found no significant difference in the times to revascularization between the radial and femoral access approaches, and the transradial approach actually resulted in slightly less times—averages of 21.4 minutes versus. 22.8 minutes, respectively (Am J Cardiol 2010;106(2):148-154).

“With the appropriate training, the staff requires much less time and effort for post-procedure patient management—with no prolonged groin hold and less frequent pulse or hematoma checks. While patients are monitored for vascular complications at the radial access site, the procedure is essentially complete once the TR band has been placed,” says Shroff. 

Clinical evidence also suggests the approach could potentially reduce post-procedure workload. A single-center study found the time spent to care for patients after PCI was reduced from 174 minutes with transfemoral access to 86 minutes with transradial access (J Cardiovasc Med 2007;8:230-237). Additionally, Amoroso et al found that nursing time outside the cath lab in the ward was reduced from 720 minutes with femoral access to 386 minutes with radial access.

“Previously, the nurses had to manage the patients in a one-to-one or one-to-two staffing ratio. Now, a single cath lab nurse can manage several outpatients in a short-stay unit, allowing the nurses to direct their attention to other responsibilities,” Shroff says. “Eventually, a provider may be able to alter its staffing ratios for the cath labs, leading to long-term savings.

“After two or three months, it was decided that our test-run was a success, and we continue to use the transradial access site as our default approach,” he adds. Even their two cardiologist-colleagues who perform just diagnostic caths are employing transradial access about 50 percent of the time, because “we share fellows who encourage its usage,” says Shroff.

While hosting CME training sessions, Shroff notes providers are concerned about inventory impact, and he advises them to cut their radial vendor options to a maximum of two. “In a larger effort to reduce inventory and further decrease vascular complications, we’ve switched to using 5F catheters for the vast majority of our procedures, as opposed to stocking as many 7F and 8F catheters,” he says. “We have minimized the depth of our inventory, while widening its breath.”

For inventory, providers don’t have to increase the amount of stock, but they have to get more creative,” Shroff says. “We generally encourage providers to engage their administrative staff up front about changes or increases. Yet, any additional radial products are low-cost items ranging between $40 and $100, unlike drug-eluting stents that are about $2,500 each.”

Shroff notes that the biggest obstacle to developing a transradial program was the learning curve for operators and staff. Their learning curve experience is closer to 50 cases for practicing interventionalists. Shroff recommends that facilities bring in outside practitioners for didactic training purposes, as well as case observations. A simulation tool that allows access also is beneficial.

The lack of early training on transradial interventions remains a hindrance to more wide-spread adoption. While SCAI is hosting the first Radial Summit this November in Boston, there are a limited number of courses. “This lack of systematic training leads to transradial PCI being viewed as a niche procedure,” wrote Rao et al (J Am Coll Cardiol 2010;55:2187–2195).

The new CMS designation for PCI may create more of an impetus for practices to transition to radial caths. “Adopting the technique has improved our bed throughput, as we are able to discharge patients who’ve received a transradial intervention two hours after their procedure,” says Shroff. “Immediately following, patients can sit up and eat lunch, and once they can take a walk to the lavatory, we monitor them over the two hours and discharge them. At first, we tested four hours, but now we’ve cut that throughput in half.” Previously, patients would consume an inpatient bed for six to eight hours after transfemoral access with manual compression.  

Some have raised concerns about discharging patients too early following a transradial PCI. Yet, in a single-center study, Small et al found that all post-procedural complications were identified within six hours of the transradial PCI or occurred more than 24 hours later when patients would have been discharged according to overnight admission protocols, based on the treatment of 1,543 ACC type B2 or C lesions in 1,174 patients, (Catheter Cardio Inter 2007;70(7):907–912).

Shroff estimates that his lab has experienced a 5 to 10 percent increase in procedure volume.

The UIC cath lab team conducted a cost-effective analysis for same-day discharge. For a small group of third-party payors, the team from UIC discovered that they could lose at most $300 to $400 in reimbursements for post-procedure patient observation if they discharged a patient after eight hours, rather than 16 to 23 hours. “However, from a financial and patient care perspective, our hospital decided it was much more valuable to have that bed available,” Shroff says.

St. Peter’s Health Care Services

As the physician champion at St. Peter’s in Albany, N.Y., Chief of Cardiology Michael J. Martinelli, MD, who uses the radial approach in 90 percent of his cases, has seen an increase of the approach by his interventionalist colleagues due to “significantly decreased bleeding risks and increased patient comfort. It will be the future of cardiac cath for these two reasons,” representing a rare complementary benefit of costs and quality of care.

In an investigation into the cost of such complications, Kugelmass et al found that in 335,477 Medicare patients undergoing PCI, adjusted incremental hospital costs (except death) varied from $33,030 to $4,278 for those experiencing vascular complications (Am J Cardiol 2006;97:322–327).

In an effort to adopt the new technique in a systematic fashion, the St. Peter’s team strategized about the pre- and post-procedure methods, which resulted in a “smooth transition,” says Martinelli.  He suggests that interventionalists require between 80 and 100 transradial procedures to become proficient. “Once an interventionalist becomes comfortable with the catheter manipulation and access site, the procedure shouldn’t take any longer than the femoral approach.”

St. Peter’s performs about 2,650 diagnostic catheterizations and 800 PCIs annually. In the six-month period following the program’s adoption in October 2009, the provider performed 400 transradial procedures—264 diagnostic catheterizations and 126 PCIs. “This shows how quickly the technique has caught on,” says Martinelli.

“Now that we’re performing transradial procedures regularly, our patients are happier and the bleeding risks are significantly reduced, which has won over the staff,” Martinelli says. Additionally, the decreased need for post-cath monitoring has “improved workflow.”

Patients who receive a transradial diagnostic catheterization currently receive one hour of bedrest and two hours with the TR band, after which they leave. For transradial PCI, patients have the TR band on for three to four hours, and they stay overnight.

With the radial approach, most patients typically ambulate within one hour, Martinelli says. As a result, St. Peter’s is planning to adopt a protocol-driven discharge strategy that is better suited for this patient population. 

St. Joseph’s Hospital of Atlanta

Once a transradial program is well-established, like at St. Joseph’s, providers can begin investigating how to uniquely serve these patients. The provider built a specific area, the Transradial Heart Cath Recovery Lounge, where patients can recover in an “internet café-like atmosphere,” according to Kirk Wilson, CEO of St. Joseph’s.

Wilson notes that the presence of the new recovery lounge has influenced certain patients with a planned transfemoral procedure to request this type of recovery process, which in turn has influenced some resistant interventionalists to begin training on the radial technique. The same-day discharge is particularly appealing, he notes, compared with a 24-hour stay for the femoral approach. 

Cooper et al examined quality of life benefits, finding that over the first day after the procedure, measures of bodily pain, back pain and walking ability favored the transradial group (P < .05 for all comparisons) (Am Heart J 1999;138:430-436). During the week after the procedure, changes in role limitations caused by physical health, bodily pain and back pain favored the transradial group (P < .05 for all comparisons). As a result, the authors noted a “strong patient preference for transradial catheterization” (P < .0001).

While the procedure staffing is currently the same (four-to-one) at St. Joseph’s for both approaches, the provider anticipates increasing the ratio for the transradial approach to five- or six-to-one, once the entire staff is more familiarized.

St. Joseph’s also saw a fiscal reason for implementing the new recovery lounge, as it reduced the cost-per-case. “CMS is reimbursing one-third less for this outpatient procedure than for the same procedure as an inpatient, and the switch in the payment from IP to OP has required us to get more creative about spending less, and a unique, standalone environment is the right way,” says Wilson.

To track its progress, St. Joseph’s has built a database to track costs associated with the two techniques, but Wilson is convinced that “the more cases conducted in the transradial approach, the greater the savings.”

St. Joseph’s cardiologists have been employing the transradial approach over the past decade, during which time the usage has gradually increased. In 2009, St. Joseph’s performed 758 transradial catheterizations—536 diagnostic and 222 PCI procedures. Even with such high volume, their complication rates were zero for the radial approach in 2009.

“Since our European colleagues have been exemplifying the clinical and economic benefits of the transradial technique for years, it is really starting to gain momentum in the states, but U.S. interventionalists really need to embrace this possibility of changing their methods, in order to reap its unique advantages for their patients and the health system,” Wilson concludes.

Snapshot of Transradial Programs
 St. Luke’s SouthUIC/Jesse Brown VA St. Peter’s St. Joseph’s of Atlanta
Six-Month PeriodTransradialTransfemoralTransradialTransfemoralTransradialTransfemoralTransradialTransfemoral
Number of procedures (Diagnostic)43443001002641,3252682,855
Number of procedures (Interventional)3335125351264001111,274
Average length of stay (Interventional)Same-day discharge24 hours8 hours23 hours24 hours24 hoursSame-day discharge24 hours
Complication rates0%2%1-2%4-5%0%0.008%0%0.68% (Diagnostic)
Post-procedural staff required (Pt/Staff)3 to 4:1 ratio3 to 4:1 ratio4 to 5:1 ratio2:1 ratio4 to 5:1 ratio4 to 5:1 ratio5:1 ratio4:1 ratio