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