Circ: Radial approach can save hospitals $275 per patient

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Using transradial access during catheterizations rather than the femoral approach can save a hospital on average $275 per patient, according to a cost-benefit analysis. The study, based on 14 randomized controlled trials, found that radial access proved less costly than femoral for catheterizations, despite radial’s longer procedure time and higher failure rate.

The radial approach has received high marks for reducing vascular complications and time to hemostasis as well as for improving patient comfort. While the RIVAL (Radial Versus Femoral Access for Coronary Intervention Study) trial found both radial and femoral approaches were safe and effective, results showed a more than 60 percent reduction in vascular complications with the radial approach.

European operators favor radial access catheterization, but uptake in the U.S. has been slow. Reasons include longer procedure time, a higher access failure rate and higher radiation exposure with the radial approach compared with the femoral approach.

Matthew D. Mitchell, PhD, of the Center for Evidence-based Practice at the University of Pennsylvania Health System in Philadelphia, and colleagues wanted to explore, from a hospital perspective, whether the benefits of radial catheterization outweighed the costs associated with unsuccessful catheterizations and longer procedure times. For the cost-benefit analysis published in the July issue of Circulation: Cardiovascular Quality and Outcomes, they augmented a previous review based on nine randomized trials with five additional trials.

Based on their review and meta-analyses, they found that patients randomized to a radial approach were five times more likely to be converted to a femoral approach. On the other hand, the complication rates for radial catheterization were 60 to 70 percent lower than for femoral catheterization.

They calculated a net hospital cost savings of $275 per patient, with the savings derived mostly from complication costs associated with the femoral approach. “To overturn the finding that radial catheterization is less costly, the rates of all those complications of femoral catheterization would have to be reduced by approximately 60 percent,” Mitchell and colleagues wrote.

A radial procedure took on average 1.4 minutes longer, but the time gap between radial and femoral would have to increase to 20 minutes to offset radial’s cost benefits, they added.

“[N]one of the changes to cost variables brought the net cost savings to a point that would favor femoral catheterization,” they wrote.

The authors pointed out that operators in the trials used in their analysis were highly proficient. Radial catheterization has a steep learning curve, though. Hospitals should not anticipate the cost savings found in the study when starting a program, but could see benefits improve over time.

“Performing enough procedures to attain proficiency may pose a practical challenge for many cardiologists in the United States who have been trained to use the femoral artery approach but do not have the opportunity to learn radial arterial access,” they wrote. “Nevertheless, our systematic review and meta-analysis indicate that it would be to the benefit of patients for cardiologists to obtain training so they can use the radial approach over the long term.”

They also acknowledged that the clinical trials in their analysis may have excluded high-risk patients who were unsuitable for either procedure, as required in a randomized trial. The use of lower-risk patients may have skewed variables such as procedure time and complication rates in favor of the radial approach.

Based on their analysis, radial catheterization offered both cost benefits to hospitals and clinical benefits to patients. They also highlighted the potential upside for healthcare systems. “Widespread adoption of radial catheterization could result in substantial savings for the U.S. healthcare system given that over one million coronary catheterizations are performed in the United States annually,” they wrote.