While some providers remain leery of reform and the changing models of reimbursement, administrators and cardiologists at PinnacleHealth are actively engaged in an effort to embrace new technologies that can cost-effectively improve care—and fractional flow reserve (FFR) has met these requirements.
“While hospitals are concerned about their economic futures, we’re mostly concerned about our patients and the quality of our care,” says Philip W. Guarneschelli, senior VP and COO at PinnacleHealth, an 884-bed health system in central Pennsylvania. The adoption of any new technology at PinnacleHealth is evaluated on three levels: quality for the patients, usability for the physicians and economic benefit to the organization.
“From the economic standpoint, FFR can really lower expenses to the organization if used properly,” says Guarneschelli. “The reformation of U.S. healthcare delivery is pushing us toward population management. When the payment structure changes, we need to examine what can benefit the patient, while lowering the cost of care and delivering higher quality.”
From a clinical perspective, Brijeshwar S. Maini, MD, an interventional cardiologist at PinnacleHealth, looks to trial data to support the use of new technology. “Initially, the adoption rate of FFR was quite low, but the FAME and FAME 2 data, along with other studies, have confirmed its value and proved its need for us.”
At two years, FAME demonstrated that the rates of death or MI were 12.9 percent in the angiography group compared with 8.4 percent in the FFR group (J Am Coll Cardiol 2010;56:177-184). In addition, incidence of revascularization occurred at a rate of 12.7 percent for the angiography group compared with 10.6 percent in the FFR group. The original one-year data found that the use of FFR was particularly helpful in assessing intermediate lesions with narrowing between 50 and 90 percent (N Engl J Med 2009;15;360:213-224).
“Interventionalists have to get more comfortable with providing care that keeps patients out of the hospital. FFR allows us to confidently send our patients home without intervening on them,” Maini says.
The PinnacleHealth cath lab team seeks to follow the FAME protocol, using FFR (PressureWire, St. Jude Medical) to determine whether a lesion is less or equal to 0.8, in order to proceed with a stent. “While physicians have convinced themselves they are proficient at eyeballing a case, this technology has taken out the guesswork,” Maini says. “Also, the most recent economic data is as compelling as the patient outcomes.”
With the quality-of-life improvements observed with PCI, the three-year projected cost for the FFR-guided PCI approach was $32,000 per quality-adjusted life year (QALY), which is below the commonly used benchmark of $50,000 per QALY gained for considering a treatment to be cost effective.
From the provider perspective, Guarneschelli says that the national average of stent per case is approximately 2.7, and FFR has the potential to bring that figure down to the 1.9. “This reduction is significant financially, as you’re talking about thousands of dollars,” he adds.
One important step in this process is communication and collaboration with the referring primary care physician to explain new technologies, such as FFR. “In doing so, we are able to demonstrate outcomes-based, objective evidence, which has positive outcomes despite the choice not to intervene,” says Maini.
As an accountable care organization, PinnacleHealth recognizes the growing trend toward managing care for populations, as opposed to the individual. “The day is coming when Medicare will give us $500 million to manage 200,000 Medicare lives,” says Guarneschelli. “Obviously, we’re going to have to be stewards of those resources and do what’s best for our patients. At the same time, we need to practice better preventive care and work to keep our patients out of the hospital, especially through readmissions that come at such a high cost.”
Preparing for the near-future changes in healthcare, the administrators and cardiologists at PinnacleHealth, with a dedication to the best possible patient outcomes, have embraced an FFR-guided PCI strategy to practice high quality, cost-effective care.