Improving efficiencies and patient outcomes in the cath lab can go hand in hand. Strategies that reduce length of stay, risk and waste often lead to better care and sometimes cost savings. But upfront investments, change in workflow and reimbursement constraints can pose a challenge to their uptake.
Nudged by necessity
Interventional cardiologists at Mount Sinai Hospital in New York City recognized that they faced a resource crunch. The problem was beds, or lack thereof, for patients treated in their cardiac catheterization laboratory. “We knew that if it was a really busy day, then there probably was not going to be enough beds for an overnight stay for all these patients,” says Michael Kim, MD, former director of the cardiac care unit at Mount Sinai.
The physicians also knew that many of their elective PCI cases would not develop complications, with patients sleeping through the night before being discharged. As far back as the mid-1990s, cardiologists had shown they could discharge low-risk patients safely within the same day of an elective PCI using a transradial approach (Am Coll Cardiol 1997;29:323–327). And so in 2001, Mount Sinai began testing the water, sending home a few uncomplicated cases the day of the procedure. By 2011, their same-day discharge numbers had grown to 2,000 for the year.
“We were way ahead of the game,” says Kim, who now serves as the cath lab director at North Shore University Hospital in Manhasset, N.Y. The Society of Cardiovascular Angiography and Interventions and the American College of Cardiology wouldn’t publish a consensus statement setting standards for short-stay PCI until eight years later (Catheter Cardiovasc Interv 2009;73:847-858).
Today same-day PCI strategies are recognized as both efficient and beneficial to patients. “When people stay in the hospital too long, you increase the list of medical errors and inappropriate testing because in the hospital [staff] order more labs, whether they need them or not,” says Ehtisham Mahmud, MD, chief of cardiovascular medicine, co-director of the Sulpizio Cardiovascular Center and director of interventional cardiology and the cardiac cath lab at the University of California San Diego Health System in La Jolla. “They don’t necessarily think through the reasons for all those labs.”
Mahmud’s group is one of many that have rolled out same-day PCI programs in the past few years as evidence and protocols have emerged. While early demonstrations showed same-day discharge after transradial PCI was safe, Kim and his colleagues at Mount Sinai provided reassurance that same-day PCI using a transfemoral approach in a diverse patient population didn’t compromise patient care, either. In an analysis of 30-day outcomes for 2,000 consecutive same-day elective PCIs between 2003 and 2008—99.5 percent done transfemorally—eight patients experienced major adverse events, another 14 had bleeding complications and one a pseudoaneurysm (J Am Cardiol Cardiovasc Interv 2010;3:851-858). The average length of stay barely topped eight hours.
“The reality is most patients prefer to go home, given the option,” says Kim, who continued offering same-day discharge at North Shore when he came on board in 2013. “At Sinai, we would offer patients to go home at midnight and nine out of 10 said ‘OK’ vs. having to spend a night in the hospital.”
Some cardiologists aren’t comfortable discharging patients from eight to 23 hours after a PCI, but Sunil V. Rao, MD, of the Duke University Medical Center in Durham, N.C., challenged an audience at the 2013 Transcatheter Cardiovascular Therapeutics meeting in San Francisco to question that position. Using CathPCI Registry data, Rao and colleagues found same-day PCI was rare among Medicare beneficiaries but that it had similar rates of vascular complication, two-day and 30-day mortality and two-day and 30-day rehospitalization as an overnight stay (JAMA 2011;306:1461-1467).
“The most important thing here is to do what you think is best for the patient,” he said at a session on same-day discharge. “But I also would encourage all of you to go back to your practice and look at the numbers of patients you are keeping overnight simply because that is traditionally what you have always done vs. the number if patients you were really worried about.”
Hospital administration also may need to be persuaded that the benefits outweigh the costs. Similar to Mount Sinai, Mahmud made a case that a short-stay program would free up resources for more complicated cases. He proposed opening an observation unit for cath and electrophysiology patients. As a physician who also holds administrative duties, he realized the importance of putting such a request in the context of the greater good of the healthcare system.
“Initially it wasn’t received that well,” he says. The proposal raised concerns about staffing and other costs until he showed it would create the equivalent of four to six new beds daily in the hospital. “That streamlines care for everybody. Yes, it will cost a little more money to staff this unit but it is better for patients, it is better for throughput and it will ultimately have downstream benefits for everybody else who is trying to get more hospital beds.”
Same-day discharge also requires careful patient selection and adherence to pre- and post-procedural protocols to ensure optimal outcomes. Mount Sinai’s patient selection criteria in the 2010 analysis excluded patients older than 65 years or who had uncontrolled diabetes or acute coronary syndrome, among other factors. Procedures need to be uncomplicated, including uncomplicated vascular closure if it is used in a transfemoral PCI.
Programs also have to account for adequate patient education, particularly an understanding by patients of the severity of their illness and the importance of following medication plans and modifying their lifestyle. The hospital needs to ensure the patient is discharged to a safe environment with sufficient family and physician support. Once out of the safety net of the hospital, patients must feel secure and able to cope with their situation.
To assess patients’ satisfaction with same-day elective PCI, the Mount Sinai group and physicians at Baylor Medical Center in Dallas conducted a trial that compared self-reported outcomes in 298 patients randomized to same-day and next-day discharge between 2008 and 2010 (Circ Cardiovasc Qual Outcomes 2013;6:186-192). In this study, patients’ age could be up to 75 years. Using seven-day and 30-day follow-up interviews, they found clopidogrel (Plavix, Bristol Myers-Squibb/Sanofi Aventis) adherence and outcomes were similar in both groups.
At 30-days, 9 percent of same-day discharge patients said they would have preferred to stay longer while 37 percent of the next-day group wished they could have been discharged earlier. If faced with another PCI procedure, 80 percent of the same-day group and 68 percent of the next-day group said they would choose same-day discharge.
High patient satisfaction also factors into reasons to support short-stay PCI, says Michael Guiry, PA-C, MBA, director or cardiology services at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York City. The facility slowly has been ramping up a same-day discharge program, performing about 40 to 50 mostly elective cases a month, he says.
Savings & reimbursement
Same-day PCI discharge programs can lead to cost savings as well, but that doesn’t necessarily translate into improvements to a hospital’s bottom line—at least, not until recently. “You get significantly lower reimbursement for same-day discharge than you would, for instance, for an inpatient stay,” Mahmud says. “However, many of the CMS [Centers for Medicare & Medicaid Services] and Medicare rules have recently changed.”
One Canadian study that compared same-day discharge after transradial PCI with overnight hospitalization found the former strategy realized a 50 percent reduction in medical costs, or about $1,000 per patient (J Am Coll Cardiol Intv 2010;3:1011–1019). They pointed out that 1,000 same-day PCIs could yield a savings of $1 million for “the trivial systems cost of implementing the early discharge program, essentially nursing time cost of $7 per patient.”
But in the U.S., reimbursement for an outpatient PCI may be 28 percent to 38 percent less than for an inpatient PCI, Guiry has calculated, with a difference in net margins of about $5,500. Still, while hospitals may lose revenue they also may gain direct cost savings.
Despite the reimbursement disincentive, early discharge for PCI appears to be gaining momentum. One analysis of patients who underwent primary PCI for STEMI between 2004 and 2009 showed a trend toward decreasing length of stay, with patients hospitalized for two days or longer dropping from 72 percent to 65.9 percent (Am Heart J 2011;162:1052-1061). Hospitals discharged about a third of low-risk patients within two days.
The reimbursement landscape underwent a tectonic shift in October 2013 with implementation of the Two Midnight Rule. Under the Two Midnight Rule, hospital stays for Medicare patients of less than two midnights should be treated and billed as outpatient. CMS launched its “probe and educate period” Oct. 1, 2013 and will extend it through March 31, 2014.
Kim describes the shift as a game-changer for PCI. “This new rule has turned everything upside down. It will affect the bottom line of the hospital budget to do PCI because for the most part only rarely will PCI be reimbursed as an inpatient reimbursement fee.”
The Two Midnight Rule will remove financial disincentives and make same-day discharge an attractive option for hospitals, Kim predicts. “The biggest obstacle to preventing widespread adoption of same-day PCI, which was hospital finances, now has been overcome,” he says. “Now hospital administrators, instead of telling you not to send patients home the same day, are going to be asking you to send home patients the same day.”
Complications obviously are bad for patients and they often carry a price for hospitals when they occur. “Complications are very expensive,” says Hitinder S. Gurm, MD, director of inpatient services at the Frankel Cardiovascular Center at the University of Michigan in Ann Arbor. “Even a blood transfusion costs a couple thousand dollars because of the added costs” such as blood draws and lab work.
As project director of the Blue Cross Blue Shield Cardiovascular Consortium Percutaneous Coronary Intervention Registry, he has collaborated with cardiologists across Michigan on quality improvement efforts to reduce risks such as bleeding or contrast-induced nephropathy in PCI. They determined, for instance, that the use of vascular closure devices reduced vascular complications and transfusions, especially in overweight patients (Ann Intern Med 2013;159: 660-666). The cost savings made up for the price of the device, they argued.
They also used the registry to devise a simple tool to help determine a safe contrast dose (J Am Coll Cardiol 2011;58:907–914). Looking at nearly 59,000 patients enrolled by Blue Cross Blue Shield of Michigan from 2007 to 2008, they assessed whether the use of contrast dose based on the calculated creatinine clearance could predict contrast-induced nephropathy. They concluded that a dose-to-clearance ratio in excess of three greatly increased the risk of contrast-induced nephropathy and the need for costly dialysis.
The results have informed practice, Gurm says. Physicians now check estimated glomerular filtration rate before a PCI. “They know going into the procedure how much contrast should be used,” he says. “That has been effective. People across the country now use that dosing strategy.”
Craig Strauss, MD, MPH, a cardiologist at Abbott Northwestern Hospital in Minneapolis and a researcher at the Minneapolis Heart Institute Foundation, offers another strategy to reduce bleeding: a decision support tool embedded in the EMR that risk stratifies patients. Results from the tool presented at the 2013 American College of Cardiology scientific session showed bleeding complications within 72 hours dropped from 7.7 percent to 2.1 percent and transfusions from 11.3 percent to 6.4 percent.
Costs also dropped, from a baseline of $15,092 to $12,641 at the end of the fiscal year, even with the use of therapies such as bivalirudin (The Medicines Company). “When we looked at our overall cost, the savings by reducing bleeding complications far outweighed the additional cost of adding bivalirudin, particularly when you add it to select patients who are at the highest risk for bleeding,” Strauss says. Vascular closure devices, where reimbursement may be variable, also offered savings in high-risk patients.
The people factor
All three hospitals now participate in the program, he says, and overall 89 percent of PCIs had a risk score calculated at the time of the procedure. But getting to that point had its difficulties.
“There is always a challenge when you change workflow, particularly in high-efficiency systems like a cath lab [where] everyone has a defined role and now you add something new to it,” Strauss says. Abbott Northwestern facilitated the change by integrating the calculator in the EMR. Cath personnel enter four to six variables to get a score that is then incorporated into cath lab reports.
Convincing highly skilled physicians to consider bleeding avoidance strategies that were not part of their normal routine also posed challenges. But the physicians responded positively to the evidence brought before them. “Overall there has been dramatic improvement in the adoption of bleeding avoidance strategies,” Strauss says. All interventional cardiologists increased their use of the strategies since the tool was deployed, although some embraced them more than others.
The Minneapolis team implemented another risk stratification tool for STEMI patients admitted for primary PCI. The tool identifies the subset of low-risk patients who safely can be transferred from the cath lab to telemetery and possibly an earlier discharge, which avoids the cost incurred in the intensive care unit.
By scrutinizing what they do every day, cardiologists can find opportunities to cut waste and improve care, Guiry advocates. “We can do a lot by not being wasteful,” he says. “That doesn’t compromise quality at all.” He cites a physician requesting equipment that is unused and gets thrown out at the end of the procedure. “That has zero impact on quality but every impact on cost.”
As a proactive approach to changes under the Affordable Care Act, leadership at NewYork-Presbyterian/Columbia reviewed opportunities to improve efficiencies. The process included an evaluation of processes of care and use of resources. The PCI group identified a practice that appeared to offer little or no clinical benefit: the standard use of an expensive contrast, largely because it was left in power injectors.
In a six-month period in 2012, cath personnel used the more expensive contrast in 87 percent of cases. The hospital then instituted a practice change that required physicians wanting to use the more expensive contrast to request it. Use of the more expensive contrast plummeted to 6 percent in a comparable six-month period in 2013. The change saved $160,000 annually.
“The goal was not to not use it; the goal was to use it appropriately,” Guiry says. “We have not had any increase in the number of patients who had any negative kidney effects from this.”
Guiry emphasizes the importance of gathering data to share with physicians. In another cost-saving effort, the cath group developed a red-yellow-green color code system to sensitize physicians to the cost of equipment. The code reflected not only cost but the value added, so the most expensive device might nonetheless be tagged as green or yellow.
“The joke is culture always beats strategy,” he says. “Unless you get everyone on board, it is doomed to fail. These initiatives were fully supported by physicians who were instrumental in making the decisions.”
Mahmud, who wears multiple hats as a physician leader, also sees cooperation and a sense of partnership as key to improving patient outcomes and efficiencies. “We as physicians want the best possible and most advanced equipment, technologies and therapies for our patients,” he points out. “They are expensive. The only way you can justifiably go to the administrative side of any hospital or health system is to be able to say, ‘I am helping by running a more efficient operation.’”
That includes making timely and informed decisions, expediting discharge when it is best for the patient and being cognizant of costs. “It is not a quid pro quo. It is showing how we all work well together.”