John Stewart (left) is CEO and president and Jack J. Hall, MD (right), is director of transradial catheterization, both at St. Vincent Heart Center of Indiana in Indianapolis.

Interventionalist’s Perspective – Dr. Hall

Years ago, after speaking with Dr. Ferdinand Kiemeneij, of the OLVG Hospital in Amsterdam, I became intrigued with transradial cardiac catheterizations. I had attended a poster session where Kiemeneij presented his first 100 patients who had received coronary stents from the transradial approach. At the time, this approach was practically unheard of in the U.S. After further literature review, my colleagues and I embarked on our own transradial program. We published the results of our first 21 patients in 1996.

The transradial approach has been slow to catch on in the U.S. Over the years, the naysayers have suggested many hurdles, some real and some imagined. The real ones, such as transradial specific equipment, have been conquered. The imaginary ones, such as increased radiation exposure with the transradial approach, have been dispelled.

One of the last hurdles holding back American cardiologists is the notion of a learning curve. Many American cardiologists fear that it will take too many cases to gain the required skills. The introduction of large lumen 5- and 6-French guides, low-profile stent platforms, transradial introducer systems and transradial hemostasis devices have simplified the procedure so dramatically that we can put this issue to rest as well.

As we have noted in the cath labs at St. Vincent Heart Center of Indiana, an interventionalist, with the aid of an experienced transradial operator or a transradial course, can quickly become adept at the procedure. Just as we were all initially slow in learning the technique of stenting, to become quick and efficient at most operations, one must commit to and perform a number of cases.

Why should we adopt the approach now? Early on, the reasons that supported a transradial approach were increased patient satisfaction and its effectiveness in certain patient populations that lend themselves to the technique. Today, through trials and registries around the world, we have come to realize the approach reduces morbidity and mortality, reduces hospital costs and facilitates same-day discharge after stenting. With this in mind, American cardiologists need to “go transradial” now, as it is obvious that hospitals, patients and payors will soon demand it.

Administrator’s Perspective – Mr. Stewart

Since medical efficacy has been established for transradial cardiac catheterization, we now look at the operational or business case. Though the debate over healthcare reform continues, it is increasingly clear that care will have to be
provided with more emphasis on quality and efficiency.

This need is being realized even without new legislation via current initiatives from the Centers for Medicare & Medicaid Services (CMS), such as reductions in reimbursement and inspections by recovery audit contractors (RACs). RAC inspectors are particularly interested in examining inpatient/outpatient designations and cath lab procedures could come under increased scrutiny.

In most hospitals, there is very little, if any, difference in the actual cost of providing care to patients having cath procedures in an inpatient versus an outpatient setting, assuming similar case types and acuity. If reimbursement is reduced and costs remain the same, margins per case are reduced, if not totally eliminated. Many hospitals already experience Medicare reimbursement rates below the actual cost of the procedure.

By reducing risk and occurrence of vascular complications with the transradial technique, the potential to reduce patient lengths of stay exists, thus reducing variable direct expenses. Given these assumptions, the transradial approach to cath procedures presents an opportunity to consider.