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Effects on Cost and Resource Use

Effects on Cost and Resource Use

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    Shroff A 201201 Shroff A 201201 Presentation Transcript

    • Transradial Angiography and Intervention EFFECTS ON COST AND RESOURCE USE Adhir Shroff, MD, MPH, FACC, FSCAI Associate Professor of Medicine University of Illinois-Chicago
    • TR Angiography and Intervention: Effects on Cost and Resource Use 2Disclosures •  I have received unrestricted educational grants from: ▫  Cook Medical ▫  St. Jude Medical, Inc ▫  Terumo Medical ▫  Medical Concepts Development ▫  Boston Scientific Corporation ▫  Teleflex •  I serve as a consultant to Terumo, the Medicines Company, and Abiomed Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 3Agenda •  Economic stakeholders •  Impact of TR on resource utilization ▫  Bleeding ▫  Staff workload ▫  Improved efficiency •  Same-day PCI discharge program: Economic implications Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 4Missed Opportunities to Realize Cost Savings andEfficiencies: Key Considerations in Adapting Care Delivery for OP sSuboptimal Operations Overlooked Clinical Solutions Ad-hoc Scheduling Bleeding, Access Site Outpatients scheduled throughout Complications day, leading to lengthy LOS Bleeding complications contribute to excess costs and extended stay Untailored Care Protocols Identical inpatient and outpatient care fails to account for lower acuity Missed Clinical Advancements of outpatients Radial access and closure devices have made significant advances in expediting ambulation Undefined Inclusion/Exclusion Criteria No hardwired criteria to determine Unaccommodated patient status Comorbidities Obesity and diabetes require Inefficient Discharge extended care and often are not Outpatients often occupy beds accounted for during pre-procedure longer than clinically necessary, planning adding to overhead costs Slide courtesy of Terumo Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 5Here is what we know… •  Access site closure is very reliable •  Less bleeding complications with TR procedures •  Earlier mobilization of the patient following the procedure How do these facts impact resource utilization? Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 6Economic Stakeholders •  Shorter recovery time Patient •  Return to work •  Less complications •  Potential to increase referral Physician base •  Improve case turnover •  Improved through-put Cath lab/Medical •  Less staff utilization Center •  +/- Complications •  Less complications Payor/Society •  Return to work Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 7Choice of Vascular Access:Cost of Post-PCI Complications •  Transradial catheterization decreases bleeding complications •  Bleeding complications have a profound economic impact on the medical center and payors (and of course the patient and physician) Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 8Choice of Vascular Access:Cost of Post-PCI ComplicationsMedicare beneficiaries (2002) 90.5% Am J Cardiol 2006;97: 322-327 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 9Choice of Vascular Access:Cost of Post-PCI ComplicationsLength of Stay Am J Cardiol 2006;97: 322-327 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 10 Cost of Post-PCI Bleeding GUSTO Trial (IIb) $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 Mild Moderate Severe Bleeding Bleeding BleedingQual Saf Health Care 2007;16:154–159 J Am Coll Cardiol 2008;52:1758–68 Am Heart J 2008;155:369-74 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 11Impact of Bleeding on Survival post-PCI HR: 1.6 HR: 2.7 HR: 10.6 Am J Cardiol 2005;96:1200 –1206 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 12Choice of Vascular Access:Resource Utilization •  Nurse staffing represents an •  200 consecutive patients important component of •  Dx and PCI cases resourse consumption •  Cath lab nursing work load: •  Small shifts in nurse staffing ▫  Mean: 103 min can account for large shifts in ▫  TR: 86 min expenses ▫  TF: 174 min •  Non-randomized study from 174 Italy 103 •  Diagnostic and/or 86 interventional procedures Eur J Card Nursing 4(2005) 234-241 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 13Choice of Vascular Access:Resource Utilization •  200 consecutive patients •  Dx and PCI cases •  Ward-staff work load for generic tasks : ▫  TR: 86 min ▫  TF: 174 min •  For generic + medical care tasks: 174 ▫  TR: 386 min 86 ▫  TF: 720 min Eur J Card Nursing 4(2005) 234-241 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 14 Choice of Vascular Access: Resource Utilization p<0.01 100 p<0.01 91.7 •  At UIC/JBVA, we do 90 TF ~2000 diagnostics 80 72.5 TR and 500 PCI 70 •  TR access will save: 60 54.6Minutes ▫  596 hrs (dx) 50 47.2 ▫  393 hrs (PCI) 40 •  Total 989 hrs x $48.50 30 •  ~$50,000/yr 20 10 0 Diagnostic PCI Schaufele TG. RAPTOR. AHA 2009 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 15Choice of Vascular Access:Costs of Diagnostic Catheterization p<0.05 $370 $447 $553 J Inv Cardio 2007; 19: 349-353 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 16 Economic Impact and Marketing Opportunities Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 17 Finding the Balance Between IP and OP PCI •  Patient Acuity a Major Factor in Determining Outpatient Shift Outpatient shift potential Case distribution TRI has tremendousPercentage of future growthCases Eligible potentialto MoveOutpatient Shaded region represents outpatient cases Low Relative Patient High Acuity Relationship Between Acuity, Case Distribution, and Outpatient Shift Source: Cardiovascular Roundtable interviews and analysis. Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 18 Choice of Vascular Access: Same-Day PCI Discharge Program EASY Trial Same-day 8.9hrs discharge DC C$1004 (No infusion)Uncomplicated TR-PCI with abciximab ® bolus 26.5 hrs Overnight stay DC C$3117 (+ infusion) Average savings of C$2,113 per patient with same-day d/c Circulation. 2008;118:S_1119 Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 19Cost Analysis: MSDRG 247 •  PCI with DES w/o MCC (low acuity case) •  Most comparable to OP case •  DIRECT costs: $1434 difference btwn 1d and 2d LOS (Medicare 2008) ▫  ~$60/hr/patient in savings •  TOTAL Costs: $2428 difference between 1d and 2d LOS ▫  ~$101/hr/patient in savings Analysis by the Cardiovascular Roundtable Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 20Choice of Vascular Access:Our Economic Basis for Same-Day PCI Discharge •  In the VA system, there is an economic cost to keeping patient in the hospital •  At the University, we found: ▫  Medicare/aid does not reimburse for observation costs therefore no difference in reimbursement for 23hr obs vs. 8hr obs ▫  Among private insurers, only a 6% difference in total payment to UICMC for a 23hr obs vs. 8hr obs stay ▫  Clearing the bed for other patients was the priority Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 21 Impact of Same Day PCI Discharge at UIC –Financial Model Total Observatio Payment Payment Change Charges n Charges for 23hr for 8hrCommercial $134,140 $7,592 $70,468 $67,176 $3292Payer (n=4) (5%)Government $105,685 $5,504 $18,577 $18,577 0Payer (n=4) (0%) Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 22Building and Marketing a Same Day DC ProgramDesigning Around the Attracting Savvy ConsumersAmbulatory Experience Staffed by dedicated RNs familiar Building off of word-of- with radial access, focused on mouth marketing expedited discharge through patients Fast and Efficient Heart Care Lounge equipped Direct-to-consumer Patients recover marketing materials sitting upright in with WiFi, TV, reading materials emphasize efficiency of lounge chairs care Source: St. Joseph s Health System, Atlanta, GA Cardiovascular Roundtable interviews and analysis. Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 23 Photo courtesy of Chris SavasRadial LoungeSt Joseph s Hospital (Atlanta, GA) Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 24Conclusions •  Primary economic driving force for TR is a decrease in bleeding events •  Decreased nursing/staff workload will contribute to decreasing costs •  Improved efficiency (including same-day PCI programs) may also yield important savings Adhir Shroff, MD, MPH Associate Professor of Medicine
    • TR Angiography and Intervention: Effects on Cost and Resource Use 25Thank you… Adhir Shroff, MD, MPH Associate Professor of Medicine