Economic Analyses for
Transradial Procedures
Adhir Shroff, MD, MPH
Associate Professor of Medicine
University of Illinois ...
2

The Value Equation in Healthcare

✓ ✓ ✓

Value

Superior
Outcomes

PatientCentered
Care

Efficiency

At Lower
Cost

The...
3

Primary Economic Drivers…
• Less bleeding and vascular complications with
transradial procedures…Avoidance of
complicat...
Adhir Shroff, MD, MPH
Associate Professor of Medicine
5

Economics of TR: Premier Registry
• Analyzed PCI cases from
2004-9
• 609 TR-PCI cases matched
with 60,000 TF-PCI
• Prim...
6

Economics of TR: Premier Registry
Post-procedure LOS

Am Heart J 2013;165:303-309.e2

Adhir Shroff, MD, MPH
Associate P...
7

Economics of TR: Premier Registry
TOTAL Costs

Am Heart J 2013;165:303-309.e2

Adhir Shroff, MD, MPH
Associate Professo...
8

Economics of TR: Premier Registry
DAY OF PROCEDURE Costs

Am Heart J 2013;165:303-309.e2

Adhir Shroff, MD, MPH
Associa...
9

Economics of TR: Premier Registry
POST PCI UNTIL DISCHARGE Costs

Am Heart J 2013;165:303-309.e2

Adhir Shroff, MD, MPH...
US: Real-world Experience
• 7121 PCI procedures from 5 US
centers, retrospective
• Primary outcomes was cost of
PCI hospit...
US: Real-world Experience
$19,000

p<0.001

p<0.035

p<0.029

p<0.038

$18,000

$17,776

$17,000
$16,000
$15,000

$14,954
...
12

Meta-analysis of TR vs TF Trials CE
Trials

Circ Cardiovasc Qual Outcomes. 2012;5:454-462.

Adhir Shroff, MD, MPH
Asso...
13

Meta-analysis of TR vs TF Trials CE Trials

Circ Cardiovasc Qual Outcomes. 2012;5:454-462.

Adhir Shroff, MD, MPH
Asso...
14

Meta-analysis of TR vs TF Trials CE Trials

Circ Cardiovasc Qual Outcomes. 2012;5:454-462.

Adhir Shroff, MD, MPH
Asso...
Adhir Shroff, MD, MPH
Associate Professor of Medicine
16

Economics of TR: SD-DC
• 370 elective PCI patients
• 3 high-volume PCI centers in
France
▫ 52.3% patients with
multive...
17

Economics of TR: SD-DC
• 370 elective PCI patients
• 3 high-volume PCI centers in
France
▫ 52.3% patients with
multive...
18

Same-Day PCI Discharge Program
EASY Trial
Same-day
discharge
(No infusion)
Uncomplicated
TR-PCI with
abciximab
bolus

...
19

Outpatient PCI at UIHHSS: Costs
Payor Mix

Mean
Variable
Cost

Expenses that vary with volume:

Mean
Direct Fixed
Cost...
Adhir Shroff, MD, MPH
Associate Professor of Medicine
PPCI for STEMI: Access Site and Clinical
Events
RIFLE-STEACS

J Am Coll Cardiol 2012;60:2481–9

RIVAL-STEMI

J Am Coll Car...
PPCI for STEMI: Access Site and LOS
RADIAL
Single Center (Greece)
Total LOS

FEMORAL

N=65

N=33

6 ± 3.2 d

7.1 ± 2.8 d

...
PPCI for STEMI: Access Site and LOS
RADIAL

FEMORAL

N=6,159

N=84,720

Less than 2d

0.93%

1.23%

Between 2 and 4d

48.7...
24

Conclusions

✓

Value

✓

✓

✓

Superior
Outcomes

PatientCentered
Care

Efficiency

At Lower
Cost

• TR access for PC...
25

arshroff@uic.edu
312-485-4511

Adhir Shroff, MD, MPH
Associate Professor of Medicine
Adhir Shroff, MD, MPH
Associate Professor of Medicine
Adhir Shroff, MD, MPH
Associate Professor of Medicine
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Shroff A - AIMRADIAL 2013 - Cost effectiveness

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Economic analyses for transradial procedures

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  • Mean estimatedpost-PCI hospital costs (including abciximab infusion when used,other medications, nursing time, meals, etc..) were $1004 ($929–$1079)in the SDD group versus $3117 ($2975–$3260) in the OHgroup, saving, on average, $2113 per patient (p&lt;0.001).
  • Shroff A - AIMRADIAL 2013 - Cost effectiveness

    1. 1. Economic Analyses for Transradial Procedures Adhir Shroff, MD, MPH Associate Professor of Medicine University of Illinois – Chicago Jesse Brown VA Medical Center arshroff@uic.edu
    2. 2. 2 The Value Equation in Healthcare ✓ ✓ ✓ Value Superior Outcomes PatientCentered Care Efficiency At Lower Cost The New Economics of Quality. Advisory Board 2011 Adhir Shroff, MD, MPH Associate Professor of Medicine
    3. 3. 3 Primary Economic Drivers… • Less bleeding and vascular complications with transradial procedures…Avoidance of complications • Access site closure is very reliable….Reduce workload • Earlier mobilization of the patient following the procedure…Decrease length of stay Adhir Shroff, MD, MPH Associate Professor of Medicine
    4. 4. Adhir Shroff, MD, MPH Associate Professor of Medicine
    5. 5. 5 Economics of TR: Premier Registry • Analyzed PCI cases from 2004-9 • 609 TR-PCI cases matched with 60,000 TF-PCI • Primary endpoint included total hospital costs • Stratified patients into low, middle and high risk for periprocedural bleeding • In hospital bleeding (1.5% TR, 2.3% TF) TR Total Inpatient Costs TF $12,400 $12,200 $12,288 P = .033 $12,000 $11,800 $11,736 $11,600 $11,400 TR TF Am Heart J 2013;165:303-309.e2 Adhir Shroff, MD, MPH Associate Professor of Medicine
    6. 6. 6 Economics of TR: Premier Registry Post-procedure LOS Am Heart J 2013;165:303-309.e2 Adhir Shroff, MD, MPH Associate Professor of Medicine
    7. 7. 7 Economics of TR: Premier Registry TOTAL Costs Am Heart J 2013;165:303-309.e2 Adhir Shroff, MD, MPH Associate Professor of Medicine
    8. 8. 8 Economics of TR: Premier Registry DAY OF PROCEDURE Costs Am Heart J 2013;165:303-309.e2 Adhir Shroff, MD, MPH Associate Professor of Medicine
    9. 9. 9 Economics of TR: Premier Registry POST PCI UNTIL DISCHARGE Costs Am Heart J 2013;165:303-309.e2 Adhir Shroff, MD, MPH Associate Professor of Medicine
    10. 10. US: Real-world Experience • 7121 PCI procedures from 5 US centers, retrospective • Primary outcomes was cost of PCI hospitalization • Direct and indirect costs combined into a Total cost • Patients stratified into bleeding risk categories using the NCDR CathPCI risk model • LOS was 0.5d less in TR group TR Group • Less STEMI, less emergent cases • More GPI, less bival • Shifted towards lower bleeding risk patients • More outpatients, same-day dc Amin, et al. J Am Coll Cardiol Intv 2013;6:827–34 Adhir Shroff, MD, MPH Associate Professor of Medicine
    11. 11. US: Real-world Experience $19,000 p<0.001 p<0.035 p<0.029 p<0.038 $18,000 $17,776 $17,000 $16,000 $15,000 $14,954 $16,115 $15,867 $15,784 $15,161 Radial $14,716 Femoral $14,074 $14,000 $13,000 $12,000 All Low (<1%) Moderate (1-3%) High (>3%) NCDR Bleeding Risk Amin, et al. J Am Coll Cardiol Intv 2013;6:827–34 Adhir Shroff, MD, MPH Associate Professor of Medicine
    12. 12. 12 Meta-analysis of TR vs TF Trials CE Trials Circ Cardiovasc Qual Outcomes. 2012;5:454-462. Adhir Shroff, MD, MPH Associate Professor of Medicine
    13. 13. 13 Meta-analysis of TR vs TF Trials CE Trials Circ Cardiovasc Qual Outcomes. 2012;5:454-462. Adhir Shroff, MD, MPH Associate Professor of Medicine
    14. 14. 14 Meta-analysis of TR vs TF Trials CE Trials Circ Cardiovasc Qual Outcomes. 2012;5:454-462. Adhir Shroff, MD, MPH Associate Professor of Medicine
    15. 15. Adhir Shroff, MD, MPH Associate Professor of Medicine
    16. 16. 16 Economics of TR: SD-DC • 370 elective PCI patients • 3 high-volume PCI centers in France ▫ 52.3% patients with multivessel coronary artery disease ▫ 22.7% patients with multilesion procedures ▫ 21.5% bifurcation lesions • At 24hrs, no MACE • At 1 month, 4 (1.9%) readmitted Catheterization and Cardiovascular Interventions 81:15–23 (2013) Adhir Shroff, MD, MPH Associate Professor of Medicine
    17. 17. 17 Economics of TR: SD-DC • 370 elective PCI patients • 3 high-volume PCI centers in France ▫ 52.3% patients with multivessel coronary artery disease ▫ 22.7% patients with multilesion procedures ▫ 21.5% bifurcation lesions • At 24hrs, no MACE • At 1 month, 4 (1.9%) readmitted • Significant cost-saving for SDDC € 2,500 € 1,214 € 1,634 € 2,304 p<10-6 € 2,000 € 1,500 € 1,000 € 500 €SD-DC Prolonged stay Conventional PCI Overhead & bed charges Drugs, supplies Personnel Catheterization and Cardiovascular Interventions 81:15–23 (2013) Adhir Shroff, MD, MPH Associate Professor of Medicine
    18. 18. 18 Same-Day PCI Discharge Program EASY Trial Same-day discharge (No infusion) Uncomplicated TR-PCI with abciximab bolus 8.9hrs DC C$1004 DC C$3117 ® Overnight stay (+ infusion) 26.5 hrs 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
    19. 19. 19 Outpatient PCI at UIHHSS: Costs Payor Mix Mean Variable Cost Expenses that vary with volume: Mean Direct Fixed Cost Total • Cath lab staff labor Expenses that do not vary with volume: • Supplies: stents, medications, VCD • Admin staff salaries • Medications • Capital depreciation Transfemoral (n=5) 4/5 Government Transradial (n=8) 4/8 Government Cost savings 1/5 Private 4/8 Private $8,856 $3,858 $12,714 $7,478 $3,519 $10,997 $1,378 $338 $1,716 13% Sample of OP-PCI cases from January 2011 – March 2011 Adhir Shroff, MD, MPH Associate Professor of Medicine
    20. 20. Adhir Shroff, MD, MPH Associate Professor of Medicine
    21. 21. PPCI for STEMI: Access Site and Clinical Events RIFLE-STEACS J Am Coll Cardiol 2012;60:2481–9 RIVAL-STEMI J Am Coll Cardiol 2012;60:2490–9 Adhir Shroff, MD, MPH Associate Professor of Medicine
    22. 22. PPCI for STEMI: Access Site and LOS RADIAL Single Center (Greece) Total LOS FEMORAL N=65 N=33 6 ± 3.2 d 7.1 ± 2.8 d < 0.05 Deftereos S, et al. Hellenic J Cardiol 2011; 52: 111-117 Single Center (US) N=46 N=104 Total LOS 3 (2-5) d 4 (3-5) d 0.112 Ibebuogu UN, et al. Am J Cardiol 2012;110:1262–1265 Meta-analysis (Jang JS, et al) From 8 trials, TR approach associated with a 2.23 days shorter LOS <0.001 Jang JS, et al. EuroIntervention 2012;8:501-510 Adhir Shroff, MD, MPH Associate Professor of Medicine
    23. 23. PPCI for STEMI: Access Site and LOS RADIAL FEMORAL N=6,159 N=84,720 Less than 2d 0.93% 1.23% Between 2 and 4d 48.7% 40.5% ≥4d 50.4% 58.3% NCDR <0.0001 Unpublished data, personal communication from S Rao N=500 N=501 CCU 3d 4d <0.001 Total 5d 6d 0.008 RIFLE Romagnoli E, et al. J Am Coll Cardiol 2012;60:2481–9 Adhir Shroff, MD, MPH Associate Professor of Medicine
    24. 24. 24 Conclusions ✓ Value ✓ ✓ ✓ Superior Outcomes PatientCentered Care Efficiency At Lower Cost • TR access for PCI can favorably impact economics: ▫ By improving clinical outcomes ▫ By safely decreasing LOS • Utilization of the transradial approach creates value across a spectrum of clinical scenarios Adhir Shroff, MD, MPH Associate Professor of Medicine
    25. 25. 25 arshroff@uic.edu 312-485-4511 Adhir Shroff, MD, MPH Associate Professor of Medicine
    26. 26. Adhir Shroff, MD, MPH Associate Professor of Medicine
    27. 27. Adhir Shroff, MD, MPH Associate Professor of Medicine

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