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Gilchrist IC 2015 radial outpatient PCI

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Gilchrist IC 2015 radial outpatient PCI

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Same day: why hospitalists & providers must transition to radial outpatient PCI: an economic reality

Same day: why hospitalists & providers must transition to radial outpatient PCI: an economic reality

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Gilchrist IC 2015 radial outpatient PCI

  1. 1. Icg 2015 Why Hospitalists & Providers Must Transi7on to Radial Outpa7ent PCI: An Economic Reality Ian C Gilchrist, MD, FACC, FSCAI, FCCM Professor of Medicine The Pennsylvania State University M. S. Hershey Medical Center Heart & Vascular InsGtute Hershey, PA SAME DAY
  2. 2. Icg 2015 CME Disclosure Statement Consultant for Cardinal (Cordis) & Terumo, Inc.
  3. 3. Icg 2015 OutpaGents: What ProporGon of PCI’s? 3.4 16.7 30.9 41.7 50.5 ProporGon of PCI paGent admissions coded as “outpaGent” Scope of the Situa-on R4Q 1st 2015
  4. 4. Icg 2015 RealiGes of Payment 2015 PCI is no longer reimbursed under DRG’s Fixed reimbursement to hospital for stay 2016 no more pass thru for ReoPro™ or Angiomax™ Example: Reimbursement $10,000 Hospital A Hospital B Time is money Length of Stay 6 hours Cash Flow $1666/hr Cash Flow $416/hr Length of Stay 24 hours 18 hrs of open bed revenue 18 hrs of cost for paGent
  5. 5. Icg 2015 Temporal Margin of Safety: Adverse Events Post-PCI 450 consecuGve PCI paGents at Emory, all transradial ElecGve, N/STEMI, CTO’s Am Heart J 2008;156:1141-6 Safety for ischemic monitoring done within 6 hrs
  6. 6. Icg 2015 Independent predictors of early events DissecMon Pre- & postprocedural TIMI flow Side-branch occlusion Procedural thrombolyMc use Previous bypass PresentaMon with unstable angina Absence of diabetes Hyperlipidemia IMPACT II: PTCA with bailout stenMng +/- epMfibaMde Events: death, peri-PCI MI, re-vascularizaGon, bailout stent Early: 6 hours or less aeer PCI Thel et al. American J Cardiology 2000;85(4)427-434. 6 hours AHA 2015 Timing Ischemic Events Post-PCI
  7. 7. Icg 2015 Myocardial Infarc7on, urgent PTCA Hours from RandomizaGon 0 6 12 18 24 0.025 0.020 0.015 0.010 0.005 0 Hazard FuncGon CABG Composite Endpoint (death, MI, urgent revascularizaGon) Temporal Ischemic Hazard IMPACT II: PTCA with bailout stenGng ± Integrilin Thel et al. American J Cardiology 2000;85(4)427-434.
  8. 8. Icg 2015 PCI Related Bleeding Post-PCI Bleeding Rates Bleeding Site: Stable Angina 70% 30% Access Site Other Bleeding Site NCDR Cath PCI Data Rao SV, Gilchrist IC, et al. J Am Coll Cardiol. 2010; 55(20):2187-2195. Peterson ED, J Am Coll Cardiol. 2010;55(18):1923-32. Only the Radial Access Approach can Reliably Minimize Vascular Access Events
  9. 9. Icg 2015 Hazard of HospitalizaGon 3.4 3.8 4.2 4.6 5.1 5.6 6.1 11.1 12.4 13.8 15.4 17 18.7 20.6 0.4 0.6 0.8 1.1 1.5 1.9 2.5 0 5 10 15 20 25 1 2 3 4 5 6 7 PredictedProbabilityofAdverseEvent(%) Days of hospitalization Infection Rx Errors Skin ulcers Hauck K, Zhao X. Med Care. 2011 Dec;49(12):1068-75. N=206,489 admissions in Victoria, Australia HAZARD OF OVERNIGHT
  10. 10. Icg 2015 AddiGonal Costs of Time Maintenance of paMent such as medicaMons, food, etc. (consumables) Occupied bed unavailable for new paMent (inefficiency) Opportunity cost for paMent, family and employer (society costs) Licensed iclipart.com
  11. 11. Icg 2015 Favors Same Day Overnight 0.01 0.1 1 10 100 Same Day v Overnight 30 Day Outcome Complications MACE Hospitalization RCT n=5 Observational n=8 Odds Ratio Mantel-Haenszel Random effect, 95% CI §  Despite analysis of >110,000 patients, unable to resolve a difference §  A non-inferiority design with a sample size of > 320,000 patients needed for certainty JACC: Cardiovascular Interventions 2013; 6(2):99-112. Favors Same Day Overnight 0.01 0.1 1 10 100 Favors Same Day Overnight 0.01 0.1 1 10 100 Subtotal (95% CI) Subtotal (95% CI) Total (95% CI)
  12. 12. Icg 2015 “We would expect, however, that the addiMon of more transradial cases would be associated with an even lower event rate, especially those related to vascular injury”. p 112 J Invasive Cardiol 2014;26(3):106-113 3479 ambulatory procedures: Using predominantly bivalirudin & closure devices… 0.2% pseudoaneursym 0.08% hematoma
  13. 13. Icg 2015 Rapid AdopGon of Radial 0 10 20 30 40 50 60 70 80 90 100 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 NCDR-US NCDR-US 2020 Long period of development followed by classic logisGc curve of a disrupGve technology USA NCDR data Ideal U-liza-on Year Percent Radial (%) BriGsh Society of IntervenGonal Cardiology (BSIC) data
  14. 14. Icg 2015 First generaMon stents AnMcoagulated out paMents Discharged same day
  15. 15. Icg 2015 Cost By Access & Admission Radial Same Day v Overnight Radial v Femoral $13,500 $14,000 $14,500 $15,000 $15,500 $16,000 $16,500 Femoral Radial Δ $839, [95% C.I. $296 - $1,364] p<0.001 Adjusted result Amin AP, JACC Cardiovasc Interv. 2013;6(8):827-34. n=5,902 n=1,219 $0 $500 $1,000 $1,500 $2,000 $2,500 Hospital Costs Doctor/ Drug Costs Δ $1,141, [95% C.I. $962 - $1,320] Rinfret S, et. al. EASY TRIAL, JACC Intv 2010 N=1005
  16. 16. Icg 2015 EvoluGon in Cath-Lab Procedures 1980’s Admit day before Dx Procedure Discharge day aeer cath 1990’s Admit day of cath PCI next day Discharge day aeer PCI 2000’s Admit day of Cath/PCI Discharge day aeer PCI 2010’s Admit day of Cath/PCI & Discharged Driven by: Technical Improvements PaGent SaGsfacGon Efficacy & Value Payer Demands Best Opera-onalized with Transradial Approach
  17. 17. Icg 2015 Thank you Contact: icg1@psu.edu

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