Optimization of TAVR Programs

1. R2C Optimization of TAVR programs
Atiq Rehman MD
Director Minimally Invasive Cardiac & Transcatheter Valve Surgery
Director for Performance & Quality Improvement
Lourdes Medical Center, NJ

2. Disclosures:
Edwards Life Sciences Proctor/Consultant for
Transcatheter Aortic Valve Therapy
Trinity CV Board Member @ HealthTrust Grp

4. Alain Cribier
“This is the stupidest idea I have ever heard!”

5. Percutaneous Transcatheter Implantation of an Aortic Valve Prosthesis for
Calcific Aortic Stenosis
Alain Cribier, Helene Eltchaninoff, Assaf Bash, Nicolas Borenstein, Christophe Tron,
Fabrice Bauer, Genevieve Derumeaux, Frederic Anselme, François Laborde, and
Martin B. Leon
Circulation, Volume 106(24):3006-3008 December 10, 2002

6. First TAVR: Trans-septal

7. Transfemoral TAVR

8. Transapical TAVR

9. TransAortic TAVR

10. TransSubclavian TAVR

14. Transcatheter Valve for Aortic Insufficiency
Successful Transcatheter Aortic Valve Implantation for Pure Aortic
Regurgitation using a New Second Generation Self-Expanding Jena-
ValveTM System – The First in-Man Implantation
Da Zhu, MD, Jia Hu MD, Wei Meng MD, Yingqiang Guo, MD
Heart, Lung and Circulation; April 2015 Volume 24, Issue 4, Pages 411–414

15. Transcatheter Aortic and Mitral Valve Replacement in a Patient With
Critical Aortic and Mitral Valve In-Ring Stenosis
Ricardo Yaryura, MD∗; Atiq Rehman, MD∗; Hakim Morsli, MD∗; Nasir Hussain, MD†,‡
J Am Coll Cardiol Intv. 2015;8(10)

16. The Majority of US Patients with Severe AS Remain
“Untreated” (no SAVR/TAVR)
SOURCE: Nkomo 2006, Iivanainen 1996, Aronow 1991, Bach 2007, Freed 2010, Iung 2007, Pellikka 2005; Bach, D. Prevalence and
Characteristics of Unoperated Patients with Severe Aortic Stenosis. J Heart Valve Dis. May 2011. (n=406); Industry estimates
2014

17. TAVR “Underutilization” is Largely Driven by Variation in
Health Policy and Reimbursement
17SOURCE: Eurostat, U.S. Census Bureau, Industry estimates

18. Estimated Global TAVR Growth
SOURCE: Credit Suisse TAVI Comment –January 8, 2015. ASP assumption for 2024 and 2025 based on
analyst model. Revenue split assumption in 2025 is 45% U.S., 35% EU, 10% Japan, 10% ROW
In the next 10 years, TAVR growth will be 4X !

19. Global $ TAVR Market Potential
($5B by 2025)
SOURCE: Edwards Lifesciences Investor Conference – Dec 11, 2013; Credit Suisse TAVI Comment –January 8, 2015

21. What is an enriching patient experience?

23. Does a better patient/customer
experience identifies your organization
as a leader in your field?

24. Harvard Business Review Analytics Services Study
• 53% considered customer experience management provides a
competitive advantage
• 45% view customer experience as an important strategic
priority
• 52% thought that the organization lacks the processes to
support their customer experience programs
• Customer experience management is markedly more important
to leading-edge companies. Seven out of ten say it’s a
significant strategic priority. Nearly half of all lagging
companies (45%), by contrast, said that customer experience
is not at all important.

26. Big picture
• Organizational Design: Comprehensiveness of
process execution and change management
• Ownership: Leadership in the program
• Performers: Identify Executors
• Infrastructure: Invest and develop necessary
infrastructure
• KPI: Set up key performance improvement metrics

27. Comprehensive Heart Team Approach

28. Comprehensive Plan & Management
It is more than learning a new procedure, it is
Building a New Service Line.
Reimbursement challenges
Patient/ancillary procedure tracking
Monthly meetings
Forecasting and development of new
technology/value analysis process
Justification for capital requests: FTE’s, clinic
space, hybrid OR, imaging software, database
Comprehensive Business Planning and
Marketing
Finance
Research to Commercial
Resourcing Growth
Operations Management
Working with internal process excellence team
(lean sigma) to maximize efficiencies

29. Processes
• Common Understanding:
– Make it visible
– Clarify roles & responsibilities
– Orient and Train employees
• Standardization and Continuous Improvement
– Promote Consistency & Efficiency
– Streamline & Eliminate Redundancy
• Promote Thinking
– Highlight interdependence between different functions
or units
– Identify key metrics for QPI

30. How does Standardization Help?

31. Duplication of Staff
Lack of Communication
Holding Area Wait Time
Too Long
Bed Availability Post-Procedure

32. 4 531 2 6
< 7 days
R2C (Referral to Care) TAVR Sequence

33. Implementing Optimization Steps
Assess Improve Sustain
• Detailed map of
workflow and patient
journeys (including
times, metrics,
interactions)
• Prioritize bottlenecks
and obstacles to a
smooth process
• Define ideal state
• Create data collection
plan
• Define optimal pathway
improvements including
best practices,
standardized practices,
cross -training and change
management
• Develop action plan and
implement sure hits
• Identify metrics to measure
impact on performance
indicators
• Provide support with
embedding new pathways
• Perform critical evaluation
of the effects of the
changes and refinement of
best practice tools
• Establish teams in
hospitals and across
pathway responsible for
monitoring and fine tuning

34. Rating
 Preceptor – Experienced
leader who teaches and
guides others
 Experienced – Able to
function independently
without supervision
 Competent – Qualified to
complete basic duties AND
requires supervision
 Orientee – Novice and
cannot yet function at a
competent level

35. New Program Launch

36. How does a New program launch, prioritize and improve?
1. Successfully launch TAVR program (0-6 months)
– Critical focus on procedure, flow, and patient throughput;
Evaluate each individual patient
2. Take note of initial financial realities vs predicted (1 year mark)
3. Calculate the “Halo Effect”
4. Drill down on LOS and clinical efficiencies that reduce it
5. Understand implications of PACT policy
– Discharge planning begins at intake interview (SNF, rehab,
home health, home)
6. Updated : Implications of Coding Change in 2014 (2 DRGs)
– Accurate, timely, and standardized coding system

37. What patient care pathways (pre, peri and post
procedures) to be implemented?
• Pre
• DC planning (SNF, Rehab, Home
health, Home)
• Determination of Route
• Admit day of or before
• Perfusion needed at all?
• PPM indication? Risk?
• Peri
• TAVR Fastrack Clinical Pathway
• Appropriate Coding
• PACT policy awareness
• Post
• Regimented FU process
• Post op studies per protocol (echo,
CXR, ECG, etc)

38. Decreasing Resource Utilization
Reducing Use of
Hospital Staff
Streamline
Procedure Related
Equipment
Understand
Location Cost
Within the Hospital

39. Financial implications for hospitals

40. MS-DRG Description Base Rate
266
Endovascular cardiac valve replacement
with MCC
$52,742
267 Endovascular cardiac valve replacement
without MCC
$39,602
40
National
average
Reimbursement

41. Fast Track TAVR pts

42. Favorable outcomes with FASTRACK protocol in TF patients
Outcomes
Fast Track
Protocol
Standard Care P-value
Intensive Care LOS 28 hours 44 hours <0.0001
Post-op LOS 4.3 days 7.2 days <0.0001
Direct Costs $44,923 $56,339 <0.0001
Marcantuono, et al., Rationale, development, implementation, and initial results of a fast track protocol for TAVR. Catheter Cardiovasc Interv.
Nov 2014

43. Simplistic Approach

44. Simplistic Approach
Early
Discharge
Conscious
Sedation
Cathlab
Procedure
Minimalistic
Approach

45. SOURCE: Babaliaros, V et al. “Comparison of Transfemoral Transcatheter Aortic Valve Replacement Performed in the
Catheterization Laboratory (Minimalist Approach) Versus Hybrid Operating Room (Standard Approach)”. JACC 2014.
Standard Approach Minimalist Approach
• Hybrid operating room
• General anesthesia
• Intubation
• Cardiac catheterization lab
• Local anesthesia
• Minimal conscious sedation
218 minutes Procedure Room Time 150 minutes
28 hours Intensive Care Unit Time 22 hours
5 days Length of Stay 3 days
$55.3k Hospital Costs $45.5k
4.2% In-Hospital Mortality 0%
84% Discharge to Home 83%
Outcomes with Minimalist approach

46. Benefits of Minimalist approach:
In appropriately selected
patients, the morbidity &
mortality is the same as standard
approach patients
The shorter LOS and lower
resource utilization with MA-
TF significantly lowers
hospital costs
These results have important
implications for the financial
viability of U.S. TAVR
programs in the future
Patient Selection:
•Appropriate for minimalist
approach
Procedure Location:
•Cardiac catheterization lab
Mode of Anesthesia:
•Local anesthesia
•Minimal conscious sedation
SOURCE: Babaliaros, V et al. “Comparison of Transfemoral Transcatheter Aortic Valve Replacement Performed in the
Catheterization Laboratory (Minimalist Approach) Versus Hybrid Operating Room (Standard Approach)”. JACC 2014.

47. Length of Stay & Readmissions

48. Effective strategies to optimize LOS can have significant
impact on TAVR quality outcomes
Decrease
length of stay
Decrease Re-
admission
Improve
procedural
outcome
Increase
efficiencies
&
throughput

49. 0
50
100
150
200
250
300
0
2
4
6
8
10
12
#ofTAVRCases
MedianLengthofStay
Academic Medical Center
TAVR Length of Stay Bench Marking Data for Academic Medical
Centers with > 70 TAVRs from April 2014 to Sept 2014
Mean LOS (Obs) Cases

50. Steps the TAVR team should consider to lower LOS
Strategies for state I: Patient evaluation and selection
Consider non-
traditional criteria
when determining
patient eligibility
Multidisciplinary
approach with
engagement of
referring physicians
Set clear
patient/family
expectations on
discharge date from
onset
Conduct the pre-TAVR
visit in the outpatient
clinic the day before
admission
Strategies for state II: The procedure
Hold a team meeting the day
before procedure
Develop clinical protocols
that reduce procedure
complexity
Local + Sedation in OR
Strategies for state III: Post-procedure recovery
Modify ICU staff
expectations on recovery
time
Have the TAVR coordinator
regularly check on recovery
workflow
Frequently re-evaluate
patient eligibility for early
discharge with SW/team
1098
765
321 4
Source: The Advisory Board Company, 10 steps to lower TAVR length of stay from the Queen’s Medical Center ,March 2014

51. Transfer Penalties
• Post Acute Care Transfer (PACT) penalty
• Geometric Length of Stay
– TAVR with MCC 7 days
– TAVR without MCC 4 days

52. “Outpatient” Same-Day TAVR
Sacre-Coeur Hospital; Montreal, CN
Philippe
Genereux
Philippe
Demers
Donald
Palisaitis

54. Change …before you have to!
Jack Welch