Costs of transradial percutaneous coronary intervention, A Amin

1. Value Driven Care for the Cardiac Cathlab
with Transradial PCI
Amit Amin MD MS,
Washington University School of Medicine, St. Louis, MO

2. Conflicts of Interest
• I have no conflict of interest to declare

3. Transradial PCI is Rapidly Increasing in
the United States

4. Exorbitant Costs of Coronary Disease Care
in the United States
$10 Billion
$6.4 Billion
0
2
4
6
8
10
12
PCI Cost CAD hospitalization
US$(Billions)
Annual Costs
Centers for Medicare and Medicaid, CAD white paper, version date 5/20/16

5. From CMS…
• “This lack of incentives for delivering high-
value care across the continuum of CAD too
often results in higher than necessary rates of
adverse events, hospital admissions and re-
admissions, and lack of appropriate preventive
services and follow-up for patients with CAD.”

6. CMS’s Aggressive Goal of Alternative
Payment Models (APMs)

7. • Time critical change

8. Newer payment changes on the
horizon…
• Will transform the delivery of PCI
• Requires physicians and administrators to
engage and understand what drives outcomes
AND costs !!

9. Risk and Complexity of PCI Patients is
Increasing
• Comorbidities are on the rise

11. Risk and Complexity of PCI Patients is Increasing

12. Outcomes
• Persistently poor
• Large degree of variation in practices
• Large variation in outcomes
• Large variation in costs

13. Large Variation in Costs of PCI across US Hospitals
$0
$10,000
$20,000
$30,000
$40,000
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100103106109112115118121124127130133136139142145148151154157160163166169172175178181184187190193196199202205208211214217220223226229232235238241244247250253256
MeanhospitalPCIcosts($)
Hospitals ranked in ascending order of their PCI costs
Variation in Hospital Costs of PCI
32% of the variation in PCI costs was explained
by ‘hospitals’ alone, despite extensive
adjustment of patient level factors
Amin AP et al. AHA QCOR conference 2015

14. Hospitals are struggling
-20%
-15%
-10%
-5%
0%
5%
10%
15%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Hospital Medicare Margins
IP OP Overall
Source: MedPAC report March 2015

15. Very Challenging to Provide “High
Value Care” when Risk is High

16. Methods
Amin AP et al. JACC Cardiovasc Interv. 2013 Aug;6(8):827-34.

17. Adjusted Costs of Radial PCI:
From 5 US Hospitals
$14,954
$15,784
$14,000
$14,500
$15,000
$15,500
$16,000
Radial Femoral
P < 0.001
Δ $ 830 favoring radial PCI
Amin AP et al. JACC Cardiovasc Interv. 2013 Aug;6(8):827-34.

18. Current Hospital Costs of PCI:
the PCI Care Pathway
Amin AP et al. Accepted for Publication JACC Intv. 2016

19. Δ $ 3,600 favoring radial SDD PCI
Current Hospital Costs of PCI:
the PCI Care Pathway
Amin AP et al. Accepted for Publication JACC Intv. 2016

20. Cost savings to a hospital performing 1,000 elective PCI procedures
annually, when converting from the current pathway of TFI NSDD to
TRI SDD
Amin AP et al. Accepted for Publication JACC Intv. 2016

21. What we did at Barnes Jewish Hospital

23. Market Leader in St. Louis Metropolitan Area
U.S. News & World Report “Best Hospitals in
America” Honor Roll for 22 Consecutive Years
During 2014:
• 955,986 OP visits
• 1,167 Staffed Beds
• 57,718 Inpatient Admissions
• 47,299 Surgeries
Heart & Vascular Program Ranked #15 via U.S.
News & World Report

24. PCI Outcomes at BJH before we
started….
• Excellent Mortality
• Excellent STEMI D2B
• However, a high rate of
bleeding complications
10.37%
8.87%
7.13%
8.96%
8.23%
7.79%
8.20%
0%
2%
4%
6%
8%
10%
12%
Q1 Q2 Q3 Q3 Q1 Q2 Q3
2011 2011 2011 2011 2012 2012 2012
PCI related Bleeding Events (%)
NCDR Avg 4.43%

25. Patient Centered Approach in the
Cathlab
• We predict patient-specific risk via a software
solution (ePRISM)
• We target those at the highest risk with
evidence based safe therapies – the goal is to
achieve high reliability

26. Consistent attention to patient specific
risks, each case, each time

27. Impact on Hospital Efficiency and
Costs

28. Rapid Uptake of Radial Access for PCI
0%
10%20%30%40%
2013 2014 2015
1 2 3 4 5 6 7 8 9101112 1 2 3 4 5 6 7 8 9101112 1 2 3 4 5 6 7 8 9101112

29. Bleeding Events Have Reduced

30. Mortality Has reduced

31. BJH Same Day Discharge Program

32. Same Day Discharge (~80%) has reduced
LOS and Cost
• Our unique “patient-centered approach” to SDD:
• Provides us the ability to perform SDD even when
PCI complexity is high

33. 68%
63%
26%
36%
67%
20%
28%
18%
0%
20%
40%
60%
80%
Type C
lesion
Long
lesion >
20 mm
SVG graft Diabetes CHF CVD PVD COPD
Prevalence of Comorbidities and Lesion
Complexity among Same Day Discharges

35. Predicted Risks of Bleeding, Mortality
and AKI

36. Patient Satisfaction is High with SDD
19%
82%
12%
88%
0%
25%
50%
75%
100%
Excellent
Care - No
Excellent
Care - Yes
Extremely
Satisfied - No
Extremely
Satisfied -
Yes

37. Lower Spend with SDD

38. PCI Cost Per Case by DRG (Medicare Pts Only):
BJH has lower spend than most hospitals
BJH Hospital National Avg

39. Total Cost Savings Annually ~ $5 Million
Savings from a reduction in PCI complications $1,235,000
Increased revenue from improved outcomes (QHIP) $884,000
Increased revenue from Medicare (VBP) program $600,000
Savings from Same Day Discharge (SDD) program $452,000
Savings on PCI medications / Pharmacy savings $494,000
Estimated total savings $3,665,000

40. Post-Implementation
Case example

41. 78 yr male with ESRD, calcified vessels, PVD, CHF,
COPD (FEV1 32%), CTS refused CABG

42. 78 yr male with ESRD, calcified vessels, PVD,
CHF, COPD (FEV1 32%), CTS refused CABG

43. 78 yr male with ESRD, calcified vessels, PVD,
CHF, COPD (FEV1 32%), CTS refused CABG

45. 65 yr old male, returns 3 weeks after CABG with
chest pain, drop in EF and EKG changes

47. CTO of OM

49. Case Example
• 86 yr old female, 46 kg, frail, severe COPD/asthma, FEV1
41%, steroids for 45 yrs, thin skin, bruised all over, CKD,
eGFR 30, HTN, PVD, CVD, Afib, on coumadin, CHF EF 35%,
RWMA, restrictive physiology, porcelain aorta on CXR,
extensive coronary calcium
• Presents with crescendo unstable angina, she thinks its
“asthma”
• EKG changes of ST–depression V1-V6 at baseline
• Refusing CABG

50. Formal Pre-procedure Risk Assessment
Maximum tolerated safe contrast limit = 124 ml
Images from ePRISM©

51. Case Example

53. Case Example

54. • 100 cc dye use, no bleeding, no AKI
• Angina Resolved
• Underwent cardiac rehab 30 mins daily
• Walking 2-3 flights of stairs

55. Thank you!

56. Thank you!

58. What will the Episode of Bundled Care
include?

59. Episode Definition

60. CAD Episode Timeline

61. Goals of Bundled Payments for PCI

62. “..mistakes will occur, and it is
not reasonable to ask for
perfection, but it is
reasonable to ask that we
never cease to aim for it…”