Jeffrey Bruckel, MD, MPH, FSCAI; Alexander Lee, MD, FSCAI; and Konstantinos Dean Boudoulas, MD, FSCAI

Introduction

Cardiac catheterization and coronary interventions are one of the highest-volume procedures in the cardiovascular service line. As interventional cardiologists, we primarily focus our efforts on performing the procedure safely and achieving a successful outcome. With ongoing challenges in reimbursement and pressure on hospitals to increase productivity and improve efficiency, it is important that interventionalists become more cost aware and understand potential drivers of cath lab efficiency. With that in mind, how can we provide better care while reducing cost?

In this Tip of the Month, we focus on strategies that may help improve cost-effectiveness in the cath lab while maintaining high-quality patient care and improving patient satisfaction.

Best Practices

In April 2021, SCAI published an expert consensus update on best practices in the cardiac catheterization laboratory.¹ Adopting and incorporating best practices will impact the value of healthcare provided and potentially affect downstream cost considerations. A detailed review of cath lab operational efficiency was also published in the Journal of the American College of Cardiology (JACC) in 2018.²

A white paper by Intelerad using LUMEDX’s HealthView Analytics highlights seven best practices to boost quality and reduce costs in the cath lab:³

1. Reduce Overuse of Expensive Contrast – When addressing the issue of expensive contrast overuse, labs should start with looking at their cath lab population and determine the percentage of patients at risk for acute kidney injury (AKI), comparing that to the percentage of cases where expensive contrast was used. Analyzing that data will determine whether an opportunity exists to ensure that expensive contrast use is truly reserved for those at highest risk. Reducing care variations would be a first step in improving not only cost-effectiveness, but also quality of care.
2. Moving From Femoral to Radial Access – In a paper by Amin, et al. analyzing patients eligible for same-day discharge (SDD) in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, patients undergoing a transradial intervention, coupled with subsequent SDD, were associated with fewer complications and lower in-hospital costs compared to patients undergoing a transfemoral intervention with non-SDD.⁴ The cost difference amounted to $3,689 (95% CI: $3,486-$3,902; p<0.0001). Labs should set goals in terms of cases performed via radial access (50%-70%).
3. Reducing Complications – Complications increase length of stay and reduce quality of care and patient satisfaction. Knowing your lab’s complication rate is important in identifying opportunities for optimizing percutaneous coronary intervention (PCI) outcomes. Many institutions participate in the NCDR CathPCI Registry, which helps track metrics such as bleeding, AKI, mortality, and stroke. Utilizing published risk calculators may help in case planning as well as in the informed consent process to help patients better understand the procedural risks.
4. Reducing Hospital Length of Stay – Elective ambulatory patients undergoing PCI should be assessed for potential SDD, as it has been proven to be safe, leads to higher patient satisfaction, and lowers hospital costs. Additionally, it has been shown that by using a patient-centered protocol based on risk of complications, SDD increased rapidly and was safe in 75% of patients undergoing elective PCI, despite patient complexity.⁵ As hospitals continue to seek opportunities to improve patient satisfaction and improve operational efficiencies, SDD should become the default and not the exception for most elective outpatients.
5. Analyzing Cost per Case by Provider – Hospital administration and cath lab directors should periodically review cost per case by provider. Physician-specific cost variability while performing similar procedures may be reviewed for potential impact as it relates to outcomes. Analysis of the cost data is useful but should also be mindfully adjusted to reflect case complexity.
6. Optimizing Lab Utilization to Cut Overtime – Optimization of lab utilization is of paramount importance when considering staffing models and patient throughput. Unnecessary delays in start times, lab turnover, and patient transport all lead to workday inefficiencies—especially when considering utilization of overtime pay. Tracking “wheels in” and “wheels out” times can better assist in understanding procedural and turnover times. Construction of detailed process maps of typical procedures can also help target areas for improved efficiency.
7. Cath CPT and Device Billing Audits –Variations in provider documentation, missed supplies, and inconsistent data between devices and procedures lead to coding and billing errors. Regular audits for supply/procedures should be performed to ensure accuracy both from a coding and billing standpoint. Implementation of inventory management technology such as radio frequency identification (RFID) scanning may enhance the ability to link supplies to patients and procedures.

Summary

Providing better patient care at a lower cost will improve operating margins. This can be achieved by careful consideration and the adoption of best practices, including evidence-based care delivery that can lead to higher patient satisfaction, improved outcomes, and lower in-hospital costs.

References

1. Naidu SS, Abbott JD, Bagai J, et al. SCAI expert consensus update on best practices in the cardiac catheterization laboratory: This statement was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) in April 2021. Catheter Cardiovasc Interv. 2021 Aug 1;98(2):255-276.
2. Reed GW, Tushman ML, Kapadia SR. Operational Efficiency and Effective Management in the Catheterization Laboratory: JACC Review Topic of the Week. J Am Coll Cardiol. 2018 Nov 13;72(20):2507-2517.
3. “Boost Quality and Reduce Costs in the Cardiac Cath Lab with Embedded Performance Analytics: 7 Best Practices.” White Paper, https://www.intelerad.com/en/wp-content/uploads/sites/2/2021/08/WP-Cath-Best-Practices.pdf.
4. Amin AP, Patterson M, House JA, et al. Costs Associated With Access Site and Same-Day Discharge Among Medicare Beneficiaries Undergoing Percutaneous Coronary Intervention: An Evaluation of the Current Percutaneous Coronary Intervention Care Pathways in the United States. J Am Coll Cardiol. 2017 Feb 27;10(4):342-351.
5. Amin AP, Crimmins-Reda P, Miller S, et al. Novel Patient-Centered Approach to Facilitate Same-Day Discharge in Patients Undergoing Elective Percutaneous Coronary Intervention. J Am Heart Assoc. 2018 Feb 15;7(4):e005733.