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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
Icg	2015	
CME	Disclosure	Statement	
Consultant	for	Cardinal	(Cordis)	
&	Terumo,	Inc.
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
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
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
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
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.
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
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
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
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)
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
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
Icg	2015	
First	generaMon	stents	
AnMcoagulated	out	paMents	
Discharged	same	day
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
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
Icg	2015	
Thank you
Contact:	icg1@psu.edu

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