How Does Your Cath Lab Stack Up?

Have you wondered what other cath lab turnaround times are? Do programs really offer outpatient cath procedures on the weekends? How successful have other programs been in implementing same-day discharge? Are cardiovascular (CV) dedicated picture archiving and communication system (PACS) and business managers becoming the norm? How are other programs filling cath lab space left open from declining elective percutaneous coronary intervention (PCI) volumes?  

As consultants for MedAxiom, we can assure you that you are not alone in trying to find answers to these basic but elusive questions. To develop a survey to meet this critical need, MedAxiom partnered with Terumo in 2016. The intent of the cath lab survey was to collect qualitative data from those intimately involved in cath lab operations. The survey was written by former cath lab staff and leaders, and is structured around 4 key axioms:

• Organizational – Structure of the program
• Operational - Day-to-day running of the lab
• Clinical Excellence – Level of focus and action quality, safety, and program development
• Transformational Actions – Leading work in the other three axioms

The survey was distributed by MedAxiom to their members and by Cath Lab Digest to readers. The survey consisted of 72 questions and received 40 responses. The survey was in depth and required participants to complete detailed questions about their program.  The MedAxiom team is using the data as a directional tool to understand what cath labs are focusing on today and need for tomorrow. The programs responding varied in size and mission, and included both community and academic programs. Programs had diverse clinical offerings, from elective PCI work to cardiac transplant programs. The common denominator was that all programs operated a cath lab. Each program that submitted a response received a report on how they benchmarked against the other participating programs.  

The survey closed at the end of 2016 and the MedAxiom survey team began reviewing the responses. Did they identify any interesting trends or unexpected responses? The answer to those questions was both yes and no. The first answer they found interesting was the survey group’s response under a question in the operations section of the survey. The question (Figure 1) read, “Does your cath lab have an organized clinical standards and policy committee?”

Although we were not surprised to find many programs do not have a formal means of reviewing clinical standards, standing procedures, and policy, this is a critical opportunity as payment models replace volume with quality and value.  Cardiology programs have been inundated with information about payment models focusing on episodes of care.  The newly approved cardiac bundles are an example of these new payment models. So how will a structure to review care process position programs for future success? Programs will need a vehicle to review current practices and policies around cardiac procedures. A clinical standards committee could be the driver of this work. Clinical protocols should be vetted based on quality of outcomes to the patient, cost to the episode, and impact on the patient experience. If a past care model, test, or interaction does not provide value under these criteria, immediate consideration should be given to eliminating that practice. Top of the list for these committees should be review of variation in care/practices. A common example found in many cath labs is variation in bed rest times post procedure. If bed rest time is a physician-by-physician choice, not based on a practice standard, this introduces too much unnecessary variation. The end result is confusion to staff and patients, and potentially wasted resources. The structure to review and understand basic practices producing best outcomes is a hidden opportunity in many programs.

In the past, growth in cath lab capital investments were a frequent and expected practice. The work done in the cath lab space generated strong revenue and drove the cardiology service line to become one of the top performers on the hospital balance sheet. However, since late 2008, when many procedures done in the cath lab began changing from inpatient work to outpatient work, the outpatient payment transition dramatically reduced cath lab procedural revenue in many programs. Payment changes were not the only activity that caused cath labs to pay closer attention to margins. The improved outcomes from medical management and refined criteria for appropriate use of PCI also drove down the elective PCI numbers. Many cath labs found themselves, for the first time, operating in the red when it came to net margin. In response to these considerable changes in cath lab finances, the survey posed a basic questions about cost per case reporting and transparency (Figures 2-3).

Based on the results above, it is still difficult for programs to measure cost per case. These results highlight the pressing need for programs to come to agreement on what costs are included and how this data will be used. Transparency in data is important so context can be put around costs and ownership can be established.Costs cannot be reviewed in isolation from quality data. Physicians need to have cost data aligned with quality data to drive standardization that achieves the highest quality outcomes at the lowest costs. We continue to hear from physicians about the need to become true partners in health care economics. System leaders that can work hand in hand with physicians, sharing financial data, upside and downside risk, and more control will significantly increase physician engagement. Programs that provide physicians with transparent data set the table for the right discussions. The culture must support a team effort led by both administrators and physicians.  

With all the changes in the cath lab environment, how are cath labs planning to achieve operational efficiency in the future (Figure 4)?

Many responding programs selected almost all the options for program optimization. The initiatives mentioned all have merit, but selecting one or two is more realistic. Here are some considerations that may help you focus on the right initiative if your program has the following concerns or attributes:

Same-day discharge if your program has:

•    High radial adaption
•    System capacity issues
•    Diversion 
•    Need for system cost avoidance

Radial program if your program needs:

•   Same-day discharge program
•   Site complication reduction
•   AMI bundle site selection – improved outcomes for STEMI patients
•   Improved patient experience
•   Lower cost per case than femoral access

Staffing redesign if your program can:

•  Leverage integrated EMRs between the office and hospital
• Partner with ambulatory sites and reduce rework
• Right size staff and care models for outpatient procedures
• Redeploy staff to new programs 

Supply contracting system opportunities:

• Investigate new purchasing groups
• Ability to manage contracts as a service line/system not just a cath lab
• Ensure inventory management practices are solid
• Quality, outcomes and costs must all be contracting considerations

Reduced clinical offerings for low volume, high cost programs:

• Consolidation of a high cost program with a partner (or)
• Consolidation of program offerings within a system 

   Examples:
– Open heart surgery programs
– Transcatheter aortic valve replacement
– Ventricular assist devices
– PCI

New program questions:

• Is it offered in close proximity?
• Is there a capital investment?
• How do the projected financials look?
• What are the personnel requirements?

Process improvement (PI) training needs:

• Executive sponsor
• PI expert/champion & supporting team
• Funding 

The cath lab environment has never been more dynamic or cost sensitive. Payment reform will require new tools and more discipline to work as a team while driving quality and reducing costs. What can be derived from the cath lab survey is that programs know they must make adjustments to remain successful in the future. The survey responses also reflect a great opportunity for programs in both clinical and financial optimization. The challenge is the resources needed to drive this kind of transformation. A good example is same-day discharge for elective PCI patients. Despite compelling research on the safety of same-day discharge, adoption has been slow. Simply sending a patient home the day of service will lend a cost avoidance approximating $500.00 per event. In order to achieve a significantly greater cost savings, upwards of $3600.00 per event, (as referenced by Amin, et. al, CLD, Nov 2016) the care teams and processes around the PCI episode must be redesigned. Health care redesign is a complex and resource intensive process. What is clear is that programs investing in these efforts will be rewarded in new care models.