Initial Experience With a Redesigned Care Pathway

In this month’s featured article, Dr. Mark Bieniarz discusses his institute’s journey into the cost saving and operational efficiencies gained from working with MedAxiom and Terumo Business Edge, and a Care Pathway redesign project. It is our hope that these articles and the information provided gives your program further insight into how a Care Pathway project can have a significant impact into your future care delivery options.                                                    - Gary Clifton, Vice President, Terumo Business Edge

The recent election remains fresh on all of our minds and its impact on the Affordable Care Act is yet to be determined. With the president-elect promising to repeal the legislation, there are aspects that remain incredibly important to improving the quality of care, no matter your political persuasion. The transition from volume to value will be an important approach to healthcare policy regardless of the politics of the White House. Healthcare has become unaffordable for the country and for the individual American. The only solution is a transition to value in order to make healthcare based in evidence and in cost containment. In our local experience, one hospital has been able to begin a successful navigation through this transition by leveraging the benefits of a progressive radial program, impacting the shift from volume to value.

Lovelace Medical Center began its journey to a high-volume radial center under the direction of two interventional cardiologists, myself and Dr. Geoff Kunz with the New Mexico Heart Institute, the aligned cardiology group. Our program quickly expanded to involve all four of the group’s interventional cardiologists, with a commitment to practice according to published outcomes studies. There was also a clear realization that a radial pathway was solidly aligned with emerging cardiovascular market trends and it positioned Lovelace at a competitive advantage, and enhanced safety and quality outcomes for patients. Dr. Kunz and I were influenced by the significant benefits of radial access, including reduced bleeding, mortality benefit in the highest risk patients, and patient comfort. We prioritized radial access as the first and preferred option for our patients, and in 2010, Lovelace Medical Center became distinguished among high-volume radial centers. Radial adoption at Lovelace Medical Center rapidly grew, reaching a rate of over 90 percent for diagnostic and interventional coronary work. This was a significant accomplishment, outpacing United States volumes, which, at that time, were struggling to hit a radial access rate of 20 percent. Lovelace Medical Center did have some unique features driving its radial work. Albuquerque as a whole has a very high rate of radial adoption, so it has become a norm in our geographic location. The physician learning curve was supported by the groups’ philosophy on procedural work being consolidated to a small group of operators, resulting in high volumes and rapid uptake of new skills such as radial access. By 2012, New Mexico Heart Institute achieved our goal of offering a radial procedure to 100% of all eligible patients at Lovelace Medical Center.  

Entering 2015, Terumo Interventional Systems, the leader in transradial products, engaged MedAxiom Consulting to visit four cardiovascular programs across the country in order to determine what drove programs to achieve success in the adoption of radial access. From the information gathered in this effort, Terumo would go on to create a separate, dedicated business unit, Terumo Business Edge, to partner with MedAxiom to deliver on their collective solution. MedAxiom is the nation’s largest cardiovascular business network, with over fifteen years of benchmarking data and former cardiovascular service leaders; as such, MedAxiom was uniquely positioned to bring information together and work with Terumo to educate the broader cardiovascular market. Lovelace Medical Center Medical, as a leader in the radial space, was selected as one of the four systems reviewed to gain an understanding of what factors drive high-volume radial adoption. During the assessment of the Lovelace Medical Center radial program, MedAxiom was able to validate the solid adoption of the radial approach and our full team commitment to the radial offering. Our program was delivering patients the intended benefits of reduced bleeding risks, reduced access site complications, and a preferred patient experience. 

What was absent at Lovelace was the full value of the radial offering in the care pathway development. The impact on the procedural room, bleeding reductions, and patient experience was evident, but the extension to the office, prep, recovery, and discharge practices had gone relatively untouched during the radial expansion. We realized the allure of a radial program was much greater than just the access site; it was the ability to change the whole episode of care for patients.  

Background

Historically, volume has been the driver for cardiovascular programs. Volume is how budgets are built, drives a positive margin and ensures physicians meet clinical volume requirements, and it supports contract negotiations. The migration from volume to value will be a challenging process in most healthcare systems. Cardiology has been and continues to be on the front line of this conversion. Most recently, the proposed acute myocardial infarction (AMI) bundle is an example of cardiology’s role in healthcare reform. This bold alternative payment model (APM) is intended to reward programs that are patient centered and patient responsive; assigning the cost of care, both the penalties and rewards, to those responsible for delivering it.¹ The goal is to move beyond traditional process improvement events, and fully develop the entire care continuum and care team that supports the patient. The leadership and team at Lovelace provide a worthy example of how a radial pathway positions programs for success in a value-based payment model.  

The episode payment model (EPM) of the AMI and coronary artery bypass graft surgery (CABG) bundle is proposed to begin July 1, 2017 and end December 31, 2021. Ninety-eight programs within a metropolitan statistical area (MSA) will be randomly selected to participate in these new APM. The criteria for AMI participation is:

• At least 75 AMIs per year;
• At least 75 non-bundled payments for care improvement (BPCI) AMIs per year;
• Of the total AMIs, have at least 50% non-BPCI AMIs.

The current proposal also outlines upside and downside risk for programs participating. In order to benefit from the upside dollars in the bundle, programs must meet quality and financial targets. So, how can your program benefit from the proposed AMI bundle? First, the cost to Medicare must come in below the approved target cost. Second, the program must meet or exceed in the following quality measures:

• Thirty-day, all-cause, risk-standardized mortality post-AMI;
• Excess days in acute care after AMI;
• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score; 
• Voluntary, hybrid 30-day, all-cause, risk-standardized mortality eMeasure data submission.

The radial approach has compelling data to support reduction in mortality in this tenuous AMI patient population. This is achieved by reducing bleeding risks in an aggressively anticoagulated patient. The data from HCAHPS is more qualitative, but operators strongly agree patients prefer a radial approach, especially if they have had a previous femoral procedure. The ability to shorten length of stay (LOS) is enhanced when the potential for femoral access site complications is eliminated. These are strong financial reasons and clinical drivers for an interventional program to aggressively grow radial adoption and a radial pathway for success in the new value model.

The time is here to focus on the care pathway around the PCI patient. Systems and providers are looking for solutions to place their PCI services in a favorable light to government payers, private payers, and the patient as a true consumer. Developing or enhancing a transradial program has the ability to competitively position a PCI program through quality, safety, patient experience, and financial performance. It can be a challenge to find a therapy that achieves the triple aim on all fronts. The radial pathway accomplishes this lofty goal.

Although beginning my career in the lab just 2 years ago I was able to
bypass the femoral era where laying in bed for patients felt like an
eternity and holding pressure to maintain hemostasis felt like it would
never end. I am lucky to be at a site where radial is the primary access
and putting a TR wrist band has substituted those sore and shaky
fingers after holding pressure. If ever I have to choose between radial
access and femoral with no hesitation I’m going to go with what I am
familiar with and less likely to feel discomfort.
— Corey Portis, RT(R)

Solutions

The work at Lovelace Medical Center was unique because of our center’s ability to achieve such high radial procedure numbers. Lovelace Medical Center had a well-defined and efficient procedural radial program, but there was room left for development of the full radial pathway. When compared to traditional femoral procedures, Lovelace Medical Center cardiologists performed percutaneous coronary intervention (PCI) procedures in the same or less time, used similar contrast amounts, and the radiation dose was the same or reduced. Despite those significant intraprocedural accomplishments, inefficiencies around the procedure room were abundant. MedAxiom identified the following opportunities for Lovelace Medical Center leadership:

• Coordinate care with the office
• Optimize prep work
• Intra-procedure
• Post procedure/recovery area

On completion of the assessment, MedAxiom shared the findings with our entire team in a live presentation. We received individualized grids, protocols, and metrics, and a prioritization template. Several of these opportunities generated solutions that could be measureable and reduce pain points in other areas of the organization. Lovelace Medical Center had the greatest potential in developing a same-day discharge program. Along with cost and resource avoidance, same-day discharge helps decompress capacity issues many hospitals are experiencing. The inpatient cardiovascular unit at Lovelace Medical Center frequently ran at capacity. This caused delays in admitting true inpatients to these beds and delayed transfers from the ICU and ED. The high-capacity situation put undue stress on the staff, resulting in a chaotic work environment and less-than-desirable experience for staff and patients. Below is an example of conservative cost avoidance calculations with implementation of a same-day discharge program. After discussions and considerations for our particular program, our finance department took a conservative approach regarding cost savings at $500 per patient in cost avoidance. Shroff et al² have reported same-day discharge savings ranging from $320 to $1523 in prior studies. They summarize the impact to the U.S. healthcare system at a $200 to $500 million decrease with a shift to 50% same-day discharges in the bundled payment setting. However, there seems to be strong evidence, as reported by Calderon Artero et al³, that the cost avoidance opportunity is considerably more when the financial cost structure is scrutinized further.

Our radial access program has allowed us to improve throughput
and decrease vascular complications. Less time is needed for
hemostasis, which improves room turnover. Our same-day discharge
program for patients who received interventions is loved by our patients
and staff in our day patient area. The financial repercussions of a
vascular complication are basically non-existent in our patients and in
today’s world of healthcare, that is valued.
— Elisa Gugerty, RN, MSN, Cath Lab Director, Lovelace Heart Hospital

Assumptions:

• 40% of the 400 annual elective PCI patients could be sent home the same day. 
• In 2013, Amin et al estimated an unadjusted savings of $1,560 per case.⁴
• In 2016, Calderon Artero et al have updated economic estimates to $3,200 per case.³

These were the cost opportunities shared with Lovelace Medical Center. There is new research taking a more comprehensive look at cost savings around same-day discharge that factors in changes to reimbursement as well as the impact of new inpatient admission requirements. This study, conducted at Barnes Jewish Hospital in St. Louis, estimates cost savings closer to $3,200 per event.³ 

Transformational Opportunity

Lovelace Medical Center has been able to make significant strides by operationalizing the recommendations provided by the Terumo/MedAxiom report. Lovelace Medical Center is leveraging the radial procedure to move forward in the new value environment. In order to accomplish this agenda, the physicians and staff drove the following work:

• Physician-driven goals in same-day discharge protocols
• Office to hospital messaging on same-day discharge
• Increase in same-day discharge from 4% to 50%
• Reduction in 30-day readmission rates — due to radial program
• Enhanced throughput and the ability to receive needed transfers — reduced diversions
• STEMI work has grown to 90 percent or greater with radial access
• Removed the risk of devastating access complications

The results at Lovelace Medical Center are impressive and speak to a practical means that clinical and administrative leaders must achieve in this new market.  

The transition from femoral approach to radial approach, initially did
not come without a little resistance from the cath lab staff. But now
we find that radial access itself takes less time than ultrasound-guided
femoral access and the coronary angiograms can sometimes be done
with just one radial catheter. I couldn’t imagine using primarily femoral
artery approach now, as radial access has improved heart caths for
overall better patient outcomes and the efficiency of our cath lab.
— Nancy Kinney, RT(R), RCIS

Conclusion

The term “risk” has taken on a new meaning to healthcare leaders today and there continues to be new ways in which stakeholders are working together to align risk and improve quality. Payers and providers, providers and hospitals, hospitals and employers; the focus on working together to achieve shared goals and success continues to expand across the market. Terumo Business Edge and MedAxiom, through their strategic partnership, are committed to providing interventional programs with concrete data and customized plans to successfully move your program into the value model.

References

1. Centers for Medicare & Medicaid Services (CMS). Notice of proposed rulemaking for bundled payment models for high-quality, coordinated cardiac and hip fracture care. Fact Sheet. July 25, 2016. Available online at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-25.html. Accessed November 17, 2016.
2. Shroff A, Kupfer J, Gilchrist IC, Caputo R, Speiser B, Bertrand OF, et al. Same-day discharge after percutaneous coronary intervention: current perspectives and strategies for implementation. JAMA Cardiol. 2016 May; 1(2): 216-223.
3. Calderon Artero PM, Winter L, Hohlt J, Digue A, Crimmins-Reda P, Amin A. A patient-centered approach to same day discharge after complex percutaneous coronary intervention. J Am Coll Cardiol. 2016; 67(13_S): 192-192.
4. Amin AP, House JA, Safley DM, Chhatriwalla AK, Giersiefen H, Bremer A, et al. Costs of transradial percutaneous coronary intervention. JACC Cardiovasc Interv. 2013 Aug; 6(8): 827-834.

Disclosure: Dr. Mark Bieniarz reports he is a consultant and radial proctor to Terumo, and a consultant and member of the speaker’s bureau for AstraZeneca.

To learn more, contact us at info@terumobusinessedge.com