The TAVR Program at Mercy Hospital Springfield

Dr. Merritt and Dr. Parvathaneni can be contacted via Jonathan Hart at jhart@jla-inc.com.

I. An interview with Robert F. Merritt, MD.

Can you tell us about the transcatheter aortic valve replacement (TAVR) program at Mercy Hospital Springfield?

We began with the introduction of TAVR in March 2013, after the FDA approval of the first-generation device. Since that time, there have been another two generations of the Sapien valve (Edwards Lifesciences) and one new generation CoreValve device (Medtronic). We have done about 160 cases since our program began. Initially, the operating room dominated the environment for TAVR, but as time has gone on, we have explored the minimalist approach. The vast majority of our cases have been done in the OR up until the last 4 to 5 months. We have now done approximately 35 TAVRs in our cath lab. We transitioned 90% of our cases to the cath lab over a very short period of time. In the OR, we were already using a kind of minimalist approach by doing transfemoral approaches with some monitored anesthesia. We also were shifting away from transesophageal echocardiography (TEE) at the same time, instead using intracardiac echo, as well as occasionally transthoracic echo. The intracardiac echo is a venous approach and we found we were able to get adequate views of the aortic valve and the surrounding structures with good enough interpretive quality to be sure of an adequate implant, along with the hemodynamics from the catheterization-based side of the procedure and an aortic root angiogram. Our confidence grew through approaching the minimalist procedure in the OR. We saw that we could successfully percutaneously close the access site in these patients with a dual Pre-close procedure, and felt we should explore moving TAVR to the cath lab. At the beginning, we looked for well-qualified patients that met specific criteria. If they were morbidly obese, we were initially less likely to take these patients to the cath lab. (That has now changed.) We also considered the approach. If the patient had very good vasculature, as seen in the CT angiography data, then we felt the patient would be easily performed in the cath lab. We also did not want to exclude patients with significant lung disease from the cath lab, because intubation is actually a potentially harmful or at least a considerable risk to these patients. We don’t like to heavily sedate patients, because it puts them at risk of having a prolonged bed rest after the procedure and certainly that is the case with anesthesia. We also found that the methodology followed for post surgical patients is not the same methodology, in general, followed for post catheterization patients. The surgical arena is dominated by a surgical incision, and the care for that incision potentially prolongs the patient’s overall recovery. Everyone moves through the same general protocol for surgical recovery, and it is slower than what a catheterization-based protocol would dictate. So, for all these reasons, we switched fairly abruptly over to performing TAVR in the cath lab and haven’t excluded anybody from the cath lab unless they required surgical access. Out of the last 35 TAVR patients, 31 have been done in the cath lab and just 4 in the hybrid OR rooms. For those patients that were done in the cath lab, our length of stay is 1.68 days, which includes one case that had a significantly longer length of stay due to pre hospitalization. The protocols and the pathways that the patients follow coming out of the cath lab instead of surgery make a big difference. We generally take the patient to a post cath lab interventional suite, where the patient recovers as if they had a coronary angiogram, using that protocol. Of course, if a patient requires a temporary pacemaker, especially if they had a CoreValve, then they go to the unit with a pacemaker in their right internal jugular vein and we check an electrocardiogram. CoreValve patients are generally going to stay two days, because we want 36-48 hours of monitoring the electrocardiographic outcome of the patient.

Why is it that temporary pacemakers are mandated for the CoreValve?

It is a consequence of the structure of the valve. The length of the valve device is longer, and it protrudes into the infundibular portion of the outflow tract of the aortic valve. The left ventricular outflow tract carries the nervous fibers of conduction, and if there is pressure placed on these fibers by the self-expanding nature of the valve, then it can cause interruption of the circuitry, resulting in arterioventricular (AV) block, complete heart block, or even asystole. These patients need to be watched for about 36-48 hours to make sure that they don’t have any potential of developing heart block that would cause them to have an adverse outcome. These patients generally go to the ICU, but it is a cath lab-based ICU, and the patients follow different trajectories of time for mobility and recovery. Even patients following the Core Valve pathway, with a temporary wire in the RIJ, can be mobilized and have their care expedited. Ambulation is from as little as 4 hours up to 6 hours. If we have a perfect closure, then we can have the patient sitting in 3 hours and walking in 4. The sooner these patients are up and moving, the sooner they get out of the hospital. That’s not just TAVR patients, that’s any cardiac patient. The sooner they are ambulated, the sooner they are going home.

Often when a patient has a surgical procedure, they end up going to skilled nursing afterward, because they are having difficulty with their wound. We have virtually eliminated any post hospital care in terms of placement in either a recovery facility or otherwise.

One problem we have encountered is that we are finding a long wait time to get patients to the TAVR procedure. It is a current and ongoing issue. The longer a patient has to wait to get to TAVR, the more likely the patient is to be debilitated or worse, has an adverse event due to aortic stenosis, either heart failure or sudden death. The more debilitated the patient, the longer the patient will take to recover from all aspects of the procedure and will likely end up needing a skilled nursing facility or some kind of assisted care afterwards. This delay to treatment ends up increasing the overall cost for the procedure and the debilitated state that the patient reaches while waiting can worsen the outcome. Given the expected growth in aortic stenosis population and thus the numbers of patients that will need TAVR, our pre TAVR evaluation is being optimized to stage patients more efficiently. The combination of the improved pre TAVR logistics and the minimalist approach should allow for expansion of our volume and throughput, with lowered overall cost and better outcomes for our patients. 

Can you talk more about the timing from when you first receive a patient to their actual procedure?

It has improved somewhat over time, but is still the main limiting factor. In early 2013, it could take anywhere from 3 weeks to 3 months to get a patient to TAVR. There was demand for the procedure, but limited supplies, training, and doctors, and thus limited access overall. We have improved access, but we still haven’t met the goal of being to evaluate a patient in one week and deploy the valve the next week. That should be the goal, because the population dynamics of TAVR are expected to increase by 3- to 4-fold over the next several years. Instead of a program doing 100 TAVRs a year, a program is going to have to do 300 TAVRs a year. The process by which we evaluate these patients and get them to the procedure needs to be improved substantially. The procedure itself is nearing its potential to provide a 1.5-hour implant time with excellent results and outcomes. We can do a TAVR procedure very safely and quickly. Now the real challenge is the length of time it takes to get the patient to the procedure. 

What we would like to do is establish a mechanism by which the surgeon receives the initial referral and places the patient in a high likelihood of being an acceptable TAVR candidate. At that point, the patient would get a CT angiogram and a cardiac catheterization on the same day, which we think we could provide with an exposure of about a maximum of 120ccs of contrast. Other centers may rely specifically on CT angiography and eliminate the coronary angiographic procedure, which might be another way to expedite patient evaluations. Generally, a TEE is not needed pre procedure, because the transthoracic echo has enough data. As long as there is not significant mitral regurgitation or some other structural heart problem, we probably only need a CT angiogram plus/minus a cardiac cath.

How has the team come together and organized for change?

Our cath lab is very dynamic and is familiar with complex procedures like chronic total occlusions, Impella-assisted percutaneous coronary intervention, and structural heart procedures. We had the background necessary for performing TAVR. Our cardiothoracic surgeons train side-by-side with the interventional cardiologists in an angiographic suite in both peripheral as well as aortic stent graft procedures. We started with all our TAVRs being performed in the OR. However, the surgeons were not only very amendable to going to the cath lab, but have actually been a strong part of the conversation about moving the patients to the cath lab. This is not necessarily something that every other site should do, because you must have a very good working relationship with your cardiothoracic surgeons. Some centers may not want to move out of the OR because they may have dedicated support by cardiac anesthesia and ancillary services.  At our institution, we felt our ancillary services were provided easier in the cath lab and our experience with conscious sedation, along with the improved safety of the devices, has allowed for a successful move to the cath lab-based TAVR procedure. 

How often does it end up that you move to another access site in a procedure?

When we started with 28 French devices, we would commonly pick surgery. Access was either transapical or the femoral, subclavian, or transaortic. The device size has reduced to 14 French and the Sapien 3 especially is associated with a lower risk of stroke and excellent transfemoral access. The CT angiogram gives you enough data to generally decide on the access. I would say 95% of the time that is the access that will work.

How has the minimalist approach affected patients and the hospital?

The percentage of patients going to a skilled nursing facility or receiving home health care has been reduced dramatically. Prior to May 2015, between 25-30% of our TAVR patients were receiving home health or skilled nursing facility care, and now it is virtually zero. Not only are patients getting out healthier and faster, but our reimbursement is also affected. There are many centers with a good length of stay for TAVR patients of 2.5 to 4 days, but if the patients are getting any sort of aftercare, the hospitals are dinged on their readmission, anywhere from $7-12k/case, due to the Centers for Medicare & Medicaid Services (CMS) Post-Acute Care Transfer (PACT) policy. At Mercy Hospital Springfield, we are getting the patients out quickly, which reduces costs, but we are also protecting reimbursement and revenue by getting these patients out appropriately.

What follow-up care is given once the patient is discharged?

Patients are seen within 1-2 weeks in our TAVR clinic, run by our valve coordinator, Carol Miller. Carol has been instrumental in instituting pathways to improve patient access to the TAVR procedure, but she is also present on the tail end, seeing all the patients with a cardiologist or cardiothoracic surgeon within 1-2 weeks following the procedure. We have very close follow-up. If a patient is anticipated to have problems, they will be seen within the week. 

Carol actually follows the patients in the post operative setting, making sure at certain times certain clinical things are happening. For example, at hour 6, making sure patients are up and moving. She is essentially acting as a nurse navigator in that post operative setting, which is vital to ensuring that these patients are moving through the continuum of care at the appropriate times. Many centers have more administrative resources available than we have had to date, so Carol has been juggling and wearing a lot of different hats. She has recently been given some more resources and help, but has been doing a great job considering how much she has taken on. She is an outstanding and an uncommon resource. Without Carol to understand what we were trying to accomplish and working hard with all of us, we wouldn’t be here today.

Do you have recommendations for other centers that might be considering a minimalist approach?

The advent of the Sapien 3 device, with its decreased risk of stroke (less than 1% major stroke risk), and its decreased mortality and major adverse complication rate of less than 2% that was recently presented, is going to drive us to higher volumes of patients. The cath lab offers a unique environment for opening up access to more patients, with quicker input and output. If people want to move to the cath lab, they need to have a very collaborative team that starts on the first day that the patient is seen, with a good valve clinic. The valve coordinator should be instrumental in applying a process for the patients to be followed and nurtured through the course of the TAVR to an early discharge. 

We use a consulting group, Jonathan Lindsey & Associates Inc. (JLA), as someone that can help us refine the process. It is always reasonable to look outside your own center in order to see how other people are doing things. It gives you more confidence. I don’t doubt that any surgeon or interventional cardiologist with the requisite training can do this procedure in as little as 40 minutes and have the patient sitting up in bed and saying how good they already feel, as long as we don’t let them debilitate in the waiting arena. That’s probably the strongest statement I can make.

How many days per week are you doing TAVRs?

We have the potential to do TAVRs 2 days a week. Tomorrow we are doing 3 cases in the cath lab. 

You mentioned the procedure is only taking around 40 minutes.

Some are a little longer; some are a little shorter. The cath lab team thoroughly understands procedure prep and catheter dynamics. Being in the cath lab removes a lot of the resource utilization that happens in the OR. The OR is a place where there is huge consumption of resources. Whenever you add more and more resources to an arena, the length of time of the procedure is also increased.  I like to say, “The shorter the procedure, the safer the procedure.” Without getting cavalier, if procedure time can be shortened to somewhere around 40 minutes, your outcomes are going to reflect that. Switching from the OR to the cath lab has also given us a 60% reduction in cost, although this is just from the OR to the cath lab, not necessarily overall. TAVR volume demands are going to require a broader platform through which we can offer this procedure to patients. Since May, when we started working on our minimalist protocols and pathways, and shifted into the cath lab, the average reduction in cost has been between $12-15k/case. As a result of the fact that most of our patients don’t go to a skilled nursing facility or home health care, the revenue has increased again. It is a testament to the work that is done on the front end with patient selection, the choice of access sites, how quickly these cases are being done, the post operative protocols, and the setting where patients are cared for, largely not being the ICU. Not only have costs come down, but revenue is protected, and the outcomes have certainly not worsened, but probably been better than before. We hope to publish our 3-month follow-up data in the next few months. On the cost side, it seems fairly obvious that when the procedure moves from a resource-intense area to a less intense area, costs will be reduced. If length of stay is reduced, if the post hospital care is reduced, then costs are lowered even further. Our data is right in line with other centers’ data. What I would like to see is whether there is any difference in outcome. The minimalist approach may actually offer a better outcome. We certainly don’t think there is any worse outcome, based on what we have seen and also because of the evolution of the valve itself. Recent data concerning the Sapien S3 device notes a reduction in all stroke from approximately 6% risk in 2013 to a less than 1% risk of major stroke today along with reduced all-cause mortality. We can all be very happy that our patients are going to get good care.

II. Interview with Sirish Parvathaneni, MD. 

Can you tell us about your involvement with the TAVR program at Mercy Hospital Springfield?

I have been involved since the program began in 2013. In the beginning, we did a lot of high-risk patients and have now switched over to more moderate to high-risk patients. Moving to the cath lab has leapfrogged our program to the point where we are a great deal more comfortable doing high-risk patients on the cath lab table. Yesterday we did three cases and were done by 3pm. All three were in the cath lab, all percutaneous. Two out of the three have gone home. The third could have gone home today, but we still wanted to watch her one more day. She will probably go home tomorrow. 

In order to buy into the minimalist approach, your surgeon has to be on board, which I was from the get-go. TAVR is a different thought process. I love doing open-heart surgery, don’t get me wrong, but I also know that these very elderly patients are very reticent about us, surgeons, putting a scar on them, even if it is a small incision, at 88 years old. If it were me, I would rather have a TAVR done, where I possibly could go home the next day with mild or no paravalvular leak. As a surgeon, I am aggressive and I like to do all the high-risk surgical procedures, but I have also seen bad outcomes from people who have been taken to the OR at 90 years old. You have successes and your bad outcomes make you think, can I do better? I think this device has made us better at offering patients an alternative to traditional surgery. 

What sets our practice apart is that our group, the surgeons and cardiologists, work collaboratively together. One is not dominant over the other; it is a collaborative approach. That has kept our group focused on the end result instead of ego trips where somebody tries to dominate. In my previous experiences at other locations, there has always been a dominant surgeon or cardiologist driving the process, which usually leads to disenchantment by the other members of the team. The cardiologists are great. They don’t force anything and they don’t push for interventions. They want to do what is right for the patient. All the members involved on our team do what is right for the patient. That is why our TAVR program will succeed. We will do around 120 TAVRs this year, maybe even higher. We are lucky to be in the Mercy system where we are a regional referral center for areas in Arkansas, Kansas, and central Missouri. I think that as systems start to implement these high-end procedures such as TAVR, extracorporeal membrane oxygenation (ECMO), etc., one needs to keep in mind the technology is not cheap and the reimbursement is flat. “No margin, no mission!” So those centers that can distinguish themselves early in the TAVR technology will have a competitive advantage. One way we have done this is by performing them in the cath lab with the minimalist approach.

How does your TAVR coordinator, Carol Miller, work with both groups?

Both the surgeons and the cardiologists decided on who was going to be our TAVR coordinator. There was no institutional or personal bias. Carol Miller runs our program and it is very important for any TAVR program to have a TAVR coordinator. We wouldn’t be able to do it without her. The outcomes are better, the database is better, and the patients have a point person they can go to. Without our TAVR coordinator, we are a bunch of guys running around doing stuff, which is not right for the patient. Her involvement with the Society of Thoracic Surgeons (STS) Transcatheter Valve Therapy (TVT) registry is also very important as we are getting more and more regulated. If you don’t have good outcomes, at some point, the government or the insurance companies will not let you perform these procedures, because bad outcomes lead to a rise in healthcare costs. 

Your TAVR program has had great success.

Moving out of the operating room greatly helped our scheduling and logistics. We don’t have anesthesia or all the OR pomp and circumstance to slow us down. We went to conscious sedation and the patients tolerate it very well. Obviously, the truly high-risk patients we put in the OR and intubate. If we do a patient in the OR, we can only do about 2 cases a day. In the cath lab, we can do about 4 cases a day. We are more facile and adaptable in the cath lab as opposed to the operating room. We do have a hybrid room, but it is not in the cath lab. We do everything in the cath lab and have never had to convert to open sternotomy. Our interventionalists have been doing conscious sedation for many years, so they know right away which patients are going to crash. Going into the cath lab has also allowed patients to recover in the cath lab recovery unit. The nurses there understand interventional procedures in the groin, as opposed to a surgical unit, where the nurses might understand somewhat, but not fully get the importance of moving, being up at 6 hours, eating, and so on. The interventional units understand and know the patients have to go home. A surgical unit just wants to keep the patient well. They don’t put that bug in patient’s ear of “you need to go home, you can’t stay here forever!” We get our echo the same day and the next day, if the patient has no complications and trace to mild leak, we send them home right away. 

Yesterday we had a patient with a pacemaker that was inserted several years ago. We probably could have sent him home the same day of the TAVR, because one of the complications of TAVR is a groin bleed and in 6 hours, he had no groin complications, and the second complication is pacemaker insertion. In that situation, we could have done the TAVR bright and early, then potentially sent this patient home around 7pm after his groin checks were okay.  Patients get a follow-up call and at one week, they come to our office. Carol, our TAVR coordinator, does a great job in communicating expectations of the procedure to the patients and in just being there for them. She will call patients up the next day after they get home, and see how they are doing. If we do patients on a Wednesday, we try to get them in on the next Monday to the TAVR clinic for follow-up. Patients have a resource and a number to call anytime. We have one person to handle it as opposed to the surgeon or cardiologist on call, who doesn’t know the patient that well. We are able to give our TAVR patients a boutique practice in a rural center.

How did things change for you as a surgeon once you started doing TAVR?

I was lucky to be trained to do abdominal aortic aneurysms (AAAs). I do a lot of distal bypasses, arteriograms, interventions, stent placements, and accessing the groin. That has helped me a great deal regarding TAVR. If I did not have that experience, it could be an issue with coming to the plate as an equal. Also I was very lucky to have a great group of experienced interventional cardiologists on this team who also love to teach. I think the interventionalists have also learned what is acceptable from an access perspective. Sometimes, as a surgeon, when you look at the CT angios, you can say, whoa, this is going to be a nightmare. It will take us 6-7 hours. It’s best we do this open, if the patient is an open candidate. That perspective has been helpful.

If you can’t do a femoral, based on the CT, what is your next choice for access?

It depends. I would like to do a subclavian, if the patient has big enough subclavian arteries. If they don’t, then it will either be transaortic or transapical. The apical sheaths are getting smaller, so that is going to be increasingly easier. We haven’t had any complication with an apical rupture yet, but if you do enough, you are going to have that problem. I am not enamored with the data on the apical. Patients have worse mortality and worse stroke rates. I would rather do a subclavian. The new Evolut valve from Medtronic and the Sapien 3 are examples of how probably sheaths are going to become smaller and smaller.

In terms of recovery, subclavian access is comparable to femoral access.

Yes, patients go home the next day if everything is okay. It is just a small incision and people tolerate it and have a one-day stay. It’s like a pacemaker. 

What about moving away from TEE use?

We have 2D echo on hand in the cath lab and we have recently performed several intra cardiac echo (ICE)-guided implants and have been very pleased with the imaging. Yesterday we did a case where we could see the whole valve, with no leak after placement. We don’t do TEE in conjunction with TAVR, because it is difficult to do conscious sedation with a TEE. But we get just as much information with 2D echo or ICE. 

It sounds like the most important elements in your minimalist approach have been moving to the cath lab, conscious sedation, and early ambulation. Is there any other important element?

We have a committed team. I have been taken out of the operating room to do TAVR. I love to operate. You have to have a surgeon that is committed. I’m not saying that I want to be the TAVR surgeon, but you can’t have a full surgical practice, because you will be too busy, not able to really see the patients, evaluate them, and move to the next step in TAVR. 

What have you learned from your surgical practice that has helped with your TAVR work?

Being a surgeon, I know how to get in quick and do what I need to do. I also know what can be a problem when we are using catheters and guide wires. Everyone brings their expertise to the table, and as a surgeon, I bring my expertise. As they say, I know what the actual anatomy looks like. But to say that one person is more important than the other is ridiculous. I think we couldn’t do TAVR without both people involved, a surgeon and a cardiologist. You can get through it, but if there is a complication, people will die. In the beginning when we were doing these cases that wouldn’t work out that well, I would say, okay, we are done; we have to convert. Now we are past the learning curve, so those issues don’t happen to us. I am fortunate in the physicians I work with.

Do you have recommendations for other labs?

Putting TAVR in the cath lab is number one, conscious sedation would be number two and either way, if a team is uncomfortable about sedating the patients, having a CRNA at their disposal. It’s also screening the patients: are they going to sit still? If they are going to get up in the middle of the case and have excruciating back pain and you don’t think you can sedate them well, that patient is best done in the operating room. I actually like to do the younger valve-in-valve patients in the operating room, because it is a high-risk procedure and you have to hit that right on. The elderly tolerate a little more than the younger population. As long as you talk to them and work them through it, the elderly handle things a lot better. The younger people, they get anxious, it snowballs, and it gets to the point that you have snowed them so much that you have impaired their breathing. Our cath lab staff is excellent. They will closely monitor the patient, make sure that they are breathing well, and will tell us if there is a problem. If so, we will stop, we will talk to the patient, wake them up a little, and then proceed once they are ready. Having great communication with your cath lab staff during all aspects of the procedure is really important.

Are there points in the TAVR procedure where the patient might experience pain?

If you rapid pace them for too long, they seem to get this withdrawal mechanism where they lift their legs up and feel as though their heart has stopped. They start having some agonal breathing. As soon as we stop it, they come back. The key is to have your rapid pacing as short as possible. Also, when the sheaths are placed, patients sometimes feel it.

How can you prepare for that?

You can’t, really. When we do it, we just say, “Mr. Johnson, it’s okay. You are in the cath lab,” and reorient them. When you go through rapid pacing, your valve will be in by the time you stop pacing and they start moving their legs up. If you are rapid pacing too long, you are going to have a problem. You have to be very deliberate in what you are going to do, and then do it. You can’t sit around, watching the screen, and have the patient in v-fib or v-tach forever. You shouldn’t be doing conscious sedation if you’re not already facile with doing TAVRs. It is not a good idea to start a TAVR program in a cath lab with conscious sedation. I would recommend getting better with the techniques, getting better with the devices, learning from some of the complications in the OR with the anesthesiologist involved, and then going on to the next step. Right now, we have it down to a system. We know that at this point we are going to rapid pace, and we rapid pace for a couple seconds and deploy the balloon. If you are just starting, you are nervous. If you deploy the balloon too soon, it is going to dogbone — shove out into the ventricle, into the aorta. All those factors are in play when you are starting a program. You should get rid of those concerns, then move to the next step. Right now we are seeing an evolution in TAVR. In Europe, they all started in the operating room and now many centers are doing conscious sedation. Some don’t even do TEEs, because they have seen that it has not changed their decision-making. They will do an arteriogram, a 2D echo, review it, see perhaps a moderate perivalvular leak, and just do a balloon vavuloplasty.

What do you think about eliminating the cardiac cath?

Once the CT angios become better, you might be able to get rid of the coronary angiogram. We just do the TAVR, separate from the coronaries, because of the dye load. Most of the patients have renal insufficiency with creatinines around 1.5 or 1.6, and we worry about giving them that repetitive dye, because creatinine is also tracked on the back end. The patient’s creatinine may be 1.6, but it could be 1.3 when we do the procedure, because we hydrated them. Maybe they are dehydrated a month later to a year later, and it is 1.6. It is then dinged as renal insufficiency. The TVT registry takes that into account. As some of the early adopters of this technology have said, appropriately, they are going to look at your results. If your results are bad, the government is going to step in and stop you. You can’t just go in there and think that everything is wonderful and have a lot of mortality. A, it is not fair to the patient; B, it is not fair to the institution, and C, it is not fair to your community. There are other centers that do a great job and patients should be referred to those centers instead. Surgeons are graded by their STS score. At the end of the day, it’s your results. Our cath lab mortality is zero, with zero vascular problems in the cath lab. I think our program is doing very well. It is flourishing, because our outcomes are excellent. We have turned that corner from learning to refining our technique.

Any final thoughts?

Our team approach is the most important thing. Each person can be replaceable, but if they don’t act like a team, it makes the program very divisive and can actually create a lot of bad outcomes. If the team itself isn’t thinking with the same mindset, you are going to have bad results. That’s in anything you do.

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An Objective Third Party: Consultants Aid in the Move to a TAVR Minimalist Approach at Mercy Hospital Springfield

Jonathan Hart, Senior Vice President, Jonathan Lindsey & Associates Inc., Austin, Texas

Jonathan Lindsey & Associates (JLA) has worked collaboratively with hospital clients to reduce cost while improving quality and length of stay in cardiovascular service lines for 30 years. 

With the adoption of TAVR being fairly recent in the U.S., there are still many centers that struggle to provide this lifesaving therapy in a cost-effective manner, while fully optimizing their structural heart program. Over the course of a few short months, Mercy Hospital Springfield has improved length of stay (LOS) to become one of the lowest in the country with exceptional outcomes; they are great example of what is possible in TAVR with a strong team committed to collaborative efforts. 

Using clinical data, JLA worked hand-in-hand with TAVR Coordinator Carol Miller, and Drs. Merritt, Cochran, Huang, and Parvathaneni, to review the continuum of care from pre admission to post discharge in order to identify areas of improvement. As an objective third party, we helped utilize best practices developed in part by Dr. Christopher U. Meduri (interventional cardiologist, Piedmont Heart Institute, Atlanta, Georgia) and the input of our TAVR team; in doing so, we were able to retool many of the key clinical and operational components of the program, including the streamlining of pre admission testing, increasing the adoption of preferred access sites, transitioning many cases out of the hybrid room into the cath lab, employing conscious sedation, avoiding the ICU for recovery, and ensuring that proper coding and discharge planning occur. By building the numerous areas of improvement into a cohesive protocol, we have seen significant change that is sustainable, as every member of the team knows what should be occurring and when. As you can see from the interviews with Dr. Merritt and Dr. Parvathaneni, we are very lucky to have a team that trusts in each other and is consistently looking for ways to improve — without that, this would have been a much more arduous process. 

Length of stay (LOS) has been reduced from 7.9 days before the implementation of our protocols to an average of under 2 days total LOS (1.75) after implementation. This has resulted in a reduction in cost of approximately $18,000 per case. With our volume on pace to more than double year over year, this will lead to savings of well over $1,000,000. Furthermore, we have been able to increase our average reimbursement per case by decreasing the percentage of patients that trigger the CMS PACT policy from 28 to 0. 

Not only have the improvements led to better outcomes, patient satisfaction, and cost, but Mercy Hospital Springfield is now well positioned to expand its service offerings in the region as a leader in structural heart disease treatment. It is our hope that as new therapies come to market, we can be a resource to other centers looking to optimize their programs.