Cost Control in the Cardiac Cath Lab at St. Vincent`s Hospital Manhattan

St. Vincent’s Hospital Manhattan has a cardiology program that includes an extensive cardiac catheterization service. With three cath labs, St. Vincent’s performs approximately 4,500 procedures per year, of which one third are interventions. Procedures include angiography, angioplasty and drug-eluting stent implants, IVUS, and rotational atherectomy. Catheterizations are performed during the day and often during evening hours. Many physicians have adopted new technology, including drug-eluting stents and distal protection devices, and their results indicate continuously improving health outcomes. Reimbursement increases frequently lag behind the cost increases associated with new technology. As a result, deployment often results in profit decreases or even losses on certain types of procedures, even as health outcomes improve and overall long-term cost to the health system decreases. At St. Vincent’s, administration and clinicians work together to help control costs, and every effort is made to reduce cost per procedure. Decision-making is always made on the basis of what’s best for the patient, and we search for areas of excess cost in technique, protocol and materials, where changes would not negatively affect patient care. As excess costs are identified, physicians and department staff are made aware of the costs and of alternatives which have neutral or positive impact on patient health outcomes. IIb/IIIa platelet-inhibitors are one example of how giving staff cost information about two separate drugs ultimately resulted in a usage reduction of the more expensive option and a usage increase of the less expensive drug. This enabled St. Vincent to save $1,400 per procedure with no adverse health outcomes. Another successful cost containment strategy involved reducing usage of arteriotomy closure devices (ACDs) for post-procedure femoral hemostasis by substituting manual or mechanical compression in most cath procedures. The current ACD usage at St. Vincent has declined to less than 13% of total procedures, down from a peak usage rate of over 40%. This has resulted in an estimated savings of over $300,000 per year. In 2001, our physicians were using ACDs far too often. Initially, the reason to adopt ACDs was to ambulate and discharge patients early to help alleviate bed crunch. If ACDs permitted earlier discharge of patients to open up beds and reduce holding time for late-afternoon and evening patients, then this would be a valuable benefit. Unfortunately, we found that using ACDs did not make enough of a difference to justify the additional cost of almost half a million dollars. Patients often are unable to ambulate early enough to improve bed utilization because of their underlying health conditions, effects of sedation and analgesia, and patient transport availability. ACD usage at St. Vincent’s has been reduced by stressing more stringent patient selection, limiting ACD availability, and providing alternative hemostasis methods acceptable to staff and patients. ACDs are now used only where the patient or the hospital realizes a benefit. We try to limit their usage to fidgety or restless patients, and on evening patients, where staff is not available to pull sheaths. Mechanical compression using the CompressAR® c-clamp (Advanced Vascular Dynamics, Portland, Oregon) or manual compression is now used to hemostase most patients. Many nurses and technologists at St. Vincent’s use the CompressAR StrongArm System, which was introduced in late 2002. It eliminates the need for manually compressing the femoral artery and was found to be simple and inexpensive. No changes in access site complication rates or patient satisfaction were observed as ACD usage declined in favor of manual and mechanical compression. Reducing ACD usage has worked well for us. We have maintained excellent quality of care and reduced our costs by hundreds of thousands of dollars in a relatively short period of time. This has helped St. Vincent’s continue our success in providing quality care to our community.

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