Meta-analysis: Transradial Access Cheaper, Safer for Coronary Procedures

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Transradial access for coronary angiography and interventions decreases overall hospital costs and complications compared with transfemoral access, according to a meta-analysis published online June 26, 2012, ahead of print in Circulation: Cardiovascular Quality and Outcomes. The investigators suggest that widespread adoption of radial access could result in substantial cost savings for hospitals.

For the study, Matthew D. Mitchell, PhD, of the University of Pennsylvania Health System (Philadelphia, PA), and colleagues reviewed 14 trials that randomized 12,544 patients to either the radial or femoral approach for coronary procedures.

Although radial access increased cath failure rates (OR 4.92; 95% CI 2.69-8.98), it reduced major complications (OR 0.32; 95% CI 0.24-0.42), major bleeding (OR 0.39; 95% CI 0.27-0.57), and hematoma (OR 0.36; 95% CI 0.27-0.48) compared with transfemoral cath procedures. Also, transradial access added 1.4 minutes to procedure time (95% CI -0.22 to 2.97) but reduced hemostasis time by about 13 minutes (95% CI -2.30 to -23.90).

There were no differences between the approaches for procedure success and MACE. However, compared with patients randomized to femoral access, those assigned to the radial approach were 5 times more likely to need conversion to the alternative access site.

A cost-analysis model estimated that a radial procedure costs $275 less than a femoral procedure from the hospital perspective. The difference was driven by substantially lower complication costs with the radial approach. No matter how the model was adjusted, radial access was always favored over femoral.

Safer Not Always More Expensive

In an e-mail communication with TCTMD, Dr. Mitchell said he was surprised by the strength of the findings.

Since most health technology assessment centers work for payers or government agencies, Dr. Mitchell noted, they tend to focus on new and often costly technologies. “This paper serves as a nice reminder that safer care often saves costs, as well,” he wrote.

The study confirms radialists’ common belief, according to Ian C. Gilchrist, MD, of Hershey Medical Center (Hershey, PA). Even though many of the studies in the meta-analysis were dated and it was overall “sort of stacked against the radial approach,” radial access was still beneficial compared with femoral, he told TCTMD in a telephone interview. If the analysis had accounted for the shorter in-hospital time required for radially treated patients, the approach would have looked even less expensive, he added.

“When you consider their cost savings, and you multiply that [by] the number of interventional procedures done per year, you’re talking about $200 million,” he observed. “That’s a significant chunk of change that could pay for all sorts of other things, and I think that’s probably a conservative estimate of cost savings since there were other cost savings that weren’t considered in this analysis.”

Overcoming the Learning Curve

In an interview with TCTMD, Philippe Généreux, MD, of Columbia University Medical Center (New York, NY), added that “we need this study to show another aspect of the benefit of radial because everybody knows [the clinical benefits] but when you pool [them all together] and you look at how much money you can save with radial, this is a very important argument from both a hospital and payer point a view.” However, he noted that the cost benefits may only be apparent in high-volume centers.

“In the United States, there are perhaps too many centers doing radial procedures,” Dr. Généreux said. “So if you restrict the number of interventional cardiologists doing this procedure, you will increase their volume and they will be able to get their [procedure] number to reach the learning curve point where they feel comfortable. We need to have fewer low-volume centers.”

That is not to say that every procedure should be performed radially, Dr. Généreux acknowledged. “Up to 80% of cases can be done radially,” he said. “There are always complex cases or specific situations where you would need to have femoral access, so it’s important to keep those skills,” he said. “[But] radial should be the default choice.”

Complex cases can cause deviations from normal practice, he continued, and the 1.4 minute increase in procedure time with radial seen in the current study is a little low in his experience. “This probably demonstrates that the cases were not complex in this study, and that’s one of the limitations,” he said, adding that complex radial cases can also cost more if they require multiple catheters.

Still, Dr. Généreux said he has “no doubt now that radial is safe, efficient, and saves money.” Nonetheless, he added, operators need to be comfortable with the approach to ensure patient safety.

Questioning Closure Devices

Dr. Gilchrist said the main obstacle to greater use of the radial approach in the United States is the “love affair with closure devices” over the last decade or so. “American cardiologists have the luxury of being able to use these different devices, but the data [have] shown that they are not really changing the complication rate in the cath labs,” he observed. “The United States has sort of been played by these devices for the past 10 years and now a lot of people are starting to question whether we need to catch up with the rest of the world.”

Since US patients are “literally the biggest in the world, they should have the biggest radial arteries in the world,” Dr. Gilchrist continued. However, “some of the countries with the smallest people in the world have some of the highest use of radial artery procedures, like China.”

With more and more published data confirming transradial access as the better choice, he described what appears to be the “beginning of a big upswing in radial.” In addition, as word of mouth spreads among patients that this technique is available and easier for them, more patients will begin asking for it. “It doesn’t take too much of that getting around for cardiologists to say we really need to change,” Dr. Gilchrist said.

 


Source:
Mitchell MD, Hong JA, Lee BY, et al. Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention. Circ Cardiovasc Qual Outcomes. 2012;Epub ahead of print.

 

 

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Disclosures
  • Drs. Mitchell, Généreux, and Gilchrist report no relevant conflicts of interest.

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