Transradial PCI Associated with Lower Costs, Shorter Hospital Stay Than Femoral Route


Due primarily to shorter hospital stays and less bleeding complications, percutaneous coronary intervention (PCI) via radial artery access is less costly than transfemoral PCI, according to a national database analysis published online November 19, 2012, ahead of print in the American Heart Journal.

Researchers led by Steven P. Marso, MD, of St. Luke’s Mid America Heart Institute (Kansas City, MO), reviewed the Premier research database, which contains one-fifth of all acute care hospitalizations in the United States. Specifically, Dr. Marso and colleagues matched 609 transradial cases with 60,900 transfemoral cases—all inpatients—performed from 2004 to 2009 to compare costs between the access methods using 2012 US dollars.

Transradial patients showed a trend for decreased bleeding complications compared with transfemoral patients (1.5% vs. 2.3%; OR 0.53; 95% CI 0.27-1.05; P = 0.071). Bleeding rates showed similar distributions when transradial and transfemoral patients were stratified according to low (0% vs. 0.4%), moderate (0.8% vs. 1.6%), and high (3.9% vs. 5.4%) bleeding risk categories. Overall, in-hospital mortality was similar between the 2 groups (0.2% vs. 0.4%; P = 0.53).

Length of Stay, Bleeding Translate to Lower Costs

Post-PCI length of stay was lower with transradial PCI compared with transfemoral interventions (0.47 days vs. 0.78 days; 95% CI 0.15-0.48; P < 0.001). These results were maintained in the moderate bleeding risk category (difference of 0.3 days; 95% CI 0.11-0.49; P = 0.002), while a trend for reduced length of stay was shown in transradial PCI patients at high-risk for bleeding (difference of 0.4 days; 95% CI 0.07-0.86; P = 0.097).

At an average cost reduction of $553, total inpatient costs were lower for transradial procedures compared with transfemoral procedures ($11,736 vs. $12,288). While the cost of care on the day of the procedure was similar between the 2 groups, costs after the day of the procedure until discharge were lower with transradial access.

Table 1. Inpatient Costs for Transradial vs. Transfemoral PCI

 

Difference (Transfemoral Minus Transradial)

95% CI

P Value

Total

$553

$45 to $1,060

0.033

Day of Procedure

-$17

-$318 to $353

0.37

After the Day of Procedure to Discharge

$571

$229 to $912

0.001


According to stepwise linear regression, 95% ($541) of the $571 postprocedure cost reduction associated with radial access was attributable to the 0.31 day decrease in postprocedural length of stay. And of the amount attributable to length of stay, 20% ($110) was attributable to a decrease in bleeding complications.

Patients at moderate (-$585; 95% CI -$49 to $1,219; P = 0.071) and high (-$1,046; 95% CI -$150 to $2,242; P = 0.086) bleeding risk also tended to have lower direct costs with transradial procedures, while there was a slight trend for higher costs with transradial access in patients at low bleeding risk ($424; 95% CI -$1,454 to $605; P = 0.419).

“In a large, nationwide administrative database, transradial PCI access was associated with meaningful cost savings, shorter length of hospital stay, and a trend toward less bleeding,” Dr. Marso and colleagues conclude, adding that although similar trends were seen in transradial patients at moderate or high bleeding risk, the study was underpowered for such comparisons.

Ian C. Gilchrist, MD, of Hershey Medical Center (Hershey, PA), told TCTMD in a telephone interview that the findings “add dollars and cents to clinically what’s been observed.”

It’s Not Magical

“Basically, the transradial and transfemoral procedures cost about the same to do the actual procedure, there’s nothing magical about it,” he continued. “But what happens after the procedure is there seems to be on average about a $500 savings with transradial. The bulk of it is the patients are going home a third of a day earlier than with transfemoral, with a little savings in the cost of the bleeding.”

Dr. Gilchrist noted that the study entirely focused on inpatient PCI cases, which is not how most current procedures are performed at his institution. “Most of our interventional procedures we do as outpatients,” he said. “Not only are they outpatients, they’re going home the same day. It’s with transradial access that we’ve really been able to take a deep breath and say these people are going to do fine, they’re not going to bleed.”

With such an approach, the potential for cost savings becomes greater “because you don’t have the cost of keeping the patient overnight,” Dr. Gilchrist added. “It becomes especially efficient when you’re space constrained in your hospital and you can open up more beds.”

He noted that the original impetus for switching to radial procedures in his practice had little to do with cost. “When I started to do transradial in the 90s it wasn’t for the cost, it was for the patients,” Dr. Gilchrist said. “The patient satisfaction is so much greater with transradial. Seeing there’s a cost saving is mainly icing on the cake.”

 


Source:
Safley DM, Amin AP, House JA, et al. Comparison of costs between transradial and transfemoral percutaneous coronary intervention: A cohort analysis from the Premier research database. Am Heart J. 2012;Epub ahead of print.

 

 

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Disclosures
  • Dr. Marso reports no relevant conflicts of interest. All compensations for his research activities, including research grants and consulting fees from Abbott Vascular, Amylin Pharmaceuticals, Boston Scientific, Novo Nordisk, Terumo Medical, The Medicines Company, and Volcano are paid directly to the St. Luke’s Hospital Foundation of Kansas City.
  • Dr. Gilchrist reports no relevant conflicts of interest.

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