Long-term health outcomes and cost-effectiveness of coronary CT angiography in patients with suspicion for acute coronary syndrome

BACKGROUND

Randomized trials have shown favorable clinical outcomes for coronary CT angiography (CTA) in patients with suspected acute coronary syndrome (ACS). Our goal was to estimate the cost-effectiveness of coronary CTA as compared to alternative management strategies for ACP patients over lifetime.

METHODS

Markov microsimulation model was developed to compare cost-effectiveness of competitive strategies for ACP patients: 1) coronary CTA, 2) standard of care (SOC), 3) AHA/ACC Guidelines, and 4) expedited emergency department (ED) discharge protocol with outpatient testing. ROMICAT-II trial was used to populate the model with low to intermediate risk of ACS patient data, whereas diagnostic test-, treatment effect-, morbidity/mortality-, quality of life- and cost data were obtained from the literature. We predicted test utilization, costs, 1-, 3-, 10-year and over lifetime cardiovascular morbidity/mortality for each strategy. We determined quality adjusted life years (QALY) and incremental cost-effectiveness ratio. Observed outcomes in ROMICAT-II were used to validate the short-term model.

RESULTS

Estimated short-term outcomes accurately reflected observed outcomes in ROMICAT-II as coronary CTA was associated with higher costs ($4,490 vs. $2,513-$4,144) and revascularization rates (5.2% vs. 2.6%-3.7%) compared to alternative strategies. Over lifetime, coronary CTA dominated SOC and ACC/AHA Guidelines and was cost-effective compared to expedited ED protocol ($49,428/QALY). This was driven by lower cardiovascular mortality (coronary CTA vs. expedited discharge: 3-year: 1.04% vs. 1.10-1.17; 10-year: 5.06% vs. 5.21-5.36%; respectively).

CONCLUSION

Coronary CTA in patients with suspected ACS renders affordable long-term health benefits as compared to alternative strategies.

Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department

OBJECTIVES

This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFR_CT) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program.

BACKGROUND

FFR_CT is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied.

METHODS

ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFR_CT were studied. FFR_CT ≤0.80 was considered positive for hemodynamically significant stenosis.

RESULTS

Among 555 patients, 297 underwent coronary CTA and FFR_CT (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFR_CT was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFR_CT groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFR_CT results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFR_CT when revascularization was deferred. Negative FFR_CT was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFR_CT (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFR_CT groups ($8,582 vs. $8,048; p = 0.550).

CONCLUSIONS

In ACP, FFR_CT is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFR_CT, which is associated with higher nonobstructive disease on invasive angiography.

Substituting hospital-based outpatient cardiology care: The impact on quality, health and costs

BACKGROUND

Many Western countries face the challenge of providing high-quality care while keeping the healthcare system accessible and affordable. In an attempt to deal with this challenge a new healthcare delivery model called primary care plus (PC+) was introduced in the Netherlands. Within the PC+ model, medical specialists perform consultations in a primary care setting. PC+ aims to support the general practitioners in gatekeeping and prevent unnecessary referrals to hospital care. The aim of this study was to examine the effects of a cardiology PC+ intervention on the Triple Aim outcomes, which were operationalized by patient-perceived quality of care, health-related quality of life (HRQoL) outcomes, and healthcare costs per patient.

METHODS

This is a quantitative study with a longitudinal observational design. The study population consisted of patients, with non-acute and low-complexity cardiology-related health complaints, who were referred to the PC+ centre (intervention group) or hospital-based outpatient care (control group; care-as-usual). Patient-perceived quality of care and HRQoL (EQ-5D-5L, EQ-VAS and SF-12) were measured through questionnaires at three different time points. Healthcare costs per patient were obtained from administrative healthcare data and patients were followed for nine months. Chi-square tests, independent t-tests and multilevel linear models were used to analyse the data.

RESULTS

The patient-perceived quality of care was significantly higher within the intervention group for 26 out of 27 items. HRQoL outcomes did significantly increase in both groups (P <0.05) but there was no significant interaction between group and time. At baseline and also at three, six and nine months' follow-up the healthcare costs per patient were significantly lower for patients in the intervention group (P<0.001).

CONCLUSIONS

While this study showed no improvements on HRQoL outcomes, PC+ seemed to be promising as it results in improved quality of care as experienced by patients and lower healthcare costs per patient.

Cardiologist service volume, percutaneous coronary intervention and hospital level in relation to medical costs and mortality in patients with acute myocardial infarction: a nationwide study

BACKGROUND

We explore whether cardiologist service volume, hospital level and percutaneous coronary intervention (PCI) are associated with medical costs and acute myocardial infarction (AMI) mortality.

METHODS

From the 1997-2010 Taiwan National Health Insurance Research Database of the National Health Research Institute, we identified AMI patients and performed multiple regression analyses to explore the relationships among the different hospital levels and treatment factors.

RESULTS

We identified 2942 patients with AMI in medical centers and 4325 patients with AMI in regional hospitals. Cardiologist service volume, performing PCI and medical costs per patient were higher in medical centers than in regional hospitals (P < 0.0001). However, the two hospital levels did not differ significantly in in-hospital mortality (P = 0.1557). Post hoc analysis showed significant differences in in-hospital mortality rate and in medical costs among the eight groups subdivided on the basis of hospital level, cardiologist service volume, and whether PCI was performed (P < 0.001 and P = 0.001, respectively).

CONCLUSIONS

These results highlight the importance of encouraging hospitals to develop PCI capability and increase their cardiologist service volume after taking medical costs into account. Transferring AMI patients to hospitals with higher cardiologist service volume and PCI performed can also be very important.

When is a "free" registrar in clinic not free?

OBJECTIVE

To investigate whether using registrars (doctors undergoing higher specialist training, whose salary is reimbursed) rather than consultants in outpatient clinics saves money

DESIGN

Development of a formula calculating the economic breakeven point and application to retrospective audit data from 273 outpatient consultations.

SETTING

General cardiology outpatient clinic in a secondary and tertiary referral NHS hospital. Outcomes Difference in probability of a registrar and a consultant making a diagnostic decision that completes a clinical episode. Use of UK costings for consultant salaries and outpatient attendances to determine the economic breakeven point.

RESULTS

The formula showed that if a registrar's episode completing probability is 12 percentage points lower than that of a consultant, then using a registrar costs the hospital more. Real life data showed that episode completion probabilities are 43 percentage points lower for registrars than for consultants (26% versus 69%, 95% CI 32% to 54%, P<0.0001).

CONCLUSION

It is wrong to assume that external reimbursement of registrar salaries makes them a money saving option for staffing clinics. The apparent service role of a registrar can be a disservice.

Cardiovascular magnetic resonance activity in the United Kingdom: a survey on behalf of the British Society of Cardiovascular Magnetic Resonance

BACKGROUND

The indications, complexity and capabilities of cardiovascular magnetic resonance (CMR) have rapidly expanded. Whether actual service provision and training have developed in parallel is unknown.

METHODS

We undertook a systematic telephone and postal survey of all public hospitals on behalf of the British Society of Cardiovascular Magnetic Resonance to identify all CMR providers within the United Kingdom.

RESULTS

Of the 60 CMR centres identified, 88% responded to a detailed questionnaire. Services are led by cardiologists and radiologists in equal proportion, though the majority of current trainees are cardiologists. The mean number of CMR scans performed annually per centre increased by 44% over two years. This trend was consistent across centres of different scanning volumes. The commonest indication for CMR was assessment of heart failure and cardiomyopathy (39%), followed by coronary artery disease and congenital heart disease. There was striking geographical variation in CMR availability, numbers of scans performed, and distribution of trainees. Centres without on site scanning capability refer very few patients for CMR. Just over half of centres had a formal training programme, and few performed regular audit.

CONCLUSION

The number of CMR scans performed in the UK has increased dramatically in just two years. Trainees are mainly located in large volume centres and enrolled in cardiology as opposed to radiology training programmes.

[Outsourced service management of the catheterization laboratory in the cardiology department: lights and shadows]

BACKGROUND

The aim of this study was to compare the economic impact and results achieved by recourse to outsourced management of the procedures carried out in the electrophysiology and catheterization laboratory of the Department of Cardiology of the Crema Hospital with the in-house setting up and operation of the same activities.

METHODS

The comparison between the two possible options, "make" or "buy in", was made using the methodology of advanced direct costing, which provides for the allocation of only direct fixed and variable costs to clinical procedures, the subject of calculation. In addition to the financial evaluation, the quality variables showing the advantages and limitations of outsourcing in terms of organizational improvements, streamlining of the organizational structure, operational efficiency and improvement of the quality of service, were examined.

RESULTS

The financial evaluation from 2002 to 2006 came out in favor of "make" as opposed to "buy in". Income derived from diagnosis-related-group payments for the more than 4000 procedures carried out was Euro26.239.034,96. On the basis of the economical evaluation the second contribution margin was slightly inferior with the "buy in" than with the "make" hypothesis. Specifically, it is Euro16.397.669,96 in the "buy in" and Euro16.753.579,16 in the "make" hypothesis, with a difference of Euro355.909,20 (-2%).

CONCLUSIONS

The economic advantage lies with the "make" alternative compared with "buy in", nevertheless, outsourcing offers greater operational efficiency, better cost control, setting up of the laboratory within a very short time, simplified administration (single point of contact) and an opportunity to concentrate on core business. However, there are limitations due to greater dependence on the supplier, not all the equipment provided for under the contract was used, and loss of management know-how in non-core business areas.

Economic appraisal of the angioplasty procedures performed in 2004 in a high-volume diagnostic and interventional cardiology unit

OBJECTIVE

Growing interest in the use of drug-eluting stents (DESs) in coronary angioplasty has prompted the Healthcare Agency of the Emilia Romagna Region to draw up recommendations for their appropriate clinical use in high-risk patients. Since the adoption of any new technology necessitates economic appraisal, we analysed the resource consumption of the various types of angioplasty procedures and the impact on the budget of a cardiology department.

METHODS

A retrospective economic appraisal was carried out on the coronary angioplasty procedures performed in 2004 in the Department of Interventional Cardiology of Reggio Emilia. On the basis of the principles of activity-based costing, detailed hospital costs were estimated for each procedure and compared with the relevant diagnosis-related group (DRG) reimbursement.

RESULTS

In 2004, the Reggio Emilia hospital performed 806 angioplasty procedures for a total expenditure of euro 5,176,268. These were 93 plain old balloon angioplasty procedures (euro 487,329), 401 procedures with bare-metal stents (euro 2,380,071), 249 procedures with DESs (euro 1,827,386) and 63 mixed procedures (euro 481,480). Reimbursements amounted to euro 5,816,748 (11% from plain old balloon angioplasty, 50% from bare-metal stent, 31% from DES and 8% from mixed procedures) with a positive margin of about euro 680,480 between costs incurred and reimbursements obtained, even if the reimbursement for DES and mixed procedures was not covering all the incurred costs.

CONCLUSIONS

Analysis of the case-mix of procedures revealed that an overall positive margin between costs and DRG reimbursements was achieved. It therefore emerges that adherence to the indications of the Healthcare Agency of the Emilia Romagna Region for the appropriate clinical use of DESs is economically sustainable from the hospital enterprise point of view, although the DRG reimbursements are not able to differentiate among resource consumptions owing to the adoption of innovative technologies.

Effects of physician-owned limited-service hospitals: evidence from Arizona

In recent years physician ownership of so-called limited-service hospitals has become commonplace in many states lacking certificate-of-need regulations. Empirical evidence documenting the effects of these facilities is sparse. This study compares practice patterns of physician-owners of limited-service cardiac hospitals and physician-nonowners who treat cardiac patients at competing full-service community hospitals. Analyses of six years of Arizona inpatient discharge data show that physician-owners treat higher volumes of profitable cardiac surgical diagnosis-related groups (DRGs), higher percentages of low-severity cases, and higher percentages of cases with generous insurance compared with physician-nonowners who treat cardiac patients in community hospitals.

Overcoming a perfect storm: an academic cardiology section's story of survival

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.

U.S. Trends In CABG Hospital Volume: The Effect Of Adding Cardiac Surgery Programs

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality.

Efficiency and cost saving of 7 day per week exercise testing utilizing all electrocardiography technologists

BACKGROUND

In most centers, exercise testing (ET) is performed by one or two trained technologists during the weekdays (0800 hours-1600 hours), leaving a void during evenings and weekends. This leads to unnecessary increased costs due to delays in management of patients. Electrocardiography technologists (ECGT) are often available for extended hours. This project was undertaken to improve the efficiency of the ET laboratory by using ECGT to perform ET during these extended hours.

METHODS

Clinical utility and cost saving of a 7 day per week ET for management of patients with suspected and/or known coronary artery disease utilizing ECGT was assessed after adequate training. Of 4099 patients undergoing ET between January 1995 and December 1997, 810 tests performed by ECGT were reviewed retrospectively.

RESULTS

Of the 810 patients (age mean 58.4 +/- 0.44 yrs; range 16-88; males: 508, females: 302), 806 (99.5%) underwent the Bruce protocol. The indications were: diagnostic, 61.3%, predischarge acute myocardial infarction (AMI), 17.7%, evaluation of angina, 19.6%, other, 1.4%. Only 8 (0.1%) patients had complications (prolonged chest pain, 6; nonsustained ventricular tachycardia, 2) with no AMIs or deaths. This strategy resulted in a savings of 158 bed days (Can189,600 dollars) on inpatients and 15 bed days (Can18,000 dollars) on those presenting to the emergency department.

CONCLUSIONS

This study demonstrates the feasibility and safety of utilizing ECGT for ET thus extending the hours of service. This resulted in efficient patient management, with a considerable cost-saving to the hospital.

Decreased patient charges following implementation of point-of-care cardiac troponin monitoring in acute coronary syndrome patients in a community hospital cardiology unit

BACKGROUND

The need to rapidly evaluate patients presenting to emergency departments and cardiology services for ruling in and ruling out acute myocardial infarction (AMI) is widely recognized as a clinical challenge. We determined the impact of incorporating point-of-care (POC) cardiac troponin I (cTnI) testing into a cardiology service regarding assay turn around time (TAT), patient length of stay (LOS), financial matrixes and patient outcomes compared to central laboratory cTnI testing.

METHODS

Patients presenting with symptoms suggestive of acute coronary syndrome (ACS) were enrolled pre-POC (PreCS, n=271) and post-POC (PostCS, n=274). POC cTnI determinations were performed at the bedside on the Dade Behring Stratus CS by nursing staff. Routine cTnI determinations were performed in the central laboratory (Dade Behring Dimension) by laboratory staff. Data were collected and analyzed on each patient per hospital stay by review of electronic medical and financial records. In addition, risk stratification outcomes for all cause death were determined at 30 days and 1 y following baseline sampling based on the 99th percentile cutoff concentrations of <0.1 microg/l for both assays.

RESULTS

There was a decrease in time from blood draw to result to healthcare provider (PreCS mean 76 min; PostCS mean 19.5 min; p<0.001) as well as a decrease trend in charge per patient admission (4281 dollars savings) following implementation of POC testing. Total charges per patient admission decreased by 25% PostCS vs. PreCS (17,163 dollars vs. 12,882 dollars); a composite of lower charges for: boarding (-21%), other departments (-58%), pharmacy (-28%), labs (-22%), non-cardiac procedures (-28%), cardiac procedures (-14%). The mean LOS also decreased 8% (p=0.05) from PreCS (2.36 days) to PostCS (2.19 days). cTnI reagents charges to the laboratory were higher for the POC assay, 10.54 dollars, vs. the central lab assay, 3.83 dollars. One year survival was greater in the <0.1 microg/l patients (PreCS 96.2%, PostCS 97.2%) compared to the >0.1 microg/l patients (PreCS 77.7%, PostCS 75.5%); both p<0.001. Kaplan-Meier survival curves showed early separation by 30 days in each group.

CONCLUSIONS

Our study demonstrates the cost effectiveness and clinical effectiveness of implementation of POC whole blood, cTnI testing for assisting clinicians with diagnostic and risk assessment of ACS patients.

Cost-effectiveness of hospital pay-for-performance incentives

One increasingly popular mechanism for stimulating quality improvements is pay-for-performance, or incentive, programs. This article examines the cost-effectiveness of a hospital incentive system for heart-related care, using a principal-agent model, where the insurer is the principal and hospitals are the agents. Four-year incentive system costsfor the payer were dollar 22,059,383, composed primarily of payments to the participating hospitals, with approximately 5 percent in administrative costs. Effectiveness is measured in stages, beginning with improvements in the processes of heart care. Care process improvements are converted into quality-adjusted life years (QALYs) gained, with reference to literatures on clinical effectiveness and survival. An estimated 24,418 patients received improved care, resulting in a range of QALYs from 733 to 1,701, depending on assumptions about clinical effectiveness. Cost per QALY was found to be between dollar 12,967 and dollar 30,081, a level well under consensus measures of the value of a QALY.

Cost of diagnosis and treatment of syncope in patients admitted to a cardiology unit

AIMS

Despite the large number of hospital admissions due to syncope, information on the in-hospital cost of management of these patients remains incomplete.

METHODS AND RESULTS

In order to assess such cost, we analysed the clinical histories of the patients suffering from syncope who were admitted to our Unit of Cardiology in 2003. We determined the length of stay (in days) for each inpatient, the number of diagnostic tests performed, and the various therapeutic procedures undertaken. Two hundred and three patients (mean age 68 +/- 14, 49% female) were admitted because of syncope. Final diagnoses on discharge were drug-induced syncope in 10 patients, vasovagal syncope in 11, syncope secondary to cardiac ischaemia in 18, valvular disease in 4, rapid supraventricular arrhythmia in 20, ventricular arrhythmia in 19, atrioventricular block in 90, and unexplained syncope in 31 patients. Of these 203 patients, 70 (34.5%) had a previous history of cardiac disease. The global cost for all 203 patients was 2,264,979 Euros. The overall cost per patient was 11,158 Euros (range: 1651-31,762) including stay, diagnosis, and treatment. The overall cost of hospital stay per patient was 3718 Euros (range: 1436-5679). The overall cost per diagnosis of the 203 patients was 1141 Euros (range: 155-3577), and the cost of the therapeutic procedures required was 6299 Euros (range: 0-23 115). The most expensive were those cases of syncope secondary to ventricular arrhythmia, the cost of which is 20 times that of drug-induced syncope.

CONCLUSION

The cost per diagnosis and treatment of a patient admitted because of syncope varies widely with important differences depending on the specific cause.

Randomized clinical trial of a postdischarge pharmaceutical care program vs. regular follow-up in patients with heart failure

OBJECTIVE

To assess the efficacy of a multifactorial educational intervention carried out by a pharmacist in patients with heart failure (HF).

METHOD

A randomized, prospective, open clinical trial in patients admitted for HF. The patients assigned to the intervention group received information about the disease, drug therapy, diet education, and active telephone follow-up. Visits were completed at 2, 6, and 12 months. Hospital re-admissions, days of hospital stay, treatment compliance, satisfaction with the care received, and quality of life (EuroQol) were evaluated; a financial study was conducted in order to assess the possible impact of the program. The intervention was performed by the pharmacy department in coordination with the cardiology unit.

RESULTS

134 patients were included, with a mean age of 75 years and a low educational level. The patients of the intervention group had a higher level of treatment compliance than the patients in the control group. At 12 months of follow-up, 32.9% fewer patients in the intervention group were admitted again vs. the control group. The mean days of hospital stay per patient in the control group were 9.6 (SD=18.5) vs. 5.9 (SD=14.1) in the intervention group. No differences were recorded in quality of life, but the intervention group had a higher score in the satisfaction scale at two months [9.0 (SD=1.3) versus 8.2 (SD=1.8) p=0.026]. Upon adjusting a Cox survival model with the ejection fraction, the patients in the intervention group had a lower risk of re-admission (Hazard ratio 0.56; 95% CI: 0.32-0.97). The financial analysis evidenced savings in hospital costs of euro 578 per patient that were favorable to the intervention group.

CONCLUSIONS

Postdischarge pharmaceutical care allows for reducing the number of new admissions in patients with heart failure, the total days of hospital stay, and improves treatment compliance without increasing the costs of care.

Smart strategic planning for cardiovascular services

Strategic planning for cardiovascular services should include formation of a cardiovascular advisory committee composed of key stakeholders. The strategic plan should include an internal assessment, external market analysis, review of operations, development of strategies and initiatives, and a financial analysis. The organization's mission and vision, as well as its financial situation, need to be considered in formulating strategies.

Surgeons' economic profiles: can we get the "right" answers?

Hospitals and payers use economic profiling to evaluate physician and surgeon performance. However, there is significant variation in the data sources and analytic methods that are used. We used information from a hospital's cardiac surgery and cost accounting information systems to create surgeon economic profiles. Three scenarios were examined: (1) surgeon modeled as fixed effect with no patient-mix adjustment; (2) surgeon modeled as fixed effect with patient-mix adjustment; (3) and surgeon modeled as random effect with patient-mix adjustment. We included 574 patients undergoing coronary artery bypass surgery at Baptist Medical Center, Oklahoma City, OK between July 1, 1995 and April 30, 1996. We found that profiles reporting unadjusted average surgeon costs may incorrectly identify high- and low-cost outliers. Adjusting for patient-mix differences and treating surgeons as random effects was the preferred approach. These results demonstrate the need for hospitals to reexamine their economic profiling methods.

Leaders with heart

Although cardiovascular care is typically a lucrative service line, competition from other providers is often fierce. To gain market advantage, providers should follow best practices of top-performing organizations and use benchmarking data to identify areas in need of process improvement.

Advance-practice nursing in heart-failure management: an integrative review

The number of patients with heart failure (HF) is predicted to escalate into the next decade, whereas the number of cardiac specialists who are skilled in evidence-based recommendations in HF practice will struggle to provide available, quality care. The advance-practice nurse, whose focus is HF management, may be an important key to improving access to this growing aggregate. This integrative review indicates the positive cost-to-benefit ratio for the advance-practice nurse's collaboration in HF management. Other measurable nursing outcomes have yet to scratch the surface, thereby inviting studies into areas that will promote the patient's quality of life.

The rise and uncertain future of cath labs

Few places have the potential to dramatically change the clinical and financial landscape."Cath labs are turning hospitals and health care upside down right now" says Skip Meador, director of cardiology for Centra Health, Lynchburg, Va."It's sure a different animal now than it was even seven or eight years ago" Cardiovascular programs--which increasingly rely on procedures performed in the cath lab--have long been the linchpin of hospital profitability, and have tended to prop up other money-losing areas. But critical issues threaten that profitability, such as the cost of technology, operating expenses and payer reimbursement. Likewise, such other technology as implantable cardiac defibrillators, biventricular pacemakers and ventricular assist devices bring more potential to change the landscape of cardiac care delivery. A case in point: the advent of primary angioplasty.

A six sigma approach to maximizing productivity in the cardiac cath lab

Cardiac catheterization laboratories represent one of the most significant capital investments for hospitals. Historically, hospitals could achieve an economic return fairly rapidly on this capital investment because of the relatively high contribution margin on many of the procedures performed in the department. However, recent changes in DRG assignments, declines in Medicare reimbursement, and the advent of new technologies, such as drug-coated stents, pose a threat to achieving planned economic return. In response, many hospitals are pursuing strategies to improve throughput in the cardiac cath lab and maximize the number of procedures performed. The case example in this article describes how a busy cardiac catheterization lab in the southeastern United States successfully applied the Six Sigma methodology to improving productivity and increasing available capacity.

Could your financial health be heading for heart break?

A new type of stent may alter demand and affect the financial performance of cardiovascular programs. Patients electing angioplasty instead of CABG as the preferred initial treatment for coronary stenosis may increase. The need for CABG procedures to correct restenosis following angioplasty may decline.