Improving Care Pathways for Acute Coronary Syndrome: Patients Undergoing Percutaneous Coronary Intervention

• Type of Material: Article
• Authors: Amit P. Amin, Washington University; John A. Spertus, Barnes Jewish Hospital; Hemant Kulkarni, M&H Research; Christian McNeely, Washington University; Sunil Rao, Duke Clinical Research Institute; Duane Pinto, Harvard University; John A. House, Premier Inc; John C. Messenger, University of Colorado; Richard G. Bach, Washington University; Abhinav Goyal, Emory University; Adhir Shroff, University of Illinois; Samir Pancholy, Geisinger Commonwealth School of Medicine; Steven M. Bradley, Minneapolis Heart Institute; Ty J. Gluckman, Providence Heart & Vascular Institute; Thomas M. Maddox, Washington University; Jason H. Wasfy, Massachusetts General Hospital; Frederick A. Masoudi, University of Colorado
• Language: English
• Date: 2020-02-01
• Publisher: Excerpta Medica Inc. - Elsevier Science Inc.
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2019 Elsevier Inc. All rights reserved.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.amjcard.2019.10.019
• Title of Journal or Parent Work: American Journal of Cardiology
• Volume: 125
• Issue: 3
• Start Page: 354
• End Page: 361
• Grant/Funding Information: Dr. Amit P. Amin – is funded via a comparative effectiveness research KM1 career development award from the Clinical and Translational Science Award (CTSA) program of the National Center for Advancing Translational Sciences of the National Institutes of Health, Grant Numbers UL1TR000448, KL2TR000450, TL1TR000449; National Cancer Institute of the National Institutes of Health, Grant Number 1KM1CA156708-01; an AHRQ R18 grant award (Grant Number R18HS0224181-01A1), and is a consultant to Terumo.
• Keywords: Health care; Hospitals; Science & Technology; Life Sciences & Biomedicine; United States; Cardiovascular System & Cardiology; Cardiac & Cardiovascular Systems; Learning curve
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Health Care Management; Health Sciences, Rehabilitation and Therapy

Abstract

Acute coronary syndrome (ACS) admissions are common and costly. The association between comprehensive ACS care pathways, outcomes, and costs are lacking. From 434,172 low-risk, uncomplicated ACS patients eligible for early discharge (STEMI 35%, UA/NSTEMI 65%) from the Premier database, we identified ACS care pathways, by stratifying low-risk, uncomplicated STEMI and UA/NSTEMI patients by access site for PCI (trans-radial intervention [TRI] vs transfemoral intervention [TFI]) and by length of stay (LOS). Associations with costs and outcomes (death, bleeding, acute kidney injury, and myocardial infarction at 1-year) were tested using hierarchical, mixed-effects regression, and projections of cost savings with change in care pathways were obtained using modeling. In low-risk uncomplicated STEMI patients, compared with TFI and LOS ≥3 days, a strategy of TRI with LOS <3 days and TFI with LOS <3 days were associated with cost savings of $6,206 and $4,802, respectively. Corresponding cost savings for UA/NSTEMI patients were $7,475 and $6,169, respectively. These care-pathways did not show an excess risk of adverse outcomes. We estimated that >$300 million could be saved if prevalence of the TRI with LOS <3 days and TFI with LOS <3 days strategies are modestly increased to 20% and 70%, respectively. In conclusion, we demonstrate the potential opportunity of cost savings by repositioning ACS care pathways in low-risk and uncomplicated ACS patients, toward transradial access and a shorter LOS without an increased risk of adverse outcomes.