Coronary CT angiography (CCTA) – a non-invasive anatomical imaging study most commonly used to identify possible stenoses in the coronary artery tree – continues to gain greater acceptance as a viable modality to diagnose or rule-out the presence of coronary artery disease (CAD). When compared to well-established techniques such as stress testing and myocardial perfusion imaging, CCTA often demonstrates comparable, if not superior, diagnostic performance. As such, proponents argue CCTA – when used for appropriate patients and indications – can obviate the need for myocardial perfusion imaging and additional testing. In addition, CCTA may result in more efficient care by safely discharging patients with a negative test result who may otherwise undergo cardiac catheterization.
Despite its utility, few studies have examined the impact of CCTA on downstream testing and procedures, and subsequently, health care spending, when compared to standard approaches. This week, two new studies helped to shed light on the impact of CCTA, though the data result in more questions than answers regarding CCTA’s ability to reduce downstream utilization and health care costs.
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The results of the highly anticipated CT-STAT trial were released this week in the Journal of the American College of Cardiology. The study objective was to compare the efficiency, cost, and safety of coronary CT angiography to rest-stress myocardial perfusion imaging to diagnose coronary artery disease (CAD) for emergent low-risk patients. Overall, CCTA was found to be more efficient and less costly than traditional SPECT imaging in the diagnostic work-up of this patient subset. While helping to further validate the role of CCTA to expedite care for appropriate chest pain patients, the study raises new questions about future opportunities for CCTA, and if it can supplant more established tests for diagnosing and ruling-out CAD.
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The financial and operational implications of the shift of procedures from the inpatient to outpatient setting remain top-of-mind for cardiovascular administrators. Urgency stems from the growing percentage of short stay (1-2 day LOS) cases and the rollout of Recovery Audit Contractors this year, particularly as medical necessity issues for audits have recently been released. Both procedural and medical short-stay cases are under close scrutiny, namely PCI, ICD, heart failure and chest pain patients. But despite the federal push and payer pressures to move these cases out, the feasibility and clinical safety has been the subject of much debate.
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Dr. Ian Gilchrist presented research at the 2010 SCAI Scientific Sessions indicating that transradial access for PCI may enable patients to be discharged the same day as the procedure who would otherwise not meet same-day discharge criteria. Notably, the patients who are suitable under radial access include diabetics, older patients, as well as those who live a significant distance from the hospital.
These patients are typically excluded from same-day discharge under the ACC guidelines for outpatient PCI. Investigators note these patients are typically not considered candidates for same-day discharge due to the assumption PCI is performed via the femoral artery. While the majority of PCIs in the United States are performed via the femoral artery, radial access is very common internationally.
Radial access may facilitate same-day discharge for these typically overnight patients due to the low incidences of bleeding with radial access. Given the small size of the radial artery compared to the femoral, serious bleeding incidences are very rare and overnight monitoring is typically not needed.
Investigators found that none of the 100 patients studied reported complications or hospital readmissions following same-day discharge. More information on the study is available here.