A Clinical Pathway for Transcatheter Aortic Valve Replacement
An interview with Christopher Meduri, MD, MPH, and Brooke Harvey, BSN, Piedmont Heart Institute, Atlanta, GA
More and more, various health care institutions around the country are implementing clinical pathways in an effort to improve outcomes and control costs. A 2003 study reported that more than 80% of hospitals had implemented clinical pathways as part of quality improvement initiatives.1 Today, clinical pathways can be found almost universally as one of the tools physicians use to treat their patients.2 The use of pathways programs in the United States has had demonstrated benefits. A 2010 report reviewing pathway usage across the United States found that the use of clinical pathways was associated with a significant reduction in hospital complications and documentation and the overall costs associated with care without negatively effecting length of hospital stay.2
Although clinical pathways are most commonly used in oncology care, they have been successfully applied in other areas of medicine as well. One example is the clinical pathway implemented at Piedmont Heart Institute in Atlanta, GA, to guide the care of patients during and after transcatheter aortic valve replacement (TAVR) procedures. TAVR is a minimally invasive catheter-based procedure in which the aortic valve is replaced by inserting a new valve into the old damaged valve. The procedure is FDA approved for people with symptomatic aortic stenosis who are considered high- or extreme-risk for surgical aortic valve replacement. Typically, valve replacement requires open heart surgery, including a sternotomy, in which the chest is surgically separated. In contrast, the TAVR procedure can be done through a tube being placed in the femoral artery. As a result, recovery times with TAVR are much shorter than for traditional open heart surgery.
Piedmont’s TAVR pathway has seen profound results for reducing overall costs and length of stay as well as improving the health outcomes of patients. To learn more about Piedmont’s pathway program, Journal of Clinical Pathways spoke with Christopher Meduri, MD, MPH, interventional cardiologist at Piedmont Heart Institute, and Brooke Harvey, BSN, manager of Piedmont’s clinical pathway development program.
How was the TAVR pathway program initiated?
CM: I had already done quite a bit of work in pathways before I came to Piedmont a little over several years ago. I had developed a mobile app called Post-TAVR Optimization, and this application is actually available for free (http://apple.co/1LmyxfV). The premise was that clinical pathways could improve outcomes for TAVR patients by providing guidance through the hospital stay as well as by helping people to understand the health economics of the procedure. The financial perspective was very important, because there is a large concern that, by shortening the length of stay for TAVR patients, you’re penalizing the hospital financially. But this is not actually true. So there was a lot of thinking, “If you don’t teach people how the pathway works from a financial perspective, they are going to resist improving outcomes and improving length of stay.”
When I came to Piedmont, I sat down with Brooke to look at how we could help TAVR patients, including using the pathways I had already built out. We started to put clinical pathways in place. We discussed how these pathways were going to exist at Piedmont and adjusted them to fit our institution. Next, we educated the staff on why we felt there was a need to further optimize care and how we wanted to accomplish this. Then we looked back at the procedure itself and asked how it could be improved for patients. Finally—and probably most importantly, I think—was implementing the clinical pathways to optimize the care of patients after the TAVR procedure.
One of the big things behind the initiation of the pathway program was that, conventionally, patients who had severe aortic stenosis underwent open heart surgery, because TAVR is a relatively new technology. As the new technology started, the patients were placed in surgical pathways, which would involve general anesthesia, inserting a lot of lines into the patient, and prolonged immobilization and typical length of stay of 7–8 days. This was very reasonable as this was a new technology we needed to gain familiarity with. After providers became familiar with the technology, it was time to maximize its potential benefits to the patients.
That raising of awareness was a big part of our process for improvement. Partly that involved educating patients up front when we thought that this was a better treatment option for them. Patients were very open to this, because they wanted to avoid staying in a hospital for 8 days if they could. Of course, now, the universal mindset of our patients is that they’ll be going home in 1 or 2 days; that’s what they’re expecting.
The next step was to look at the procedure and say: how am I optimizing the procedure for patients? We felt the most important thing for expediting recovery was to transition from doing almost all general anesthesia to doing only light conscious sedation, which is similar to what would be done for a cardiac catheterization procedure. Finally, and most importantly, the development of the clinical pathway itself helped to get us out of the rut of treating these patients like cardiac surgery patients.
What were the key components of the clinical pathway that you developed?
CM: The biggest component was based on the idea that every patient recovering from a procedure needs to ambulate soon and often. So we ensured that every patient was sitting in a chair by 4 hours after the procedure and walking around by 6 hours after the procedure. And then we encouraged them to walk as much as possible. This really minimized any need for recovery.
The second component was to avoid administering any narcotics or sedatives, which we know are very dangerous for elderly patients. And the third component was to minimize any central lines or other barriers from the patient being back to their baseline. Our overall goal is to bring the 6–8-day stay down to a 1–2-day stay by returning patients to a normal state of health as quickly as possible.
What we’ve seen at Piedmont is that our median length of stay about 1.5 years ago was 7 or 8 days, and our median length of stay for the last 18 months has been 2 days. On top of that, we’ve reduced our cost of hospitalization by over almost $8,000. We’ve had outstanding health outcomes; in fact, we have a mortality rate that is one-third of the national average, and we have not had a single case of complications from conscious sedation or early ambulation in over 200 cases. We take great pride in these results, and I would argue that our performance on these metrics is as good, if not better, than any similar centers in the country.
What is so beneficial about reducing patients’ length of stay at the hospital?
CM: Reducing patients’ length of stay is important because we know that, in elderly patients, every additional unnecessary hospital day is an opportunity for something bad to happen. The clinical pathways eliminate the minutiae and redundancies that cause wastefulness and delays in care; for example, putting something off onto the next shift or committing errors in patient monitoring.
Now, the only thing you really have to account for is whether the patient is getting up and moving around. This is where Brooke has been great in working with her team to ensure patients are moving. Brooke’s team has actually built out a wonderful sheet that follows the patients through their hospital stay so that the nurses can document when the patient is reaching their milestones. A lot of this is just built around education. We’ve had to go back in to re-educate everyone involved in treating the patient—the socials workers, the NPs, the care coordinators—so that everyone understands what we’re trying to do. When we started this, the nurses didn’t necessarily buy into it. They didn’t want just another form to fill out. But now they totally buy in, because they see that these patients do so much better. It took a lot of time, but we are where we are because we made sure that everyone was educated and everyone bought into the program.
Is there ever a need to deviate from the pathway?
CM: Absolutely. And the nurses know and will comment that the patient is off pathway. If there is a procedural complication then the patient will of course have to come off the pathway. And again, we know that in TAVR cases there is a percentage of patients who are going to face some kind of complication because of their risk procedure. At Piedmont, we think we’ve done a lot to mitigate that risk, but when those patients do incur something like that, they will be off the pathway. With each individual scenario, we then tailor the treatment plan ourselves. We still want patients to ambulate quickly and to maintain other aspects of the pathway if possible, but obviously there are circumstances where the severity of illness of the patient forces us to modify these things. However, over 90% of our patients are on the pathway.
Can you talk a little bit more about how the clinical pathway helped to reduce costs for the hospital?
CM: If you look across the US, in 2012, the average hospital lost a little over $7,000 per TAVR case. There is a lot of variability in hospital reimbursement for Medicare cases —and remember that more than 90% of these patients are covered by Medicare—because DRG payments are affected by the number of trainees, the location, and other factors. But, regardless, there are a lot of places that are losing a lot of money on TAVR programs. From the initiation of the program at our center, the average cost dropped to somewhere in the neighborhood of $7500 per TAVR case. What we found was that we could improve outcomes and reduce costs at the same time through the use of our pathway. So this was one of those unique situations in life where everybody can win.
Was reducing costs something that you specifically set out to do when you developed the program?
CM: Reducing costs was not the primary goal for us, no. The primary goal was providing patients with the best possible care; that was the first question we asked ourselves, and one that we kept asking ourselves. But we were conscious that the changes we were making could have a positive financial impact as well. And, you know, that’s really the beauty of what Brooke and Piedmont do so intelligently with the clinical pathways programs; they recognize that investment in these types of changes most importantly improve care for the patient, but also provide huge financial benefits. Not only do they improve quality metrics, which is obviously going to drive a lot of reimbursements, but they also seem to reduce costs as well. So, again, this is really one of those rare situations where everyone wins. And that is what is so great about clinical pathways: when built correctly, they improve outcomes and, by nature of their being used repeatedly and consistently, really drive improvements in costs. I don’t think we anticipated quite the reduction in costs, or at least not as quickly, but we’ve obviously been very pleased with the results.
Tell us more about the clinical pathways team and what specific objectives you have.
BH: I manage a team of people who are dedicated to clinical standardization and quality improvement for the employed physicians within the cardiovascular, neurosciences, pulmonary/critical care, and primary care service lines. Our responsibility is to work with our physicians to determine what the priorities are for quality improvement and clinical standardization. We look for opportunities to reduce variation in order to improve the quality of care that our patients receive and inevitably reduce costs to the health care system.
We have a role on our team called a patient outcomes specialist. This person is responsible for making sure that we at Piedmont are adhering to the clinical pathways by monitoring quality and financial outcomes. Specific to TAVR, this person is responsible for going to the unit the day that the patient comes out of the operating room from having the TAVR procedure to make sure that the patient is on pathway, answer questions from the staff, and ensure that the patient and family have their patient-centered recovery pathway.
Has the success of this pathway for the TAVR procedure encouraged you to push for the development of other pathways?
BH: Our clinical pathway program started about 3 years ago with cardiovascular disease–specific pathways. We were able to demonstrate a significant cost savings by reducing variation in care and improving quality through clinical standardization. We focused our efforts on a few procedural pathways such as TAVR and cardiac surgery, with which we were able to reduce costs through decreasing lengths of stay and eliminating unnecessary labs and imaging. Therefore, the health care system has invested in our team to build these clinical pathways for multiple service lines. We enjoy recognizing and highlighting programs that show great outcomes through clinical pathways, such as the TAVR program.
1. Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med. 2010;8:31.
2. Rotter T, Kinsman L, James E, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;3:CD006632. doi:10.1002/14651858.CD006632.pub2.