Shifting PCI Procedures to Outpatient Centers: Safety First?

Regulators are on board and the reimbursement is there, but should more complex percutaneous coronary intervention (PCI) procedures be shifted from a traditional hospital setting to an ambulatory surgical center (ASC)?

"Obviously we're not advocating that [PCI in a] high-risk patient with high-risk anatomy should be performed in an ASC setting at this point. Probably, those patients should stay in the hospital," said Georges Nseir, MD, of Premier Cardiovascular Center in Chandler, Arizona, at a panel discussion during the virtual meeting of the Society for Cardiovascular Angiography and Interventions (SCAI).

"Just because you can do it in the hospital doesn't automatically mean it will translate to the ASC or OBL [office-based lab] setting," cautioned Jeffrey Carr, MD, of Tyler Cardiac and Endovascular Center and CardiaStream in Tyler, Texas.

But when stars align for experienced operators and appropriate patients, the benefits of complex coronary procedures in outpatient settings can include improved efficiency of care, increased access to care, and better patient satisfaction.

Reduced costs -- especially with same-day discharge after elective PCI -- are also tempting: CMS anticipates a $20 million savings if just 5% of PCIs were moved to ambulatory surgical centers, said Deepali Tukaye, MD, PhD, of Northside Hospital Cardiovascular Institute in Cumming, Georgia, during the SCAI session.

Numbers from the National Cardiovascular Data Registry support PCI at ambulatory surgical centers, given the "fairly low" rates of major complications among elective patients, Tukaye noted.

In addition, Nseir cited research that patients with complex lesions -- as well as those with left main lesions, chronic total occlusions, and elderly patients -- have been shown to be safely discharged from the cath lab within 6 hours. Moreover, one group reported a less than one in 1,000 incidence of referral to emergency bypass surgery.

The key is that ASCs need to meet certain criteria for physicians, staff, equipment, and facilities, and choose the right PCI patients, Nseir said.

Yet "everyone has a plan until they get punched in the mouth," said Anbukarasi Maran, MD, of the Medical University of South Carolina in Charleston, quoting boxer Mike Tyson. She took the stance against ambulatory centers taking on complex PCIs during the discussion.

"Would you rather have a member of your family ... have their cardiac cath in a state-of-the-art cath lab, which has access to all kinds of atherectomy, all kinds of advanced mechanical circulatory support [MCS], vascular and CT surgery backup if you need it?" Maran asked.

Or, she posed, would an ASC, with the "bare minimum," that can only fix type A lesions, be preferred? "There is no access to advanced MCS apart from a balloon pump, no access to atherectomy, no CT surgery or vascular surgery, and [it takes] 60 minutes to one hospital either by ambulance or helicopter," she continued.

Maran emphasized that the <1% complication rate following PCI should not be viewed the same as the 1% also cited for dermatologists giving Botox injections.

"Complications in the cath lab can be cognitive errors. [It] can be, you are just putting your head in the sand, you're not seeing the first mistake, and you're making more and more mistakes," she said. "Those you can learn from, you can get better, you can improve."

"PCI, my dear friends, is not a Botox injection, and it cannot be, should not be recommended in an outpatient ambulatory surgical setting. Complications are rare, but can be devastating," Maran concluded.

Other discussants agreed that patient safety comes first, but did not believe in a blanket rejection of PCI in ASCs.

"I think of the analogy of a [road]. Some roads are safer to drive on than others. That [doesn't] mean you [can't] drive on them. But, you probably [shouldn't] take your [Porsche] at 120 mph down a country road," wrote Lyndon Box, MD, of West Valley Cardiology Services in Caldwell, Idaho, in the virtual chatroom for the session.

"People often ask the 'would you have you or your family member get a PCI in an ASC?' I can definitely say that I would rather have Jeff Carr do my PCI in his ASC than a lot of other people doing it in their large academic medical center," Box added.

Carr shared several tips for outpatient centers performing PCI and same-day cardiac interventions:

• Having an array of devices to bail out when necessary (e.g., covered stents, thrombectomy catheters)
• Considering staged procedures for sicker patients
• Maintaining skill in different techniques, alternative access
• Using ultrasound guidance
• Participating in mentorship and remote case support for less experienced operators
• Routine bailout drills to sharpen skills

Besides safety concerns, the potential drawbacks of shifting coronary procedures to outpatient centers also include a change in an affiliated hospital's finances and a rise in inappropriate PCIs, Tukaye said.

CMS reimbursement for coronary interventions in ASCs began in January 2020. In response, guidance for starting such a program was set forth by an SCAI group -- led by Box, with Carr and Tukaye as co-authors -- in July.

This January, CMS also started reimbursing for atherectomy at ASCs.

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