The current study of Oleg Roussanov et al describes the cost-effectiveness of the radial approach to diagnostic catheterization compared with the femoral approach, with and without use of closure devices.1 Despite the fact that this is a non-randomized study, this paper gives accurate insight into the elements determining total procedural costs in the 3 study groups. Access costs were higher for the radial group because of the use of expensive puncture and cannulation sets. Surprisingly, more catheters were used in the femoral group. This might be due to a greater use of multipurpose catheters in the radial group.
A major contributor to cost effectiveness is reduced recovery cost, since the patient is immediately mobile post catheterization and hemostasis can be immediately obtained.
It is not surprising that differences in cost occur between radial and femoral access with the use of expensive closure devices. Prior research has compared costs with procedures in which femoral closure devices have been used.2 In 2000, Dr. Tift Mann et al reported on this strategy. In the closure device group, costs were significantly higher, not only because of higher supply costs, but also because of costs due to a higher number of vascular complications.
In this study, the average cost reduction was $77.40 and $183.90 per case. Of course these amounts may vary depending on various local and external factors. Overall, the radial approach will lead to major cost savings when calculated on a national scale.
Since its introduction, the cost-effectiveness of the radial approach has been demonstrated in a variety of different ways. This approach has consistently been cheaper compared with femoral access, both for diagnostic procedures and for coronary angioplasty. One of the first papers on this issue came from our laboratory in 1995.3 We compared 3 areas of interest: 1) Procedural consumption of material; 2) Post-procedural need for diagnostic and therapeutic access related to complications; and 3) duration of hospital stay. In the first area of focus we identified factors which might increase costs for the radial approach. These included more expensive needles and introduction sets, longer procedural times and use of more guides (depending on the learning curve for the operators), and finally, the use of hemostasis devices. However, with growing experience, procedural times have become similar to those in femoral procedures and the consumption of guides has stabilized. In fact, when using multipurpose backup radial guides, guide consumption can even decrease. Other less technical means of hemostasis (use of gauze and adhesive elastic straps) can be used and result in cost reduction. One of the major cost savers is the achievement of immediate hemostasis without the use of human resources (need for prolonged manual compression).4
Our second area of focus, which is more pronounced for PCI procedures, found that femoral access complications are consistently more frequent.5 This difference is associated with costs for diagnosis (laboratory, ultrasound, angiography, CT, etc.) and also costs for treatment (extra devices, surgery and transfusions). And finally, it is apparent that shorter hospitalization time can be achieved by immediate mobilization of the patient. An important factor is the cost savings that can be achieved by less involvement of medical and nursing personnel in management of the patient during the post-procedural phase. Patients can be more self-supporting and require less care by the health care professional.
Currently, approximately 95% of procedures in our practice are performed via the radial artery and we have re-engineered the process of care for patients undergoing coronary catheterization and interventions. Patients are not admitted to a traditional hospital ward, but are placed in a comfortable environment with amenities to make their wait as pleasant as possible, and most are discharged the same day. This “lounge” is staffed by a nurse practitioner and a small number of nurses. Flow through this unit is much faster when compared to flow through a medical ward, allowing more patients to be processed. Although a formal cost comparison to the more traditional hospital setting has not yet been undertaken, this new concept contains many features and options that may help to further decrease costs and improve on the efficiencies that are gained by using the radial approach.6
1. Roussanov O, Wilson SJ, Henley K, et al. Cost effectiveness of radial versus femoral artery approach to diagnostic cardiac catheterization. J Invasive Cardiol 2007;19:349–353.
2. Mann T, Cowper PA, Peterson ED, et al. Transradial coronary stenting: Comparison with femoral access closed with an arterial suture device. Cathet Cardiovasc Intervent 2000;49:150–156.
3. Kiemeneij F, Hofland J, Laarman GJ, et al. Cost comparison between two modes of Palmaz Schatz coronary stent implantation: Transradial bare stent technique vs transfemoral sheath protected stent technique. Cathet Cardiovasc Diagn 1995;35:301–308.
4. Amoroso G, Sarti M, Bellucci R, et al. Clinical and procedural predictors of nurse workload during and after invasive coronary procedures: The potential benefit of a systemic transradial access. Eur J of Cardiovasc Nurse 2005;4:234–241.
5. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–356.
6. Amoroso G, Laarman GJ, Kiemeneij F. Overview of transradial approach in percutaneous coronary intervention. J Cardiovasc Med 2007;8:230–237.