Hospitals push to remove minimum case requirement for TAVR

[Man o War]

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Thoughts?
First of all, had no idea Medicare paid $45k for a TAVR!
Second, interesting that Medtronic supports keeping case minimums and Edwards doesn’t.

https://www.google.com/amp/s/www.kpbs.org/news/2018/aug/17/hospitals-battle-for-control-over-fast-growing/?amp=amp

 

[POW16]

Thoughts?
First of all, had no idea Medicare paid $45k for a TAVR!
Second, interesting that Medtronic supports keeping case minimums and Edwards doesn’t.

https://www.google.com/amp/s/www.kpbs.org/news/2018/aug/17/hospitals-battle-for-control-over-fast-growing/?amp=amp

These cases can go south very quickly. IMHO they should definitely be done in high volume centers used to the case, complications, etc.

 

[Man o War]

These cases can go south very quickly. IMHO they should definitely be done in high volume centers used to the case, complications, etc.

I agree. We do a lot of them and that’s my concern as well.

 

[d9sccr]

Yeah but an emergent thoracotomy is another source of revenue, no?

 

[Robotic Wis-Hipple]

So easy a NP can do it! Let’s just turn the hybrid OR into another IR with anybody that’s done a few “procedures” able to throw these babies in!

It’s not just the admittedly low intraop complication risk to think about, the hospital needs a good cardiology department and stroke/neuro IR service imo.

This is so obviously about the money it makes me sick, all these local/rural hospitals see TAVRs as a high margin procedure with low bed utilization and so they want it to keep them in the black. Nobody is thinking patient first.

 

[Mman]

Yeah but an emergent thoracotomy is another source of revenue, no?

not if the hospital is getting a flat fee for the procedure and management of any complications that occur

 

[dannyboy1]

So easy a NP can do it! Let’s just turn the hybrid OR into another IR with anybody that’s done a few “procedures” able to throw these babies in!

It’s not just the admittedly low intraop complication risk to think about, the hospital needs a good cardiology department and stroke/neuro IR service imo.

This is so obviously about the money it makes me sick, all these local/rural hospitals see TAVRs as a high margin procedure with low bed utilization and so they want it to keep them in the black. Nobody is thinking patient first.

Everything is about money. Everything. Then again who am I to judge, it’s not like I work for free...

 

[coffeebythelake]

Everything is about money. Everything. Then again who am I to judge, it’s not like I work for free...

if there is someone clearly not optimized you would cancel the case for patient safety hopefully above your paycheck

 

[dannyboy1]

if there is someone clearly not optimized you would cancel the case for patient safety hopefully above your paycheck

Lol. Cancellations are rare but we are all employees. The older guys who remember when we were FFS reminisce about a time when cancellations were non - existent . In all seriousness if your small hospital gets approved to do TAVR, what are you going to do, refuse to provide anesthesia for these cases because it could be done better at another institution?

 

[nimbus]

Lol. Cancellations are rare but we are all employees. The older guys who remember when we were FFS reminisce about a time when cancellations were non - existent . In all seriousness if your small hospital gets approved to do TAVR, what are you going to do, refuse to provide anesthesia for these cases because it could be done better at another institution?

True. You gotta start somewhere. EVERY program starts out low volume.

 

[coffeebythelake]

Lol. Cancellations are rare but we are all employees. The older guys who remember when we were FFS reminisce about a time when cancellations were non - existent . In all seriousness if your small hospital gets approved to do TAVR, what are you going to do, refuse to provide anesthesia for these cases because it could be done better at another institution?

I don't disagree with you.

 

[sevoflurane]

I would not want to get a TAVR at a place that does100 open heart cases a year (most of which would likely be CABGs).

You need to be prepared to do valve in valves, alternative access (transaortic, subclavian, transapical), crash on to bypass, understand the risk of and prepare for complete heart block, etc...

Sure we all need to start somewhere, but I would guess that morbidity and mortality will be higher at institutions that have low numbers of caths, tavrs and valve cases.

Having been part of a TAVR/Mitral clip start up program, there is definitely a learning curve and complications do happen.

We now can do 5 TAVRs by 5pm and 4 by 3pm. Volume of cases has made things safer as well as having a dedicated multi-diciplanatary structural heart team that reviews cases pre-op and post-op. (cardiac anesthesia, cardiac surgery, cardiology, radiology amongst others)

The more you do per year the better you get at it.

I want to get my TAVR at a the program that does 100-200+ tavrs a year. Not the one that does 10. That is just nonsense and a way of putting your patients at uneasesary risk.

My 2 cents

 

[dhb]

5 TAVRs by 5pm

5x45=

 

[Psai]

Guys it says clearly in the article that the material costs like 30k. Theyre ballin on a budget.

 

[urge]

These cases can go south very quickly. IMHO they should definitely be done in high volume centers used to the case, complications, etc.

You can make that argument about any procedure.

The only way to get good at anything is doing a lot butvif you don't let them do any how are they supposed to get good at it?

Do you think the ones currently doing tavrs were born knowing? Of course they harmed a lot of people to get where they are.

 

[coffeebythelake]

You can make that argument about any procedure.

The only way to get good at anything is doing a lot butvif you don't let them do any how are they supposed to get good at it?

Do you think the ones currently doing tavrs were born knowing? Of course they harmed a lot of people to get where they are.

Ideally they learn under the guidance of someone else who has done them plenty

 

[drmwvr]

Ideally they learn under the guidance of someone else who has done them plenty

Yes and with the lowest risk/comorbid population possible. For lots of cases.

 

[WholeLottaGame7]

Ideally they learn under the guidance of someone else who has done them plenty

How did that person get good at them?

I think the determinant of whether or not a place is able to do them should depend on their ability to manage complications. Do they have CT surgeons who do valves? A CTICU? CT anesthesiologists?

It's not the type of procedure where you can say, "Well, we f'd that up, let's fly 'em a couple hours to the nearest major hospital..."

 

[POW16]

You can make that argument about any procedure.

The only way to get good at anything is doing a lot butvif you don't let them do any how are they supposed to get good at it?

Do you think the ones currently doing tavrs were born knowing? Of course they harmed a lot of people to get where they are.

No you can't make that argument about any procedure. Those patients are incredibly sick and everything is high risk. As others have stated it's all about having the resources including radiologists, CT surgeons, neurologists, intensivists, nursing staff,etc prepared to deal with potential complications. I'm not saying that this should not be done in new places but simply that each place should have extensive resources to start doing these.

 

[Mman]

How did that person get good at them?

They got good at them by killing people. It's called a learning curve. While they might be really good at them now, they weren't when they first started doing them. And at this point there are probably enough people that are getting good enough at it that you'd rather have them doing the procedure and proctoring new learners than somebody else just winging it on the steep part of the learning curve.

 

[AdmiralChz]

Yeah but an emergent thoracotomy is another source of revenue, no?

I’ve yet to see a patient personally survive this.

 

[Psai]

I’ve yet to see a patient personally survive this.

We've had a few

 

[Arch Guillotti]

I’ve yet to see a patient personally survive this.

How many have you seen?

 

[AdmiralChz]

How many have you seen?

Not a ton, 20-30. Half don’t make it out of the trauma bay, the other half haven’t made it out of the OR.

Of course it’s anecdotal, but I wonder what the literature statistics on this are

 

[Robotic Wis-Hipple]

The tragedy with this “progress” towards improved access will be the major stroke in an intermediate, or shortly low risk TAVR patient at a small hospital without a good neuro service.

I’ve seen some bad strokes caught in PACU that were in the IR suite within 20min for the embolectomy.

I totally get that grandpa doesn’t want to go get his TAVR at a hospital 3 hours away, but he also doesn’t want to get flown to that same tertiary hospital while his grey matter is dying then come back to his small town SNF that is also likely sub par.

Just because everybody wants the lesser trained providers to be considered equal doesn’t mean they are

 

[Robotic Wis-Hipple]

Not a ton, 20-30. Half don’t make it out of the trauma bay, the other half haven’t made it out of the OR.

Of course it’s anecdotal, but I wonder what the literature statistics on this are

I’ve seen a few disaster TAVRs crash onto bypass that made it. That’s why the pump is in the room and a CT surgeon should be involved not just available imo.

 

[Man o War]

I’ve seen a few disaster TAVRs crash onto bypass that made it. That’s why the pump is in the room and a CT surgeon should be involved not just available imo.

This x1000. We always have a surgeon ready to go. And CT anesthesia, and all necessary equipment. I’ve seen it enough times to know I wouldn’t undergo this procedure personally without that process in place.

 

[sevoflurane]

This x1000. We always have a surgeon ready to go. And CT anesthesia, and all necessary equipment. I’ve seen it enough times to know I wouldn’t undergo this procedure personally without that process in place.

Our surgeons scrub in, get access and deploy the valve. Cads scrubs in as well. They alternate what they do. Having them both scrubbed in makes it go faster... and when we have a problem they are already there.

 

[Man o War]

Our surgeons scrub in, get access and deploy the valve. Cads scrubs in as well. They alternate what they do. Having them both scrubbed in makes it go faster... and when we have a problem they are already there.

Same. This idea that we should sacrifice quality and safety for access makes me really nervous.

 

[deleted697127]

This problem will work itself out. The complications aren’t exactly rare or subtle. Cardiac surgery on standby but not in the room isn’t ideal but from what I’ve seen our role seems locked in. Good luck managing these complications without an anesthesiologist.

 

[urge]

The tragedy with this “progress” towards improved access will be the major stroke in an intermediate, or shortly low risk TAVR patient at a small hospital without a good neuro service.

I’ve seen some bad strokes caught in PACU that were in the IR suite within 20min for the embolectomy.

I totally get that grandpa doesn’t want to go get his TAVR at a hospital 3 hours away, but he also doesn’t want to get flown to that same tertiary hospital while his grey matter is dying then come back to his small town SNF that is also likely sub par.

Just because everybody wants the lesser trained providers to be considered equal doesn’t mean they are

Are you talking about random patients ending in IR or specifically tavr patients?

I have yet to see a tavr patient end up in IR. I imagine it is possible.

How many tavr patients have you seen with a post op stroke? I haven't seen many.

 

[Arch Guillotti]

Not a ton, 20-30. Half don’t make it out of the trauma bay, the other half haven’t made it out of the OR.

Of course it’s anecdotal, but I wonder what the literature statistics on this are

This isn't really analogous. Trauma thoracotomies usually croak.

TAVR was not around when I was a resident. The other poster mentioned an emergent thoracotomy but TAVR's gone wrong need to crash onto bypass.

 

[Robotic Wis-Hipple]

Are you talking about random patients ending in IR or specifically tavr patients?

I have yet to see a tavr patient end up in IR. I imagine it is possible.

How many tavr patients have you seen with a post op stroke? I haven't seen many.

My group has seen 3 bad strokes in the last year or so. This is explained by the “high risk” patients our surgeons take (that clearly nobody else does right?....). We also trialed the Sentinel device, and believe me, there is lots of calcified debris caught in every single one of those things. In the Sentinel study they diagnosed strokes in 9% of pts post TAVR by MRI, debilitating/clinically obvious strokes were in the 1-2% range iirc so that jives with our short term findings.

 

[urge]

My group has seen 3 bad strokes in the last year or so. This is explained by the “high risk” patients our surgeons take (that clearly nobody else does right?....). We also trialed the Sentinel device, and believe me, there is lots of calcified debris caught in every single one of those things. In the Sentinel study they diagnosed strokes in 9% of pts post TAVR by MRI, debilitating/clinically obvious strokes were in the 1-2% range iirc so that jives with our short term findings.

Very verbose reply but you didn't answer the question.

I'll assume no tavr patient in IR then. Did it matter if you did them having IR if you didn't send them to IR?

3 "bad" stokes in 1 year sounds like a lot. I haven't seen that many in 5 years. But without an N you cannot really draw conclusions.

 

[anbuitachi]

I wonder if there are ways to better design hybrid ORs cause the way the room is set up is horrible for anesthesiologists. Not only are we next to tons of radiation, the chunky c arm is right above the patient and it makes it so hard for us to work if something goes wrong!

 

[Robotic Wis-Hipple]

Very verbose reply but you didn't answer the question.

I'll assume no tavr patient in IR then. Did it matter if you did them having IR if you didn't send them to IR?

3 "bad" stokes in 1 year sounds like a lot. I haven't seen that many in 5 years. But without an N you cannot really draw conclusions.

2 of the 3 went to IR for embolectomy. We do >200 TAVRs per year

 

[AdmiralChz]

I’ve seen a few disaster TAVRs crash onto bypass that made it. That’s why the pump is in the room and a CT surgeon should be involved not just available imo.

Apologies, I was only referring to trauma emergent resuscitative thoracotomies.