Implementing the Minimalist Approach

CVForward > Implementing the "Minimalist Approach" to TAVR Procedures

IMPLEMENTING THE
"MINIMALIST APPROACH"
TO TAVR PROCEDURES

Contributor

Josh Roberts

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The triple aim in healthcare is lower costs, better outcomes, and increased patient satisfaction. With a program that implements a “minimalist approach” for transcatheter aortic valve replacement (TAVR) where appropriate, your facility can accomplish all three.

A brief history

As far back as 2012, the Journal of the American College of Cardiology highlighted the work of physicians who were pioneering a “minimalist approach” to TAVR—without the use of general anesthesia or transesophageal echocardioagraphy. Their protocol called for conscious sedation and local anesthesia, eliminating sternotomy, cardiopulmonary bypass, and tracheal intubation.¹

Those first cases were considered risky, but the safety and benefits of a minimalist approach soon became clear.

In recent studies, patients who underwent “minimalist” TAVR procedures had death rates that were lower than or equivalent to traditional TAVR. Every other outcome was resoundingly favorable. Conscious sedation allowed for monitoring of neurological status during the procedure, giving clinicians the ability to detect early signs of stroke and eliminated the need for ventilators.

Additionally, conscious sedation dramatically reduced procedure time, time in the ICU post-procedure, and patients’ hospital stay, resulting in lower costs, better health outcomes, and greater patient satisfaction. In Europe, where TAVR therapy originated, clinics have long employed a minimalist approach. But North American hospitals were slower to adopt the practice, concerned about the short- and long-term outcomes for patients. Today, nationally-renowned programs such as the Piedmont Heart Institute’s Marcus Heart Valve Center in Atlanta, Georgia, are leading the way toward a less invasive and more efficient TAVR process.

A team approach

The Piedmont heart team initially struggled with the idea of conscious sedation due to nominal US examples. At first, they started with the simplest patients, which went very well. After that, the team agreed to fully transition to this approach as they felt it helped reduce complications and led to faster recovery times for patients.

Josh Roberts is Executive Director of Cardiovascular Services with Piedmont Healthcare. He helped bring minimalist techniques to the TAVR program in 2014 and continues to guide the team in optimizing the approach.

We worked very heavily with anesthesia to develop a transcatheter-specific pathway for certain patients. Every Monday, the team met to talk about the specific approach for each case. Would it be performed in the cath lab with conscious sedation or in the OR with general anesthesia? Everything is discussed thoroughly with a multidisciplinary team.”

A look at the results of "minimalist" TAVR at Piedmont

The team at Piedmont has experienced unmitigated success in implementing an optimized approach to TAVR procedures. Patients undergoing minimalist TAVR at their facility can expect a hospital stay of 1 to 2 days. They are sitting in a chair an average of 4 hours post-procedure and walking after about 6 hours. The team at Piedmont is seeing fewer lung-related issues among TAVR patients; there’s less delirium due to narcotics. And after an initial investment in the new minimalist paradigm, their balance sheet is in the black.

Sure, we lost some revenue up front because we were doing less invasive, less costly procedures. But it’s what was right for our patient population. Once we were comfortable with the process, the efficiencies really started to kick in.

Originally, they had 10–12 people in the room for every procedure, but reduced that number significantly. Now, they have a maximum of 2 cath lab staff and 2 OR staff for every basic TAVR case.

They had a 92-year-old patient on oxygen ask a few hours after the procedure to go home. They, of course, say not today. But this is proof that their patients are feeling better with the minimalist approach and don’t feel they have much to recover from.

Reaching the Triple Aim with a "minimalist" approach to TAVR

1) Lower Costs: By reducing days in the hospital, cutting down on the number of staff needed during the procedure, and eliminating the use of general anesthesia, transesophageal echocardioagraphy, rapid pacing, and/or tracheal intubation, you can maximize the value of reimbursement and increase volume, while providing patients with superior care.

2) Better Outcomes: All TAVR patient populations have demonstrated better health outcomes with the use of conscious sedation, local anesthesia, and a percutaneous procedure. This is especially true of frail, elderly patients. Clinics practicing a minimalist approach see fewer complications related to pulmonary disease, stroke, infection, and narcotic use as well as significantly lower rates of in-hospital death.2

3) Greater patient satisfaction: Patients report being happier and more comfortable with a faster conscious sedation procedure that allows them to leave the hospital after only a few days. A minimalist approach generally leaves patients feeling healthier and more able. This is a case where less medicine is better medicine—for everyone involved.

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About Piedmont Healthcare

A private, not-for-profit organization serving nearly 2 million patients across Georgia, Piedmont is transforming healthcare, creating a destination known for the best clinicians and a one-of-a-kind experience that always puts patients first. Today, more than 110 years since it was founded, Piedmont is known as a leading health system in cancer care, treatment of heart disease and organ transplantation with 7 hospitals, 20 urgent care centers, 28 Piedmont QuickCare locations, 527 Piedmont Clinic physician practice locations and 1,782 Piedmont Clinic members. Our 16,500 employees dedicate themselves to making a positive difference in every life we touch and our commitment doesn’t stop there. In FY 2017, Piedmont provided more than $215 million in uncompensated care community benefit programming in an effort to better the health and well-being of the people in the communities we serve.