Cath Lab Digest Email Discussion Group

The following Email Discussion Group was sponsored by the Society for Invasive Cardiovascular Professionals (SICP). Does your hospital plan on stocking drug-eluting stents? If yes, will you have strict criteria for usage? Patient Selection Criteria Under Discussion We are going to begin performing interventions without surgery in January and have been watching the news very closely with regards to drug-eluting stents. We are hoping/planning to stock them when they become available. In our discussions with the physician who is coming as our interventionalist, we have talked about patient selection criteria. Natalie D. Beiler, Cardiac Cath Lab Supervisor Rockingham Memorial Hospital nbeiler@rhcc.com Selective Use? Our hospital will stock DES as soon as the product is available. There has been some discussion with the physicians regarding selective use of this stent, but I don’t hold out much hope. In my opinion, the only deterrent will be if the stent is hard to maneuver or sizing is limited. KVaughn, Kathy.Vaughn@wth.org Important for Market Share Although we are very conscious of the financial impact that will be caused with drug-eluting stents, we will have them available for use. With consumerism as it is, to not offer this new technology would be devastating to keeping and growing market share. We are just starting discussions for criteria-based use of drug-eluting stents and would be interested in what other organizations are doing. Ginny Latty, Manager, CCL Covenant HealthCare, Saginaw, MI GLatty@chs-mi.com No Discussion Yet We are planning to stock the stents; however, there has been no discussion on limiting their use. Terri.Mosey@medicorp.org DES? Not Yet There are no plans to stock them at this time. We do not do PCI at our facility; we do, however, do peripheral intervention. Steve Gressmire RT(R)(CV) ARRT Cardiology Services Manager Northwest Mississippi Regional Medical Center Clarksdale, MS Steve.Gressmire@nwmrmc.hma-corp.com Use of Non-Coated Stents Will Dwindle We plan to stock both types of stents and all sizes that are offered. At present, we have no criteria for restricting usage of these products. I predict that all other non-coated stents will not be utilized very often unless the other manufacturers are willing to provide a letter to physicians that they will cover any liability issues that may arise. dhansen2@yahoo.com No Restrictions Planned We are planning to stock them and have no plans to restrict their use. Bobby C. BCole@ftsm.mercy.net Suggestions Yes. We will be stocking drug-eluting stents. We have just begun to discuss whether criteria can be set. Many of the MDs feel that ethically and legally, they will be obligated to use these stents. I attended a webcast last month with 200 other participating sites; apparently, this was the general consensus. There were a few sites that were attempting to set criteria, but were having a very hard time doing so. Right now, the only saving grace for our budgets is that the stents will not be available in all sizes on the initial release! My thoughts at this time are to suggest: a) Where restenosis rates between drug-eluting and regular stents are not extremely different (larger vessels), can we set a preference for the regular stent? b) To minimize waste (use of multiple stents) due to estimate errors for stent length, can we require the use of IVUS (or other measuring parameter) for use of any drug-eluting stent? c) Guidant is coming out soon with a new alloy for stents, which so far is very promising in reduced restenosis. Can this be an alternate consideration? (We already use them.) d) Consider criteria for drug-eluting stent usage if possible. MDs must help facilities contain overall costs to help off-set the increased stent cost. Consider changes in practice Outpatient vs Inpatient, 23-hr stay, staffing practices, etc., as well as use of less expensive supplies. e) Explore other areas of procedure performance that can be more efficient/effective and reduce other costs. f) Texas Heart, in the webcast I participated in, was working with their vendors in effect saying: Okay, I’ve got to increase costs based on your stent; where are you going to reduce costs in your other products to help balance this out? (I thought this was an excellent approach.) g) Negotiate contracts: 1) Now with Cordis as the first to release, but; 2) With other vendors as theirs are released to market to obtain best price. Combine volumes within your hospital system for higher tier levels and lower pricing. (If not a member of a healthcare system, partner with other local facilities to form your own buying group based on local volumes!) Pam_Ragland@bshsi.com 70-80% Usage? We are trying to develop criteria/guidelines. Even with these, we predict that 70-80% of the patient population will utilize the drug-eluting stents. We are exploring the possibility of a 23-hour stay option. kstair@wmhs.com No Criteria Yet Our lab is planning to stock DES and we have not set any criteria for usage thus far. Annie Ruppert RN, San Diego, CA Annie.Ruppert@sharp.com Planning to Stock We are planning to stock the drug-eluting stents in our facility, and I haven’t heard of any strict criteria on the usage. Charlene Houston RN Winchester, VA charlene@shentel.net Singing the Same Music We will stock drug-eluting stents in the future, but to what extent, we’re not sure. We have a task force with cath lab staff, invasive cardiologists, accounting, coding and risk management working together on how we’ll tackle this new product. We’ve already compiled some data through online conferences and joint teleconferences. I believe with this kind of preparation, we’ll have a solution that will work for us. We want to be able to provide everything we can for our patients while remaining fiscally sound. We’re actually working with the two other hospitals in our area while presenting to Tennessee Blue Cross Blue Shield. We hope that by singing from the same sheet of music and telling the same story that we’ll get a better carve out for specific reimbursement on DES. Craig Cummings, RCIS FSICP, Cardiac Cath Lab Erlanger Health System Chattanooga, TN CumminCG@erlanger.org A Plan of Attack I do believe that DES are the future and there is no way to turn back. This is an exciting, new and greatly improved way to treat de novo lesions. It is a bandwagon that everyone’s jumping on, and it is the one that may break the bank of many healthcare providers. I do have some questions: 1. Are we going to pay more than the Europeans for the same stent? 2. Why is everyone focusing on the in-stent portion only? If you have somewhere around 2% in the stent segment, but your edges have 7-9%, do we not have a restenosis rate for the patient of plus-9%? 3. If the market has other stents with restenosis rates around 15% or less, are DES worth the additional $$$? 4. Will the restenosis rate increase greatly once the genie is let out of the bottle? 5. Will your cardiologist use IVUS to ensure proper deployment and sizing? We as a organization will be having a symposium on DES next month. Our focus group will be family practice, internal medicine and the local media. The more information we get out to people outside of cardiology, the better off we will be. Each facility needs to discuss: 1. Ethically and legally, do you have to place this stent? Do you have to treat in-stent restenosis with brachytherapy vs. just placing another stent? Do you have to place the best stent on the market based on studies of stainless steel stents in a patient or can you place one with a restenosis rate of 30% plus? 2. Guidelines “ We have developed a system-wide workgroup to look at this problem. The group has CEOs, CFOs, finance, cardiologists, directors and managers. 3. Cobalt/Chrome stents “ The restenosis rate is somewhere in the single digits, from what I am hearing. Now we are getting pretty close to the DES in-segment restenosis rate. 4. Negotiating contracts with vendors. Scott Fylling, scott.fylling@bhsnet.org Negotiate as a Large Group I think all of us who were around when J&J brought their stent (and the only stent for a while) to market in 1993 remember the incredible hit our hospital budgets took to accommodate the newest technology. It was amazing to see how stent prices tumbled when competition arrived. A system-wide work group of CEOs, CFOs and managers will be crucial to the outcome here. Only time will tell how organized that system will be come April. We’re running out of time. We need to use CYPHER, SIRIUS and viewpoints from cardiovascular research groups to develop documentation and create guidelines. Scott Fylling had some great ideas (group member response, above): Inspect and investigate pricing in Europe vs. USA. Introducing DES requires a complete hospital team effort financial and clinical Create, document and enforce a strict guideline for DES use. Don’t ignore the cobalt, chrome and PCI stents. Pay attention to the data that supports them and then document again. Negotiate contracts with your insurance companies and payers. Develop carve-outs within your reimbursement-payer community Be sure that all hospitals within your community have the same story for insurance payers as to how DES should be used. If we don’t act together as a group, creating the same request for use, need, reimbursement and concessions, we will not be successful in diminishing this cost. The luxury of time is not on our side. CPT coding has been established before the technology is here; that’s a first. I'm not convinced that lesions have always been treated with the best stent. Now that the stakes ($$) have changed, I'm afraid there’s a fever that will grow somewhat in comparison to when the J & J stent came out in 1993. We need to negotiate contracts and do it now, collectively, as a LARGE group. If we wait much longer, the legalese WILL dictate what we can and can’t do when we place stents. We’ll then be hard-pressed refusing to place DES while demanding better reimbursements. Because of the pending media blitz, it’s likely that our communities are going to demand DES as a standard of care. Craig Cummings, RCIS FSICP, Cardiac Cath Lab Erlanger Health System Chattanooga, TN CumminCG@erlanger.org (We have 3 heart hospitals within 10 miles of one another. We have committees working on DES solutions.) No Choice We have no choice but to stock and use DESs exclusively. Legally, we don’t have a leg to stand on if a patient who gets a bare metal stent has ISR. What’s your plea, it was too expensive...? Yeah, right. Gordon Reichard, Executive Director Santa Fe Heart & Vascular Center, St. Vincent Hospital Gordon.Reichard@stvin.org RECOMMENDED READING Thanks to Craig Cummings, RCIS FSICP, Cardiac Cath Lab, Erlanger Health System, Chattanooga, TN, for the following recommended reading: Gunn J, Morton AC, Wales C, et al. Drug eluting stents: maximising benefit and minimising cost. Heart 2003; 89:127-131.

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