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A less costly and safer pathway for percutaneous coronary intervention (PCI) may require just two changes: a "radial first" strategy coupled with same-day discharge, a study suggested.

After adjusting for baseline differences between groups, a propensity score model showed that each transradial intervention was $916 cheaper than the transfemoral alternative (95% CI $778-$1,035); similarly, same-day discharge was associated with $3,501 in savings (95% CI $3,486-$3,902), according to of Washington University School of Medicine in St. Louis, and colleagues.

Taken together, both measures lowered the price of PCI by $3,689 (P<0.0001), they wrote in .

Radial access coupled with same-day discharge cost $13,389 (95% CI $13,161-$13,607), compared with the $17,076 price-tag of femoral access and later discharge (95% CI $16,999-$17,147).

With a "relatively small" 30% shift from current practice for elective PCI -- largely dominated by femoral access and later discharge -- to adoption of the two measures, the U.S. would save $300 million a year, the authors determined. Each hospital that performs 1,000 PCIs annually stands to save $1 million.

The study spanned the years from 2009 to 2012 and showed that the majority of interventions were transfemoral and followed by later discharge (86.9%). Just 9.0% of cases used transradial access; 5.3% had same-day discharge; and 1.2% incorporated the two measures.

Amin's group included 279,987 procedures, inpatient and outpatient alike, from the National Cardiovascular Data Registry CathPCI Registry. That database was, in turn, linked to Medicare claims.

Over this period, in-hospital bleeding was less common after transradial access (1.4% versus 3.0% for transfemoral, P<0.001). Also reduced with this strategy were rates of transfusion (0.5% versus 1.2%, P<0.0001) and other vascular complications (0.2% versus 0.4%, P<0.0001).

"Particularly noteworthy, the observed bleeding reduction in the transradial intervention group was achieved despite frequent use of other bleeding avoidance strategies (e.g., 51% bivalirudin use, 58% closure devices) in the transfemoral intervention group," Amin's group noted.

"I would bet that future analyses looking at PCI data for 2017 will demonstrate that we have innovated even further in the transradial space such that we have found ways to tackle more complex cases, sicker patients, and improved our processes to mobilize transradial patients home faster," commented, of Atlanta's Emory University Hospital Midtown, who was not a part of the study.

"I'm not sure that our practices have similarly evolved as much for transfemoral patients in this same time frame," he continued in an email to 番茄社区. "Thus, it is possible that these cost saving calculations, while impressive, may actually underestimate how much savings could be realized with increased adoption today."

Importantly, Amin's group did not perform a societal-level analysis taking into account downstream costs, they stated.

"Another way that we underestimate the savings involved with a move to transradial PCI same day discharge is from the larger societal picture," Devireddy agreed. "These patients, I presume, experience higher patient satisfaction, quicker return to work, and increased mobilization which creates added savings that are not accounted for by looking at hospital data alone."

The propensity score analysis was left open to the possibility of unmeasured confounding and selection bias, the authors added.

, of the University of California Los Angeles, wrote in an accompanying editorial that "it is virtually impossible to attenuate fully the risk of bias without randomization."

"On the basis of the information provided by the authors, there seems to be good balance in the observed characteristics after the propensity score method is applied. This is encouraging, but even balance across observable characteristics does not guarantee an unbiased result," according to Ladapo.

"Patients most likely to undergo a transradial procedure and same-day discharge are the least complicated, lowest risk patients. Indeed, some patients in the non-same-day discharge group would almost certainly have been discharged on the same day if they had not experienced a complication that prolonged their hospital stay."

Nevertheless, Ladapo deemed studies like these "critical" to informing society about how to provide high-quality care without excessive costs.

"PCI procedures represent a large share of procedural costs for U.S. healthcare. This data, however, implies that the minimally invasive nature of transradial PCI and the culture of innovation of interventional cardiology can drive tremendous cost reductions with no apparent tradeoffs in quality or outcomes," Devireddy concluded.