The Workflow and Economic Rationale for an AtherectomyFirst

The Workflow and Economic Rationale for an Atherectomy-First Strategy Adhir Shroff, MD, MPH Associate Professor of Medicine University of Illinois – Chicago Jesse Brown VA Medical Center arshroff@uic. edu @ARS_MD 2004 #Radial. First

2 Disclosure Statement of Financial Interest Within the past 12 months, I have had a financial interest/arrangement or affiliation with the organization(s) listed below. Consulting Fees/Honoraria/Speakers Bureau: • Terumo • Medicines Company/Chiesi • Medtronic • CSI Equity Interests: None Royalty Income/Intellectual Property Rights: None Salary/Salary Support/Employee: None Adhir Shroff, MD, MPH Associate Professor of Medicine

Case: 68 yo Asian F with exertional angina • Diagnostic angiography: 5 Fr, RRA, universal catheter • LM, LAD, LCX normal • Heavily calcified vessel with focal, severe, mid RCA lesion Adhir Shroff, MD, MPH Associate Professor of Medicine

1 2 Case: 68 yo Asian F with exertional angina • Diagnostic angiography: 5 Fr, RRA, universal catheter • LM, LAD, LCX normal • Heavily calcified vessel with focal, severe, mid RCA lesion 3 4 • PCI: 6 Fr JR 4, UFH 7, 000 (ACT 280), aminophylline infusion (250 mg iv over 5 min prior to OA) 1. PTCA 1. 5 x 10 mm at 8 atm 2. OA at 80 k rpm x 2 passes (no bradycardia) 3. PTCA with 2. 5 mm balloon 4. 3. 5 x 23 mm DES at 18 atm Adhir Shroff, MD, MPH Associate Professor of Medicine

Case: 68 yo Asian F with exertional angina • Diagnostic angiography: 5 Fr, RRA, universal catheter • LM, LAD, LCX normal • Heavily calcified vessel with focal, severe, mid RCA lesion • PCI: 6 Fr JR 4, UFH 7, 000 (ACT 280), aminophylline infusion (250 mg iv over 5 min prior to OA) 1. PTCA 1. 5 x 10 mm at 8 atm 2. OA at 80 Krpm x 2 passes (no bradycardia) 3. PTCA with 2. 5 mm balloon 4. 3. 5 x 23 mm DES at 18 atm Adhir Shroff, MD, MPH Associate Professor of Medicine

Coronary Atherectomy for Calcified Lesions: What are the economic considerations? • Technical factors: ▫ Respond poorly to balloon…under-expansion, dissection ▫ Stent delivery and deployment are suboptimal ▫ Potential for uneven drug delivery • Longer procedure times, more procedural resources • TVR/TLR • Recoup cost of atherectomy device Adhir Shroff, MD, MPH Associate Professor of Medicine

CE Model: Orbital Atherectomy (1 yr) • Compared OAS from ORBIT II (>65 yo) to: ▫ Index: Medicare patients with severe Index Hospitalization calcified lesions ▫ 1 yr outcomes: used pooled data from HORIZONS/ACUITY • Lower Initial cost • Lower LOS (~1 day) Ther Adv Cardiovasc Dis 2016, Vol. 10(2) 74– 85 Adhir Shroff, MD, MPH Associate Professor of Medicine

CE Model: Orbital Atherectomy (1 yr) • Compared OAS from ORBIT II (>65 yo) to: ▫ Index: Medicare patients with severe 1 year MACE calcified lesions ▫ 1 yr outcomes: used pooled data from HORIZONS/ACUITY • Lower Initial cost • Lower LOS (~1 day) • Less MACE events ▫ Less cost ▫ Improved health outcomes Ther Adv Cardiovasc Dis 2016, Vol. 10(2) 74– 85 Adhir Shroff, MD, MPH Associate Professor of Medicine

CE Model: Orbital Atherectomy (1 year) CE range from cost savings of $1118 to $11, 895 per life-year gained Ther Adv Cardiovasc Dis 2016, Vol. 10(2) 74– 85 Adhir Shroff, MD, MPH Associate Professor of Medicine

Coronary Atherectomy in the US (2012) Data from Nationwide Inpatient Sample (n=107, 131): RA compared to propensity matched cohort w/o RA In-Hospital Adverse Events 16% 14% P<0. 001 13. 5% 12. 7% 12% 10% P<0. 001 In-hospital Costs $26, 000 $25, 000 9. 7% 9. 1% $24, 000 8% $23, 000 6% $22, 000 4% 1. 6% 2% 1. 1% 0% Any In hospital death Vascular Complication + Complications complications Atherectomy No atherectomy *Essentially only rotational atherectomy cases $ 25, 341 P<0. 001 $ 21, 9 84 $21, 000 $20, 000 Cost Atherectomy No atherectomy Am J Cardiol 2016; 117: 555 e 562 Adhir Shroff, MD, MPH Associate Professor of Medicine

12 Reimbursement for Coronary Atherectomy: 2015 CMS Hospital Outpatient Prospective Payment System • Both DES and BMS with atherectomy qualify for increased reimbursement Adhir Shroff, MD, MPH Associate Professor of Medicine

Case: 68 yo Asian F with exertional angina • Diagnostic angiography: 5 Fr, RRA, universal catheter • LM, LAD, LCX normal • Heavily calcified vessel with focal, severe, mid RCA lesion • PCI: 6 Fr JR 4, UFH 7, 000 (ACT 280), aminophylline infusion (250 mg iv over 5 min prior to OA) 1. PTCA 1. 5 x 10 mm at 8 atm 2. OA at 80 Krpm x 2 passes (no bradycardia) 3. PTCA with 2. 5 mm balloon 4. 3. 5 x 23 mm DES at 18 atm • • Access 0815; case completed 0911 Observed until 1700, d/c home Adhir Shroff, MD, MPH Associate Professor of Medicine

UIC Experience • Increase in overall atherectomy volume as well as % of PCI cases • OAS is the default system in our lab but use of RA in selected cases (ostial lesion, ISR) • Greatly improved efficiency: ▫ Set-up ▫ Need for pacing nearly eliminated ▫ Less inventory (1 size fits all) 2/15 OA introduced at UIC Financial Variable 2014 2015 2016 Mean Variable Costs $9, 279 $10, 447 $9, 788 ± 1276 ± 1559 ± 2421 Fixed Costs $1, 932 $1, 968 ± 521 ± 655 Net Revenue $10, 738 $17, 646 $15, 970 ± 1994 ± 6293 ± 3926 $474 ± $5, 185 $4, 639 2810 ± 7082 ± 6011 Operating Margin - $1, 544 ± 880 Adhir Shroff, MD, MPH Associate Professor of Medicine

Conclusion • Treatment of coronary calcium is underutilized ▫ Worse clinical outcomes ▫ Adverse economic consequences • Atherectomy is cost-effective by improving outcomes and efficiency • Adjustment in OP reimbursement for atherectomy has made it more favorable • Important to adjust one’s care pathway to fully benefit from OAS Adhir Shroff, MD, MPH Associate Professor of Medicine

16 Questions? ? ? Thank you. arshroff@uic. edu @ARS_MD 2004 312 -485 -4511 Adhir Shroff, MD, MPH Associate Professor of Medicine