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Factors Influencing Adoption of Radial Access for Percutaneous Coronary Intervention in the Veterans Affairs Health Care System
Helfrich CD, Rao SV, Eugenio EC, Vidovich MI, Shroff AR, Speiser BS, Neely EL, Sulc CA, Orlando RM, Sayre G, Liu C, Bradley SM, Bryson CL. Factors Influencing Adoption of Radial Access for Percutaneous Coronary Intervention in the Veterans Affairs Health Care System. Poster session presented at: American Heart Association Quality of Care and Outcomes Research Council Annual Scientific Session; 2014 Jun 4; Baltimore, MD.
Though the safety of transradial percutaneous coronary intervention (TRI) has been demonstrated in clinical trial and registry studies, adoption of TRI in the United States has been slow. We fielded a national survey with VA interventional cardiologists to understand factors influencing TRI use.
The structured survey was developed from telephone interviews with interventional cardiologists, catheterization laboratory nurses and radiology technicians at 3 VA hospital cath labs. The survey assessed extent of interventional cardiologists' experience with TRI, perceptions of the advantages or disadvantages of TRI relative to transfemoral PCI (TFI), and barriers to adopting and implementing TRI. We used the the Cardiovascular Assessment Reporting and Tracking (CART) registry to define our sampling frame, all VA interventional cardiologists, and to obtain cath lab TRI rates. We tested whether respondents' opinions of the relative advantages of and barriers to TRI were associated with site-level TRI rates in a 13-month period following to the survey (January 2012 to January 2013).
We received responses from 78 of 235 interventional cardiologists representing 48 of 65 VA cath labs (33% response rate; 73% of cath labs). The most prevalent barriers to TRI adoption cited by cardiologists were increased radiation exposure to the cardiologist (63% cited as a major or minor barrier) or staff (51% of respondents), and the steep learning curve (44%). Other barriers such as difficulty obtaining necessary equipment (25%), lack of support from cath lab staff (23%), and lack of training opportunities (18%), were less prevalent. The majority of cardiologists rated TRI as superior for ease of post-procedure monitoring (52%), patient comfort (60%), early discharge (65%), fewer vascular access complications (69%), and less bleeding (72%). However, a majority rated TFI superior for shorter procedure duration (69%) and technical results (47% rated superior, 49% as no difference). One-year cath lab TRI rates ranged from 1.1% (3 of 270) to 90.2% (286 of 317), with a median of 7.3%. Only nine cath labs had a 1-year TRI rate greater than 50%. No barriers were correlated with TRI rates; however, all of the relative advantage measures were significantly, positively correlated. The strongest correlations were for faster procedure time (r = .59, p < .0001) and ease of post-procedure monitoring (r = .52, p < .0001).
This study demonstrates that while interventional cardiologists are familiar with the advantages of TRI over TFI, there is still limited adoption of TRI on a broad scale. There were no reported barriers associated with site-level radial rates suggesting that obstacles to TRI adoption are likely multifactorial. Effective TRI training programs should focus on methods to reduce radiation exposure and manage expectations about the radial learning curve.