May 15, 2020 – The Society for Cardiovascular Angiography and Interventions (SCAI) issued a position statement on the performance of percutaneous coronary intervention (PCI) in ambulatory surgical centers (ASCs) during its 2020 virtual meeting. The document was also published in SCAI’s official journal, Catheterization and Cardiovascular Interventions.
Earlier this year, The Centers for Medicare and Medicaid Services (CMS) began reimbursement for PCI performed in ASCs in response to data on patient outcomes from observational studies and randomized controlled trials supporting same-day discharge (SDD) after PCI.
“One of the biggest stories in interventional cardiology this past year was the initiation of payment by CMS for PCI performed in ambulatory surgical centers or ASC,” said Lyndon Box, M.D., FSCAI, chair of the writing group and interventional cardiologist at West Valley Cardiology Services in Idaho. “SCAI recognized the potential for this new rule to decrease cost, improve patient satisfaction and increase physician autonomy.”
For that reason, SCAI sent a letter of support for the changes to CMS, but also emphasized the need for these outpatient centers to provide high-quality care. After the passage of the reimbursement changes by CMS, SCAI created a writing group to create a set of guidelines for the management of quality for these centers, which resulted in this new document.
The position statement makes recommendations for facility and equipment standards, procedural and periprocedural standards, transfer protocols, and operator standards based on an examination of the evidence for potential benefits and harms. The statement also provides an overview for operators on regulatory considerations. When defining appropriate treatment in the ASC, the writing groups suggests that diagnostic procedures (ie. left and right heart catheterization, coronary and graft angiography) are appropriate for ASCs. Invasive diagnostic testing that involves intravascular imaging (IVUS and/or OCT) or functional evaluation (FFR and/or resting indices) and coronary angioplasty and stenting were also deemed appropriate.
Box said it is important to follow the SCAI recommendations outlined for selecting appropriate patients in an outpatient setting and which cases should be referred to a hospital setting. Also, these centers need to have plans in place for transferring patients if they experience major complications.
"There should be a peer-review program in place, similar to any other cath lab," Box explained.
The document also includes a section on ethical concerns for out patient PCI programs, most of which deals with finances.SCAI has concerns that outpatient surgical centers have more incentive to preform more fee for service procedures that might not be appropriate, self-referral or open to schemes for fee splitting. "There is potential for financial inlace to affect patient care," Box reiterated in his presentation.
Notably, the document advises that only patients who are considered appropriate for SDD should be considered for intervention in an ASC. The 2018 SCAI Expert Consensus Document on Length of Stay Following PCI provides guidance on patient suitability for SDD. Additionally, the writing groups suggests that not all patients that might be suitable for SDD in the hospital setting are appropriate for ASC-based PCI, stating that the ASC setting does not provide the option of easily converting a patient to overnight observation. PCI in patients with high-risk clinical features should be avoided in the ASC setting.
The document concludes that the decision to perform PCI in an ASC should be made in the context of the local healthcare environment, while initiation of an ASC PCI program should require transparent adherence to state and federal regulations and operational standards.
“It is crucial that patients in the ASC receive the same quality of care as those in the hospital setting. The paper covers regulatory issues, standards, protocols, quality assurance and ethics. This paper is a ‘must-read’ for anyone involved with PCI in an ASC,” said Box.
For more information: www.scai.org
1. Amir Lotfi, Lloyd W. Klein, Ravi S. Hira, et al. SCAI Expert Consensus Statement on Out of Hospital Cardiac Arrest. Catheterization and Cardiovascular Interventions. First published online 14 May 2020. https://doi.org/10.1002/ccd.28990.
2. Arnold H. Seto, Adhir Shroff, Mazen Abu‐Fadel, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheterization and Cardiovascular Interventions. First published 24 April 2018. https://doi.org/10.1002/ccd.27637.