Image by Christa Regina from PixabayNot too long ago, it may have seemed far-fetched to have your heart surgery performed outside of the traditional hospital setting.
But that’s increasingly happening, as more types of cardiovascular procedures are being shifted into the ambulatory surgery center (ASC) setting. The trend is likely to continue, too, prompting more ASC operators to consider solidifying their cardiovascular strategies.
About 121.5 million people are diagnosed with heart disease each year, though only 6.5 million in the U.S. receive vascular interventions — meaning heart disease often goes undiagnosed or untreated.
Ambulatory surgery centers can play a vital role in the transformation of cardiovascular care in the United States. There are technological advancements enabling the trend, and accumulating data demonstrates the safety of these procedures in outpatient settings.
“Cardiology did a phenomenal job of gathering data to prove these procedures can be safely done in an ASC setting,” Dr. Samuel Jones, a cardiologist with the Chattanooga Heart Institute, told ASC News.
Operating in Tennessee, Chattanooga Heart Institute specializes in interventional procedures, electrophysiology, imaging and vascular disease.
The shift of cardiovascular procedures into ASCs has been gaining momentum since around 2018 or 2019. According to Jones, the initial move involved performing diagnostic heart catheterizations in outpatient settings.
“Things really changed in 2020 when percutaneous interventions (PCIs), such as stent placements, were added to the CMS (U.S. Centers for Medicare & Medicaid Services) covered procedure list,” Dr. Jones said.
This inclusion marked a significant shift, making it feasible for ASCs to handle more complex cardiovascular procedures.
“CMS sent out a request for comment saying, ‘We think we may want to do this in an ASC. Do you think this is appropriate?’” Jones said. “Many people commented on it, but most notably, the medical cardiology societies, American College of Cardiology (ACC), and the Society for Cardiac Angiography and Interventions commented, saying, ‘We feel that this could be appropriate if done appropriately in these settings with these patients.’ These are things that need to be carefully considered.”
Jones said that because of that feedback, in 2020, CMS created a payment mechanism so that patients could be covered under Medicare insurance for cardiac surgery in outpatient settings. And more private payers began to follow suit.
With the increase in ASC cardiac procedures, ACC has launched a registry to track and provide insights on cardiac procedures performed in ambulatory surgical centers.
The registry helps facilities measure and compare their patient care and outcomes with those of similar procedures performed in hospital outpatient settings — often finding that patient satisfaction and safety is higher than hospitals in the outpatient setting.
“Every year, year after year, we’re starting to see more of this,” Jones said. “I think that we’re starting to see what other things can be done in the cardiac ASC.”
Still, there is work to do and factors for operators to consider to safely integrate cardiac surgery into their outpatient clinics.
Factors fueling the trend
Jones said that cardiologists gathered extensive data proving that these procedures could be done safely without overnight hospital stays. Interventional cardiologists tested same-day discharge within hospitals and monitored patients rigorously to ensure there were no complications or readmissions.
“Over several years, they started looking at patients and, instead of keeping them in the hospital overnight, asked, ‘Can we discharge them the same day?’” he said. “By getting data on these patients, following them rigorously, making sure they were not coming back with readmissions or having any problems, not returning to the emergency department, not having increased heart attacks, and not needing to go back to the cath lab, they eventually proved that, yes, they can be discharged the same day without any complications.”
Cardiologists also demonstrated that coronary angiograms and subsequent stent placements could be performed safely without needing cardiothoracic surgery support on-site. This was crucial as it allowed these procedures to be done outside of hospitals.
“Importantly, they also said it’s not every patient, and this is critical when we talk about patients doing this without CT surgery,” he said. “Cardiology did a great job of identifying which patients are appropriate for that.”
Armed with this data, cardiologists received support from major cardiology societies like the Society for Cardiovascular Angiography and Interventions (SCAI) and ACC. CMS agreed with the findings, enabling these procedures to be performed in ASCs.
Jones also said technological advancements in interventional cardiology, such as transitioning from groin access to arm (radial) access for certain procedures, further improved safety and efficiency.
The pandemic significantly accelerated the shift of cardiovascular procedures to outpatient settings as well.
When COVID-19 struck, hospitals faced a shortage of beds, and patients were reluctant to stay in hospitals. This situation forced many providers who hadn’t previously adopted same-day discharge practices to implement them during the pandemic.
“Every organization was performing a certain percentage of radial procedures, and then COVID hit,” Ginger Biesbrock, executive vice president of care transformation services at MedAxiom, told ASC News. “The whole radial approach really supports same-day discharge because the risk of bleeding is a whole lot less when you work through the wrist versus the top of the leg.”
MedAxiom is a member organization composed of cardiovascular delivery organizations across the country and owned by the American College of Cardiology.
Solidifying a cardiovascular strategy
The U.S. cardiology procedures market size is expected to reach $92.32 billion by 2030, expanding at a CAGR of 7.7% from 2024 to 2030, according to statistics from global market-data service ResearchAndMarkets.com.
In a recently released report on the cardiology-procedure space, the research firm specifically mentioned ASCs as a factor fueling cardiology-procedures growth.
“Technological advancements and innovations in cardiac surgery are anticipated to propel the [ASC] segment,” the firm wrote. “Hospitals and [ASCs] offer less invasive procedures and alternatives to open heart surgery owing to the high number of benefits, such as low blood loss and shorter hospital stay, which is projected to boost the adoption of advanced cardiac procedures in the U.S. market.”
With cardiovascular procedures increasingly moving into ASCs, operators must adapt to this trend.
“Patients [should] get the right care, at the right place, at the right time,” Biesbrock said.
Biesbrock explained that ownership is significant because it emphasizes their focus on care delivery and performance. Other health care organizations come to them to understand best practices and high performance, she said.
“We also do a lot of data benchmarking on the operational and patient throughput side, while the ACC handles quality benchmarking related to CD procedures,” she said.
Due to the fact that before 2020, cardiovascular care at ASCs was minimal, integrating cardiovascular care into an outpatient setting will require a different operational strategy, Biesbrock said.
“We wanted to be part of authoring, partnering and producing the right way to do this. We decided to approach this in two ways: through education [and] resources, and tools for our larger membership,” she said, adding that MedAxiom partnered with Atlas Healthcare Partners to support their expansion of cardiovascular care.
Arizona-based Atlas Healthcare Partners provides nonprofit health systems with network development support.
“Although it wasn’t a CV yet, they were good experts in their field,” she said. “They chose to partner with us to bring in deeper CV expertise, and we wanted to partner with them because of their great work in ambulatory surgical center spaces.”
Kristen Richards, vice president of cardiovascular operations at Atlas Healthcare Partners, told ASC News that developing a cardiovascular strategy involves several key steps.
“ASCs need to ensure they have the right staff, technology and accreditation to perform these procedures safely,” Richards said.
She added that this involves recruiting skilled cardiovascular specialists, investing in advanced medical equipment and obtaining relevant certifications to meet regulatory standards.
Reimbursement and payment models also play a critical role.
While CMS provides funding under the Outpatient Prospective Payment System, private payers are also showing interest, Jones said.
“Typically, the cost of doing a procedure in an ASC is about a third cheaper than in a hospital setting,” he said, adding that this makes ASCs an attractive option for both patients and payers.
While CMS might pay for ASC services in some states, state regulations can significantly differ depending on region, Jones said.
For instance, states like Arizona, Texas and Florida have more lenient regulations, and, thus, more ASCs. In contrast, some states are more restrictive, though changes are happening, with states such as Michigan, Pennsylvania, Mississippi, North Carolina and South Carolina reconsidering their laws on ASCs.
“This is one thing that is sort of helpful about the country; you can look at places that are doing it, and we can learn from each other,” Jones said. “In Arizona and Texas, for example, you may see more ASCs. The state of Florida is another state that typically has more ASCs, and you may see less regulation in those states.”
Operators can learn from states that have expanded their ASC presence, he continued.
“When we find that, it’s important for us to learn from those states, look for the organizations that have done it, and learn how to do it well,” Jones said. “[And ask] how do we ensure that patients are getting the quality care they need?”
