Background: Of the two approaches to performing cardiac catheterization, cardiologists in the VA and US overwhelmingly choose the approach that is known to be less comfortable and more dangerous to patients and more costly to the health care system. The trans-radial approach (TRA), which is accessed via the wrist, is more comfortable for patients; is much safer with half the rate of bleeding complications; and has lower overall costs per episode of care than the trans-femoral approach (TFA), which is accessed via the groin. Yet, today in the US TRA is used in only 25%-30% of cardiac catheterizations, and in the VA is used for just over 40% of catheterizations. The reasons are that TFA predominates in the fellowships where cardiologists train to perform catherizations; certain aspects of TRA, such as the anatomy of the radial artery, make it initially more challenging than TFA; and there is a lack of training resources that address the needs for hands-on training, feedback from an expert, and training of the team. This challenge is common to many medical and surgical specialties where new, superior procedures emerge regularly. We previously developed and piloted a coaching intervention to help cath labs become ?TRA-dominant.? The coaching intervention was team-based, included hands-on instruction with multiple opportunities for corrective feedback, and included a period of support and accountability beyond a training session. The pilot test garnered positive reports from participating teams; however, we do not know if it successfully increases use of TRA. Nor do we know if the coaching intervention works the way we believe it does, through creating a non-punitive atmosphere where participants develop self- efficacy with TRA, overcome the steep learning curve and become proficient. Finally, we do not know the budget impact of the coaching intervention, and whether the costs may be offset by the savings from reduced complications and associated costs. Objectives: Our objective is to improve the VA?s ability to systematically implement new technically challenging, evidence-based clinical procedures. We have 3 aims.
Aim 1 : Test the effectiveness of a successfully-piloted, team-based coaching intervention in increasing implementation of radial-artery access cardiac catheterization.
Aim 2 : Adapt, test and refine a conceptual model of team-based coaching for implementation of new procedures based on the Promoting Action on Research Implementation in Health Services framework.
Aim 3 : Perform a cost analysis of the coaching intervention and effects on costs per episode of care. Methods: We will use a stepped wedge design (i.e., graduated participation) to maximize validity and permit formative evaluation of the coaching intervention to improve it in real time. The primary outcome will be change in number of TRAs as a function of all catheterizations. Secondary outcomes will include improvements in complications, and cost per catheterization. We will conduct qualitative interviews and structured surveys at baseline, again just after the coaching intervention and a third time at 6 months follow-up to adapt, test and refine a conceptual model of team-based implementation that can inform modifying the coaching intervention to other clinical procedures and settings by understanding how the coaching intervention affects factors such as different types of perceived evidence related to TRA, contextual factors related to psychological safety, and team self-efficacy and outcome expectancy.
Aim 3 will include two components: 1) estimate the costs of the organizational efforts needed to implement the coaching intervention, and 2) assess the effect of the coaching intervention aimed to increase adoption of TRA on healthcare costs. This will help establish the business case for the coaching intervention cost. Trial data suggests TRA leads to substantial cost savings. By developing a VA business case for the coaching intervention, we will help foster support for dissemination of the proctoring intervention.
Our goal is to improve the VA?s ability to systematically implement new technically challenging, evidence- based clinical procedures by testing the effectiveness of a team-based coaching intervention in increasing implementation of trans-radial access (TRA) cardiac catheterization. We will also test and refine a conceptual model to better understand how factors underpinning the coaching intervention, such as participant perceptions of TRA, psychological safety and participant self-efficacy are associated with TRA implementation. This will help us apply findings to other clinical procedures and contexts. We will perform a cost analysis of the coaching intervention and effects on costs per episode of care in order to help establish the business case for the coaching intervention. By increasing implementation of TRA, relative to the dominant trans-femoral approach, this study has the potential to reduce complications, which occur in approximately 2% of cases, by nearly 80% for the approximately 50,000 Veterans receiving cardiac catheterizations at VA facilities annually.
