1. New VAMC Clinical Programs I: Radial Sunil V. Rao MD Duke University Medical Center Duke Clinical Research Institute Durham VA Medical Center

2. Disclosures n Consultant/Honoraria l The Medicines Company, Medtronic, Astra Zeneca, ZOLL n Research funding l Ikaria n Off-label uses of drugs/devices may be discussed

3. The radial program in the VA n Why? l Rationale for a nationwide radial education program n What? l Design of the pilot program n How? l National program

4. The radial program in the VA n Why? l Rationale for a nationwide radial education program n What? l Design of the pilot program n How? l National program

5. Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention. Insights from the National VA Clinical Assessment, Reporting and Tracking Program Antonio Gutierrez MD, Thomas T. Tsai MD MSc, Maggie A. Stanislawski, Mladen Vidovich MD, Christopher L. Bryson MD MS, Deepak L. Bhatt MD MPH, John Rumsfeld MD PhD, Sunil V. Rao MD

6. Results PCI Cases by Access Site: Overall Population FY 2008-2010 Gutierrez A, et. al. Circ Intv 2013

7. Results Unadjusted Blood Transfusion: Overall Population (3.1, 4.2) (1.3, 3.8) Gutierrez A, et. al. Circ Intv 2013

8. Blood transfusion & Mortality Sites performing ≥ 50 radial cases annually Propensity Matched Seven sites in the VA system perform ≥ 50 radial cases annually Gutierrez A, et. al. Circ Intv 2013

9. The radial program in the VA n Why? l Rationale for a nationwide radial education program n What? l Design of the pilot program n How? l National program

10. Pilot to Implement Radial PCI in VA Catheterization Laboratories Christian D. Helfrich, MPH, PhD, Thomas T. Tsai, MD, MSc, Sunil V. Rao, MD, Jaclyn M. Lemon, BS, BA, Mladen I. Vidovich, MD, Adhir R. Shroff, MD, MPH, Bernadette S. Speiser MSN, CCRN, Chris L. Bryson MD, MS

11. Radial PCI: Pilot Study Elements of study: o Semi-structured interviews with cath team members to examine barriers and facilitators to rPCI implementation o Training intervention in Chicago3 cath lab teams; 11 attendees o Support site visits to 3 cath labs post-training o National survey to VA interventionalists Slides courtesy of Christian Helfrich and Emily Neely

12. Radial PCI: Pilot Study Semi structured interviews: o Pre-training in-depth interviews with 8 participating cath lab personnel  Radiation exposure concerns (staff & patients)  Perceived weak evidence for radial access  Logistical challenges, including instructing floor staff o Post-training in-depth interviews  Perceptions of evidence changed  Logistical challenges largely ameliorated; particularly after site visit Slides courtesy of Christian Helfrich and Emily Neely

13. Radial PCI: Pilot Study “Reverse site visit” in Chicago, July 25 th & 26 th, 2012 o Didactic sessions o Simulators o Viewing live radial cases  Diagnostic, PCI, or diagnostic + ad hoc PCI Slides courtesy of Christian Helfrich and Emily Neely

14. Radial PCI: Pilot Study Coaching site visit o Occurred several months after reverse-site visit o Nurse manager and interventionalist coach visited participating sites o Coaches helped teams identify and address practical improvements  Optimal equipment, technical tips and tricks, etc…. Slides courtesy of Christian Helfrich and Emily Neely

15. Radial PCI: Next steps Increasing rPCI adoption may be best achieved by educating operators about the ultimate improvement of procedure times and technical results with rPCI proficiency rPCI training programs may be optimized by providing continuous support to cath lab teams during the steep learning curve period Slides courtesy of Christian Helfrich and Emily Neely

16. The radial program in the VA n Why? l Rationale for a nationwide radial education program n What? l Design of the pilot program n How? l National program

17. Radial PCI: Next steps Multi-site trial to test both: o Increase in utilization of radial PCI o Effect on patients (bleeding, transfusions, hospital days, costs) and cath lab team (satisfaction) Slides courtesy of Christian Helfrich and Emily Neely

18. Summary n The CART-CL data allowed for the identification of a care gap that, if addressed, could improve the care of veterans n The implementation pilot project was designed to test the intervention of didactic education + proctoring n National roll out of the program could accelerate adoption of radial approach faster than in the private sector