Of the two approaches to performing cardiac catheterization, overwhelmingly cardiologists in the VA and US use the approach that is known to be less comfortable and safe for patients, more difficult for staff to monitor, and more costly to the health care system.
In cardiac catheterization, a long thin tube is threaded up to the coronary arteries via the radial artery in the wrist (trans-radial approach, or TRA) or via the femoral artery in the groin (trans-femoral approach, or TFA). Then the catheter is used to obtain real-time images of the arteries that deliver blood to the heart (coronary angiography) and/or alleviate blockages that obstruct delivery of blood to the heart (percutaneous coronary intervention). Both TRA and TFA are considered standards of care; however, major bleeding (the primary complication from coronary catheterization) is 78% lower for TRA cases relative to TFA. Lack of awareness of those benefits is not what accounts for the slow rate of adoption of TRA. Rather, TRA is technically more challenging, and cardiologists and their teams have to sustain using TRA through a steep learning curve where TRA cases take longer and have a higher crossover rate (i.e., they cannot complete the case using TRA and have to switch to TFA). However, if they persist, after performing approximately 50 TRA cases they become as proficient with TRA as TFA.
Our primary goal is to improve the VA's ability to implement new technically-challenging, evidence-based clinical procedures, such as TRA. We will test a previously-piloted, team-based coaching intervention to support adoption and implementation of TRA that is designed to help shorten the learning curve and sustain teams until they become proficient. Toward that goal, we want to build on, and contribute to conceptual models of innovation implementation and the cognition of development of expert skills that can help us understand why clinical procedures that have so many apparent advantages are implemented so slowly. Our specific aims are:
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 and refine a conceptual model of team-based coaching for implementation of new clinical 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.
We will conduct a stepped wedge trial design, with a mixed-methods formative evaluation. In the stepped wedge trial, all participating sites ultimately receive the intervention, but are randomized to receive it at different time points or "steps." Sites serve as internal controls to account for site-specific confounders before and after the intervention. Because they are randomized to receive the intervention at different times, they also serve as controls for each other to account for secular time trends.
Some might also characterize this study as a hybrid implementation trial because we are assessing both implementation (i.e., practice) outcomes and clinical outcomes. The primary outcome is implementation of TRA, assessed as the proportion of radial catheterization performed at the cath lab; and secondary outcomes include bleeding complications, employee job satisfaction and organizational commitment.
We have no preliminary results at this time.
VA seeks to become a learning organization, and one of the central tenants of learning organization theory is that the organization invests in how to learn better (i.e., learns to learn better). That means identifying ways to more systematically integrate new practices or knowledge.
External Links for this Project
Grant Number: I01HX002043-01A2
- Doll JA, Beaver K, Naranjo D, Waldo SW, Maynard C, Helfrich CD, Rao SV. Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018. Circulation. Cardiovascular quality and outcomes. 2022 May 1; 15(5):e008359. [view]