Applegate RJ - AIMRADIAL 2013 - Learning curve
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1) The document discusses the learning curve for radial artery procedures in the US based on multiple data sources. 2) Recent data shows the radial learning curve may not be as steep as once believed, with initial competence reached after 25-40 cases, though improvement continues with greater experience and volume. 3) Procedural metrics like fluoroscopy time improve with experience but are influenced by many factors, making direct links to patient outcomes difficult to establish. Nonetheless, radial procedures in the US are being adopted quickly and appear to achieve better safety outcomes than femoral procedures.
Applegate RJ - AIMRADIAL 2013 - Learning curve
- 1. Impact of Learning Curves on Clinical Outcomes in the US Robert J Applegate, M.D. Professor of Internal Medicine-Cardiology
- 2. Disclosures Advisory Board Abbott Vascular Research Grants Abbott Vascular St Jude Medical Consultant Abbott Vascular Serruys, PW. PCR 2010 Wake Forest School of Medicine AIM Radial 2013
- 3. The learning curve for radial artery procedures: historical perspective No differences in primary entry site complications, or MACE, but “there was a clear trend toward more technical difficulties and more problems with the radial approach.” Wake Forest School of Medicine AIM Radial 2013
- 4. The learning curve for radial artery procedures: historical perspective “In conclusion, it is evident, when reviewing this study, that the difficulties associated with the learning curve must be overcome before a randomized study can be carried out.” Wake Forest School of Medicine AIM Radial 2013
- 5. Radial “learning curve” identified early on with attempts to quantify the “steepness” of the curve Inflection ?? Plateau ?? Wake Forest School of Medicine Spaulding et al: CCI 1996; 39:365-370 AIM Radial 2013
- 6. The word in the US Interventional World The first person to describe the learning curve was Hermann Ebbinghaus in 1885, in the field of the psychology of learning is that the radial learning curve is “steep” But is that really true? Radial ?? Radial ?? Radial ?? Wake Forest School of Medicine AIM Radial 2013
- 7. The learning curve for radial artery procedures: Quantifying the curve and Linking the learning curve to outcomes • Complex interaction of factors that influence the learning curve: Operator and center experience and volume; presence of fellows Cath lab tolerance for ramp up, longer cases if needed Case mix including STEMI, graft cases • Metrics to define the curve include both procedural process metrics (eg floro time) as well as traditional patient outcomes(eg access complication rates); not uniformly accepted standards • Data establishing causality between individual learning curve procedural process metric and patient outcome metric are lacking Wake Forest School of Medicine AIM Radial 2013
- 8. Recent worldwide data on The learning curve for radial artery procedures: RIVAL Trial data Wake Forest School of Medicine Jolly et al; JACC CI 2013; 6:258-66 AIM Radial 2013
- 9. Recent worldwide data on The learning curve for radial artery procedures: RIVAL Trial data Center center Operator air kerma Operator andVolume volumes associated with lowerVolume Interaction between operator and center volumes remains to be fully elucidated Wake Forest School of Medicine Jolly et al; JACC CI 2013; 6:258-66 AIM Radial 2013
- 10. Recent worldwide data on The learning curve for radial artery procedures: Registry data (Dedicated radialist) (Standard radialist) Case volume affects failure rate Both low and high volume operators continue to improve over time Both p<0.05 vs 2005-2006 Wake Forest School of Medicine Burzotta et al AHJ 2012; 163:230-238 AIM Radial 2013
- 11. The US experience of radial artery procedures: NCDR CATH/PCI Registry data Wake Forest School of Medicine Feldman et al; Circ 2013; 127:2295-2306 AIM Radial 2013
- 12. The US experience of radial artery procedures: NCDR CATH/PCI Registry data 16.1% 3rd Q 2012 Wake Forest School of Medicine Feldman et al; Circ 2013; 127:2295-2306 AIM Radial 2013
- 13. The US learning curve for radial artery procedures: Wake Forest Registry data Wake Forest School of Medicine Turner et al; CCI 2012; 80:247-257 AIM Radial 2013
- 14. The US learning curve for radial artery procedures: Wake Forest Registry data Wake Forest School of Medicine Turner et al; CCI 2012; 80:247-257 AIM Radial 2013
- 15. The US learning curve for radial artery procedures: Wake Forest Registry data Transition to preferred radial approach resulted in better patient centered outcomes including lower access site and bleeding complications Wake Forest School of Medicine Turner et al; CCI 2012; 80:247-257 AIM Radial 2013
- 16. The US learning curve for radial artery procedures: Wake Forest Registry data Radial artery access metrics by period Metric Transition Radial (N = 610) Preferred TR Radial (N = 897) 7 (5-10) 26 (20-36) 66 (51-85) 50 (38-71) 6 (4-9) * 24 (19-34) * 64 (53-83) 49 (40-52) 7 (5-12) 21 (16-30) 16 (10-24) 7 (5-11) * 21 (15-27) 14 (10-19) 76 (56-98) 190 (147-250) 132 (86-191) 74 (55-99) 194 (142-246) 111 (92-122) Generalized decrease in procedural metrics with Access site crossover, n (%) 80 (8.9%) reduced inter quartile ranges 57 (9.3%) Sheath size, Fr CATH only 5.0 (0.2) 5.0 (0.1) Efforts to quantify learning curve(0.4) PCI 6.0 complicated by * 5.7 (0.5) Procedure time intervals, minutes affectinsertion Sheath of new fellows on monthly basis 5 (3-10) 5 (3-9) * Intubate coronaries Total procedure, CATH only Total procedure, CATH + PCI Total procedure, PCI only Fluoroscopy time, minutes CATH only CATH + PCI PCI only Contrast volume used, mL CATH only CATH + PCI PCI only Wake Forest School of Medicine Turner et al; CCI 2012; 80:247-257 AIM Radial 2013
- 17. The US learning curve for radial artery procedures: Wake Forest Registry data Radial artery access metrics by period for operators with highest and lowest proportion of radial artery access Attending A (HIGH) Attending B (LOW) Transition Preferred TR Transition Preferred TR Metric (N = 350) (N = 329) (N = 272) (N = 277) Radial artery access, n / total volume (%) Access site crossover, n / TR volume (%) TR procedure time intervals, minutes Sheath insertion Intubate coronaries Total procedure, CATH only Total procedure, CATH + PCI Total procedure, PCI only TR fluoroscopy time, minutes CATH only CATH + PCI PCI only TR contrast volume used, mL CATH only CATH + PCI PCI only 202/350 (58%) 12/202 (6%) 233/329 (71%) † 12/233 (5%) 93/272 (34%) ‡ 15/93 (16%) ‡ 171/277 (62%) †‡ 18/171 (11%) ‡ 6 (4-11) 6 (4-8) 24 (17-33) 61 (47-74) 50 (43-62) 6 (3-10) 5 (4-7) † 20 (16-28) † 53 (41-66) † 51 (28-52) 6 (4-8) 8 (5-13) ‡ 29 (21-37) ‡ 72 (52-95) 39 (36-41) 5 (3-9) ‡ 6 (5-9) †‡ 25 (21-35) ‡ 68 (59-89) ‡ 40 (40-40) Similar to Burzotta found a volume – outcome relationship among both higher and lower 5 (4-8) 5 (3-7) † 9 (6-15) ‡ 8 (6-13) ‡ 18 (12-26) 15 (11-19) 26 (20-39) ‡ 22 (16-29) ‡ volume operators† 14 (10-23) 16 (10-19) 23 (21-24) 12 (12-12) 61 (50-83) 141 (106-176) 95 (74-177) 65 (43-83) 141 (119-180) 105 (30-122) 76 (50-98) ‡ 191 (153-253) ‡ 150 (109-190) 74 (60-91) ‡ 197 (149-231) ‡ 92 (92-92) † p<0.05 vs Transition, ‡ p<0.05 vs Attending A. CATH indicates diagnostic catheterization; PCI, percutaneous coronary intervention. Wake Forest School of Medicine Unpublished observations AIM Radial 2013
- 18. The US learning curve for radial artery procedures: Vanderbilt Registry data Wake Forest School of Medicine Kasasbeh et al; JIC 2012; 24:599-604 AIM Radial 2013
- 19. The US learning curve for radial artery procedures: Vanderbilt Registry data 60% radial Wake Forest School of Medicine Kasasbeh et al; JIC 2012; 24:599-604 AIM Radial 2013
- 20. Floro time (min) The US learning curve for radial artery procedures: Vanderbilt Registry data Procedure time (min) Room time (min) Incorporation of radial access to our cardiac catheterization laboratory led to a decrease in fluoroscopy time in each operator, operator group, and institute-wide over the last 3 years. This improvement was seen after approximately 25 cases and further improved after 75 cases. Wake Forest School of Medicine Kasasbeh et al; JIC 2012; 24:599-604 AIM Radial 2013
- 21. The US learning curve for radial artery procedures: NCDR Wake Forest School of Medicine Hess et al; ACC 2013 AIM Radial 2013
- 22. The US learning curve for radial artery procedures: NCDR Wake Forest School of Medicine Hess et al; ACC 2013 AIM Radial 2013
- 23. The US learning curve for radial artery procedures: NCDR More complex cases performed by higher volume operators Wake Forest School of Medicine Hess et al; ACC 2013 AIM Radial 2013
- 24. The US learning curve for radial artery procedures: NCDR Procedural metrics reduced by higher volume operators Wake Forest School of Medicine Hess et al; ACC 2013 AIM Radial 2013
- 25. The US learning curve for radial artery procedures: NCDR Wake Forest School of Medicine Hess et al; ACC 2013 AIM Radial 2013
- 26. The US learning curve for radial artery procedures: NCDR Wake Forest School of Medicine Hess et al; ACC 2013 AIM Radial 2013
- 27. Impact of Learning Curves on Clinical Outcomes in the US- Summary • Recent data indicate that the radial learning curve may not be as “steep” as once believed • Threshold for initial “competence” 25-40 cases • • Improvement continues with greater experience consistent with a volume-outcomes interaction Learning curve may be influenced by practice setting, eg academic vs non-academic • Procedural metrics are easily measured but are influenced by multiple factors making interpretation challenging, and linkage to outcomes difficult. • Nonetheless, these data suggest that radial adoption is occurring quickly and efficiently while achieving a better safety profile than femoral artery procedures Wake Forest School of Medicine AIM Radial 2013