Economic impact of TAVI pathway optimisation: the experience of the University Hospital of Parma.

Economic impact of TAVI pathway optimisation: the experience of the University Hospital of Parma. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Economic impact of TAVI pathway optimisation: the experience of the University Hospital of Parma. Simone Fanelli, Gianluca Lanza, Lorenzo Pratici, Giorgio Benatti, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4741137/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Transcatheter Aortic Valve Implantation (TAVI) has emerged as a standard of care for patients suffering from symptomatic severe aortic stenosis. However, organisational analyses and investigations of this intervention’s economic impact are lacking. This study aims to assess the potential impact of implementing a process designed to optimise the TAVI pathway regarding organisational, human, material, and economic resources. Methods: The research is conducted through a case study. The methodology consisted of three stages: 1. mapping of the current TAVI pathway; 2. identification of the organisational changes necessary to optimise it and implementation of the identified action with a multidisciplinary teamwork; 3. simulations of the organisational and economic impact of the optimisation process. Data related to costs, revenues, and activities were provided by the hospital’s Management Control office. The data analysed refer to a 12-month period. The TAVI pathway optimization presented in this analysis is aligned with the best practices described in the BENCHMARK study. Results: The analysis of the current TAVI pathway in the studied hospital highlighted several critical points during the three phases of the course (pre-procedure, peri-procedure, and post-procedure). The working groups identified five areas for TAVI pathway improvement: patient and family education, coronary risk stratification, conduction disorders management, fast-track discharge eligibility, nurse-led rapid mobilisation and early discharge. The organisational solutions highlighted by the working groups outline a new TAVI pathway capable of generating a significant impact not only from an organisational point of view, but also from an economic point of view. We estimated that in our cohort TAVI optimisation would have saved approximately 112 ICCU bed-days and have led to an average cost reduction of about €3,900 per patient. Conclusions: This study showed a process of optimisation of the TAVI pathway highlighting the positive impacts for patients, caregivers, healthcare workers, and the hospital. A Clinical Valve Coordinator may help to manage the procedural programme for individual patients while maintaining seamless communication with the Heart Team throughout the patient care journey, making the process even more streamlined. The case study analysed can be useful to all hospitals wishing to undertake processes aimed at improving the TAVI pathway. economic impact organisational process healthcare management management control transfemoral TAVI Clinical Valve Coordinator capacity enhancing innovation Figures Figure 1 Background The healthcare sector is strongly characterised by a high number of specialisations and medical professions, complex therapies, and equipment, and often different service units revolve around different organisations [ 1 ]. All these characteristics mean that opportunities for integration and coordination should be found while continuing to respect all fields of specialisation. Doing so allows knowledge to be transferred with high-grade professionalism and a high technological level in contexts such as hospitals [ 2 ]. Since the 1990s, both studies and management experiences have paid increasing attention to the management of organisational processes [ 3 ]. International contributions [ 4 ] recognise the “pathway perspective" as an alternative to the functional approach insofar as organisations are understood not as sets of vertically integrated functional units, but as collections of interrelated processes that create value. In functional models, the governance of the production activity, whose management aims to achieve economies of scale, and hierarchical control systems drive the control of the value creation process rather than its management. In the pathway approach, value creation is seen as a non-hierarchical process that requires non-vertical co-ordination mechanisms (lateral coordination) of the chain of events that can transcend the boundaries of the organisation. The shift from functional to pathway-oriented organisational models represents a significant change in the perspectives of an organisation’s management, focusing on the management of pathways rather than structures and orienting strategic choices to increase value creation and enhance forms of coordination [ 5 ]. The debate about pathway-based management originated in the business world and can offer countless stimuli to improve the pathway management of healthcare organisations. Researchers have offered different definitions of pathway. According to Davenport (1993) [ 6 ], a pathway is a set of structured and measured activities designed to produce a specific output for a particular market or customer. The main characteristics of pathway can be noted in the pathway is associated with a spatial-temporal sequence of activities [ 2 ]. In the field of healthcare, organisational pathways (along with clinical competences and technology) are recognised as pivotal elements for achieving high levels of performance [ 7 ]. However, it is crucial to acknowledge that no single set of organisational pathways can be deemed universally perfect for all organisational contexts [ 8 ]. It is incumbent upon management to thoroughly examine the current pathways implemented within their organisations with the aim of pinpointing any critical issues and subsequently proposing better organisational and managerial solutions tailored to their specific organisational contexts. It is envisioned that such initiatives can enable resource optimisation and enhance the efficacy of patient care. Thus, each healthcare organisation must therefore undertake the task of identifying the most suitable pathway based on its own unique set of resources and requirements, and this imperative applies equally to the TAVI (Transcatheter Aortic Valve Implantation) pathway. As a matter of fact, the aim of our study was to analyse how to optimise, from an economic–organisational perspective, the TAVI pathway, identifying the most critical aspects of the process and proposing alternative solutions to use the resources and the technologies in a better way. This article reports on a study conducted at the Cardiology Unit of the University Hospital of Parma, Italy. Empirical studies conducted in other healthcare settings have already demonstrated the feasibility of identifying TAVI organisational pathways that not only ensure heightened patient safety, but also yield organisational and managerial advantages [ 9 – 11 ]. However, there is a paucity of evidence on the outcomes of TAVI pathway optimisation and there is a lack of studies that quantify the economic impact of TAVI pathway optimisation. TAVI pathway TAVI has emerged as a standard of care for patients suffering from symptomatic severe aortic stenosis after its introduction almost two decades ago. Previous studies have shown that TAVI generates greater economic and clinical benefits compared to other techniques [ 12 – 13 ] and that it helps in reducing costs, resources usage, and waiting times [ 14 – 16 ]. Its implementation leads not only to increased productivity, but also to a reduction of indirect costs due to a general reduction of staff overload as well as the elimination of costs related to unnecessary procedures [ 14 , 17 – 22 ]. Studies concerning the cost-effectiveness of TAVI have been performed since the 2010s. Multiple cost-effectiveness analyses indicate that TAVI is more cost-effective than medical management for inoperable patients and highly cost-effective in comparison to surgical aortic valve replacement for high- and, intermediate-risk patients [ 13 ]. In recent years, around the world more and more studies have assessed the cost-effectiveness of TAVI in severe aortic stenosis patients at low risk of surgical mortality [ 16 , 20 – 24 ]. All these studies aimed to assess the economic value of TAVI when well implemented; however, as other researchers have claimed [ 23 , 25 ], organisational analyses of this technique have been lacking. McClamont et al. (2014) [ 19 ] were the first to discuss the clinical pathway to streamline patient care with the aim of improving standards of care by reducing the length of stay in hospital. Their analysis was a comprehensive study of organisational and economic aspects, but no clear conclusions were reached in terms of organisation, as data were lacking at the time the study was carried out due to challenges in data collection. Subsequently, other authors addressed the organisational aspects of the TAVI pathway [ 9 , 26 ]. Recently, using a clear set of quality-of-care measures, Frank et al. (2024) [ 27 ] introduced the organisational aspect to the scholarly discourse by studying the implementation of a set ofbest practices within the BENCHMARK registry. This was a multicenter international registry enrolling patients with severe symptomatic aortic stenosis undergoing TAVI at 28 European centres. This study highlighted how the adoption of simple, standardised, TAVI-specific quality-of-care measures can help select patients for early discharge. In fact, the authors demonstrated that after the implementation of BENCHMARK practices mean length of stay was reduced from 7.7 ± 7.0 to 5.8 ± 5.6 days (median 6 vs. 4 days; P < .001), without compromising patients’ safety at 30-day follow-up. Pibarot (2024) [ 28 ], in his editorial referred to Frank’s study, has also highlighted that the TAVI procedure has become more efficient with BENCHMARK and that the BENCHMARK study “represents by far the largest and most ambitious attempt at achieving and generalizing best practices in TAVI”. In particular, Pibarot states that the optimisation of TAVI pathways is definitely cost-effective and that represents a good investment for every hospital performing TAVI. Another comprehensive research on the organisational aspects of TAVI was performed by Tchetche et al. (2019) [ 29 ]. The authors discussed why clinicians need to make the TAVI pathway more efficient and described the most important steps to take, from screening to early discharge, including procedural optimisation. This study suggests that the core idea behind an efficient TAVI program is that it should ensure the ability to treat all patients who need the procedure from several aspects: optimisation, a minimalist approach during the procedure, and early discharge without compromising clinical outcomes. However, although Tcheche et al. ’s (2019) [ 29 ] study highlighted important and innovative results from an organisational point of view, it contained little discussion of the potential impact of new organisational procedures. The actual research aims to focus on the importance of defining suitable ways to manage TAVI optimisation. In particular, this study aims to assess the potential impact of TAVI pathway optimisation in terms of organisational, human, material, and economic resources. Best practices and protocols from the BENCHMARK study were followed to define and implement the optimisation of the TAVI pathway in the University Hospital of Parma. Methods The research was conducted through a case study: the University Hospital of Parma, in the Emilia-Romagna Region, Italy. Case study analysis is considered suitable for interpreting change in organisational processes [ 30 ]. Yin (2009) [ 31 ] argued that multiple sources should be used when building the “case”. Thus, setting up the framework of our methodological strategy, we used both documentary analysis and interviews. Research data were triangulated, as is usual in case study research, for ensuring validity [ 32 ]. Yin (1994) [ 32 ] and Bowen et al. (2010) [ 33 ] find that multiple methods are useful in qualitative research to triangulate results and reduce the impact of possible biases. The research consisted of three stages: 1. mapping of the current TAVI pathway; 2. identification of the organisational changes necessary to optimise it and implementation of the identified action with a multidisciplinary teamwork; 3. simulations of the organisational and economic impact of the optimisation process. The TAVI pathway optimization presented in this study, as well as the protocols introduced and changes implemented are aligned with the BENCHMARK Study [ 27 ], which represents by far the largest attempt at generalizing and standardizing TAVI practices. The first phase aimed to identify the TAVI pathway currently used in the hospital (before the optimisation process was implemented). For this purpose, internal documents, such as clinical pathways, internal reports, and organisational guidelines, were analysed. In addition, 27 semi-structured, in-depth, face-to-face interviews, lasting approximately 40 minutes each, were conducted with the key actors (16 physicians and 11 nurses) involved in the TAVI pathway in the hospital to triangulate the evidence provided by the documents. The four main topics discussed in the interviews were the professionals involved and their competencies; the activities carried out in the three phases of the TAVI pathway (pre-, peri-, and post-procedure); the role of caregivers; and any problems arising during the TAVI pathway. The main interview questions developed for this study are reported in Additional file 1 (see Round 1). The interviews were conducted between June and July 2023. The interviews were recorded, after which a team of three researchers analysed them to jointly collect the information to reduce the subjectivity of interpretation. During the second phase, the organisational changes necessary to ensure effective implementation of the actions needed to optimise the pathway were identified and subsequently implemented. For this purpose, five working groups were defined, each one focused on a different phase of the process and with a specific goal to solve one or more critical issues detected in the TAVI pathway currently in use in the hospital (see phase 1). The groups were interdisciplinary, with members having different areas of expertise. At least one member of each working group was interviewed. Furthermore, all the documents (checklists, protocols, flow charts, etc.) developed by the working groups were analysed. Thus, a second round of interviews was conducted to match the evidence provided by the documents with the activities put in place by the groups. The objectives of the interviews were to understand the organisational solutions identified, highlight the responsibilities of the different professionals involved, assess the benefits of change actions, and identify possible resistance to change. All groups were active during the summer of 2023 (July and August), and the second round of interviews was conducted during September 2023 (Additional file 1 – Round 2). The interviews were recorded and then analysed by the team of researchers. In the last phase, simulations of the organisational and economic impacts of the optimisation pathway were carried out by the University Hospital of Parma. Simulation models are very often used in the literature to study healthcare processes [ 34 ], because they represent a new process dynamically rather than statically, thus presenting stakeholders with a more realistic picture of the situation [ 35 ]. In particular, in our study, the following issues were analysed: the potential increase in production capacity of the new process, the economic impact of the new use of structural resources (beds, operating room, anaesthesia hours, intensive care beds), and the organisational effect on the operating unit related to the pathway improvement. The costs and revenues of the TAVI activities, as well as the activity data, were provided by the hospital’s Management Control office. The data analysed refer to the 12-month period between July 2022 and June 2023. The sample analysed identified 25 out of 35 patients treated by the unit, representing those patients who provided consent to be involved in the study and eligible for the fast track. Patients were deemed eligible for the fast track if they had no clinical complications or emergency admissions. Data analysis was performed using Microsoft Excel software. Results The results are presented below for each phase described in the method section. Before TAVI-Pathway optimisation The first phase aimed to identify the TAVI pathway currently used in the hospital. During the first phase, internal documents were analysed. In particular, the clinical pathways of TAVI used for both planned outpatients and emergency situations were analysed. Furthermore, semi-structured interviews were conducted with the different healthcare professionals involved in the TAVI pathway. Of the interviewees, 16 were physicians (59%) and 11 were nurses (41%), while 15 were women (55%) and 12 were men (45%). The document analysis and interviews thus made it possible to define the TAVI pathway currently in use in the hospital. The TAVI pathway before the optimisation is represented in Fig. 1 . The pathway begins with the patient’s first access. When patients arrive at the hospital, they have already had an ultrasound scan and been referred by a specialist as a possible TAVI patient. Then, during the pre-admission, physicians explain the TAVI pathway. If the patient agrees, they are placed on the waiting list to receive invasive coronary angiography (second access) and then a CT scan (third access), these being the preliminary examinations for the TAVI procedure. Once the coronary angiography and CT scan reports are available, a multidisciplinary group of experts (Heart Team) discusses the cases on a weekly basis. The Heart Team defines when the patient will be treated, the type of TAVI device to be implanted, and the pathway to be followed. The Heart Team comprises several professionals, namely, general cardiologists, interventional cardiologists, cardiac surgeons, anaesthetists, and electrophysiologists. Once the TAVI procedure has been scheduled, the patient is admitted to the cardiology ward a few days before the procedure (2.16 days). After the procedure, the patient is admitted to the Intensive Coronary Care Unit (ICCU) and, if there are no complications, transferred to a rehab facility approximately 130 h later (5.53 days) or home approximately 120 h later (5.05 days) (see Fig. 1 ). The interviews made it possible to highlight several critical points linked to the current TAVI pathway described above. For convenience, these can be referred to as the three main phases of the pathway: pre-procedure, peri-procedure, and post-procedure. Pre-procedure With reference to the first phase, the first critical element identified concerned patient access. The waiting time between the first access and coronary angiography was about one month, while three weeks elapsed between the coronary angiography and the CT scan. According to some interviewees, such waiting times may be problematic for the organisation of activities, as the risk of the patient no longer being traceable is high. The large number of CT scan requests, not only for TAVI patients, but also for other indications, could create a bottleneck. Moreover, according to the interviewees, invasive angiography is an avoidable examination that could be replaced by the CT scan as first screening tool to rule in/rule out the presence of significant coronary artery disease. In addition, several professionals pointed out that some problems were arising from the first patient access: the selection of the patient, a fundamental moment in starting the whole pathway, sometimes was not taking place correctly (namely, problems of futility assessment may occur). The patient also often appears confused and inadequately informed. Informing patients and caregivers is the responsibility of physicians during the pre-admission phase. However, given the advanced age of the patient, the state in which the patient may be, and the facts that the patient is not always accompanied by a caregiver and the subject of communication is not standardised but depends on the physician on duty, the effectiveness of communication may be significantly reduced. The Heart Team also identified some criticalities. Key stakeholders, such as anaesthetists, geriatricians, and electrophysiologists, did not always attend Heart Team meetings. During the admission to the cardiology ward the day before the procedure, the patient was assessed by the anaesthetist, but this assessment did not always yield an adequate level of information. There have been cases in which the patient did not have all the information about the procedure (e.g., type of anaesthesia) or was not physically ready (e.g., urinary tract infection, had not discontinued medication), and therefore procedure might be postponed. There is a protocol for the TAVI pathway at the ward level, but this is not shared among all the professionals involved. Peri-procedure Only one critical issue arose during the procedure, namely the excessive use of the bladder catheter even when this could be avoided. Post-procedure The two main critical issues in the post-procedure phase concerned the days spent on the ward (ICCU) and the patient’s mobilisation, and these issues were found to be interrelated. The nursing staff on the ward were not properly trained on early mobilisation, which slowed the process down and makes not only mobilisation itself, but also the rehabilitation and discharge, less efficient. The lack of a checklist for early discharge increases the length of stay during hospitalisation, generating organisational and economic problems for the hospital and discomfort for patients. Finally, the lack of information for patients and caregivers on the rehab pathway out of the hospital and the lack of coordination with rehab facilities run by the local health authority may also represent sources of delay in discharge. In light of the pathway described above, several optimisation opportunities could be highlighted: (1) waiting time reduction, (2) coronary angiography bypass, (3) bladder catheter bypass (4) better selection of patients, (5) communication improvement, (6) early mobilisation and early discharge. After TAVI-Pathway optimisation To identify organisational approaches to increase the level of performance of the TAVI pathway at the University Hospital of Parma, five working groups were created. Table 1 summarises the goals and results of the groups. Table 1 Working groups: members, goal, results. Phase Members Goal Organisational action pre-procedure Three cardiologists that work on pre-admission Define and structure educational materials to inform patients and caregivers. The goal of this activity was to provide all patients with clear and standardised information to avoid misunderstandings Three educational materials were drawn up for patients and caregivers: one concerned aortic stenosis disease; one was related to TAVI and the diagnostic process; and one with a focus on the pre-discharge phase and describing follow-up and post-procedure recovery. Three cardiologists that work on pre-admission Define a checklist to stratify the coronary risk. The aim was to identify patients who can undergo CT scan while also avoiding coronary angiography A checklist (Additional file 2), with the increase of CT scan slots dedicated to TAVI patients, has an impact in terms of more productivity, waiting list reduction, and reduction of costs for unnecessary tests. These changes allow the organisation to achieve two different outcomes: reduction of patient no-shows between first access and CT scan and greater speed in bringing case discussion to the Heart Team. Physicians from the pre-admission had put in place a collaboration with Geriatrics so that after the first visit, patients identified as frail will be evaluated by Geriatrics to have a more comprehensive assessment useful for patient selection. Four general and interventional cardiologists Build a checklist to evaluate patients eligible for a fast track to early discharge Pre-procedural criteria to include patients eligible for early discharge (Additional file 3) were identified. The checklist had two parts: one on clinical-anamnestic criteria evaluated by the cardiologist and the other on clinical criteria evaluated by the Heart Team. post-procedure Two cardiologists and a nurse coordinator Define a close monitoring and nurse-led early mobilisation protocol and create a pre-discharge checklist. The protocol allows the identification of patients eligible to be mobilised within 6 h after arrival in ICCU and to be discharged during the next 48 h. Patients who are eligible for early mobilisation could avoid a bladder catheter. The protocol was made up of three different checklists. The first monitored patient conditions over time (at arrival, after 30 minutes, after 60 min, after 2 h, after 3 h, after 4 h, after 5 h, and after 6 h). The second concerned nurse-led early mobilisation to facilitate a progressive return to baseline status with monitoring of patient’s clinical conditions. The assessment will be conducted on a regular basis: 6–7 h, 9 h, 10 h, and night rest. The third checklist evaluated patient conditions after 24 h, 36 h, and 48 h to evaluate the possibility of discharge. Two electrophysiologists Define a flowchart to manage the conduction disorders. This protocol is used to standardise the decision process that could lead to permanent pacemaker implantation based on close monitoring of ECG. Standardisation is crucial to create a consistent approach that does not depend on the physician on duty. Twenty-four hours after the procedure, the patient will be monitored, and if there are no complications, they will be eligible for a standardised pathway (e.g., fast-track discharge). If any complications appear (any variations on ECG), the patient will be monitored regularly: 24 h for balloon-expandable valves and 48 h for self-expanding valves. When identifying the right valve, the Heart Team should take into consideration any pre-existing conduction disorder. TAVI pathway: the impact of the optimisation process Table 2 shows the main figures for TAVI activities at the University Hospital of Parma for the period July 2022 – June 2023. Table 2 TAVI descriptive data for the University Hospital of Parma (2022 – 23) Item Number Patients 35 Male 17 Female 18 Age average (youngest; oldest) 82.21 (72; 89) Length of stay (min; max) 12.69 days (3; 105) The organisational solutions highlighted in the previous paragraph outline a new TAVI pathway capable of generating a significant impact not only from an organisational point of view, but also from an economic point of view (Table 3 ). Table 3 The optimisation process: organisational and economic impact Phase Critical issues Organisational action Organisational impact Economic impact pre-procedure The waiting time between the first access and coronary angiography A checklist to stratify pre-TAVI coronary risk, also avoiding coronary angiography, was created Reduction of waiting lists. Reduction in the number of coronary angiographies Increase in the number of slots for coronary angiographies The waiting time between coronary angiography and CT scan Agreement with the imaging department to increase the number of TAVI-dedicated slots Reduction of waiting lists. Increased productivity of TAVI operations Increase in productivity and in revenues linked to TAVI operations The selection of the patient does not take place correctly A collaboration with geriatrics to better evaluate frail patients was started Better patient selection helps avoid unnecessary procedures (futility assessment) Reduction of unnecessary procedures and related costs The patient is often inadequately informed Educational material about aortic stenosis, TAVI, and the diagnostic process was prepared All patients receive clear and standardised information. Misunderstandings are avoided Reduction of the time spent by physician per patient during the pre-admission phase Key figures do not always attend the Heart Team meetings The Heart Team can seek advice from geriatricians if necessary. Anaesthetists regularly attend Heart Team meetings A better assessment of the patient is made. A fast track for some patients can be identified The best TAVI path to follow is defined for each patient, avoiding waste and inefficiencies The assessment of the patient by the anaesthetist the day before the operation does not always yield an adequate level of information Anaesthetists are always involved in the Heart Team, so they know the patient in advance Advance knowledge of the patient’s history reduces the likelihood of postponing TAVI procedures Reduction of costs related to pre-procedural tests that must be repeated due to postponement of the of the surgical procedure peri- procedure The excessive use of the bladder catheter, even when this could be avoided Patients who are candidates for early mobilisation could avoid a bladder catheter. Reduction in the number of bladder catheters Reduction in the number of infections and consequent prolonged length of stay Reduction of costs related to the use of the bladder catheter Reduction of infection costs post-procedure Delays in patient mobilisation A protocol to identify patients eligible to be mobilised within 6 h was created. Nurse-led early mobilisation of the patient Possibility of discharging the patient early Reduction of the days spent in ICCU and related costs The time spent by patients in the ICCU after the intervention Pre procedural criteria used to identify patients eligible for fast-track (pre procedure) Pre-discharge checklist to ensure a criteria-driven discharge decision making to be assessed at 24 and 48h (post procedure) - the effect of this second one is the reduction of ICCU days Reduction of the number of days spent in ICCU Reduction of the days spent in ICCU and related costs The lack of information for patients and caregivers on the rehab pathway out of hospital Educational materials about follow-up and post-operative recovery were prepared. Better information for patients and caregivers on the post-procedural course Reduction of resistance to discharge Reduction of the days spent in hospital and related costs Table 3 shows how optimising the TAVI pathway enables the organisation of the process to be improved, generating several economic savings at all stages of the path (pre-, peri-, and post-procedure). In order to evaluate the economic impact of the introduction of the new optimised TAVI pathway to a population of 25 patients (the number of planned patients without complications from July 2022 to June 2023, thus potentially eligible for the fast-track pathway) in one year is hypothesised below. The new pathway after the optimisation establishes that invasive coronary angiography is no longer performed on most patients (e.g., between − 70% and − 90%). At the same time, the reduction in waiting lists and increase in the number of CT scan slots dedicated to TAVI would probably lead to an increase in production of around 30%. The reimbursement rate for TAVI in the Emilia-Romagna Region was €28,518. Therefore, 20 patients would avoid bladder catheter insertion (saving €1,500, given the cost of €75 per catheter); in terms of lengths of stay, the new pathway would allow patients to be admitted the day before the procedure (24 h) instead of the current average of 51 h (2.16 days); they would also be discharged after 48 h, if discharged home, or 24 h, if discharged to a rehab facility, instead of approximately 130 h later (5.53 days) when discharged to rehab facility or approximately 120 h later (5.05 days) if discharged home. It should be borne in mind that the cost of a day of hospitalisation in the ICCU is €852. The average cost reduction related to the optimisation of the pathway would be about €3,900 per patient, which would generate an overall cost reduction for 25 patients of about €97,000 per year (see details in Table 4 ). Table 4 shows the main differences in terms of activities and costs before and after the TAVI-pathway optimisation. Table 4 “Before” and “after” the TAVI-Pathway optimisation : average patient Phase Activity Differences Note Before € After € Pre-admission Coronary angiography* Yes No No need in 80% of cases Pre-procedure Stay 2.16 days €1,840 1 day €852 Peri-Procedure Catheter Yes €75 No €23 No need in 70% of cases Post-procedure Stay if discharged home 5.05 days €3,442 2 days €1,363 80% of patients Stay if discharged to another facility 5.27 days €942 1 day €170 20% of patients Total costs Before After Cost reduction Average for 1 patient €6,299 €2,408 €3,891 Average for 25 patients €157,489 €60,203 €97,276 * Coronary angiography is a procedure performed before admission, so it is not part of reimbursement rate. The reduction in hospitalisation after TAVI procedures would free about 112 days of hospitalisation in the ICCU (from an average length of stay of about 7,5 days to 3 days) to be used to increase the number of TAVI procedures (if there is a waiting list) or by other operating units in the hospital. Evaluating potential revenues, if all these days were used to perform TAVI procedures with a reimbursement rate of €28,518, we can assume an average potential revenue of €1,148,000 (about 40 TAVI procedures). Furthermore, the real economic advantage could be even more significant if a series of costs that are more difficult to evaluate are considered: Reduction in time spent by physician per patient during the pre-admission phase; Reduction in costs related to pre-procedure examinations that must be repeated due to postponement of the procedure; Reduction of infections and their related costs, etc. Discussion The findings of this study show how the organisational solutions identified by the University Hospital of Parma can create new conditions for the efficiency and quality of the TAVI pathway. Efficiency is evident not only in the amount of economic savings, but also in the reduction of waiting times for patients, in the optimisation of the use of available resources, and in the increase in productivity for the hospital. A higher quality of service is achieved thanks to a better assessment of the patient's pre- and post-procedure conditions, the reduction of avoidable hospital days, a decrease in infection risks, and improved overall well-being for the patient. However, the change of the pathway described here is characterised by a certain level of organisational complexity. Many actors are involved in the TAVI pathway. A first question concerns patients. TAVI patients are often very elderly, and communication with them is not easy. The active involvement of caregivers therefore becomes important. Furthermore, many healthcare professionals are involved, and they have different skills and act at different moments of the pathway. The University Hospital of Parma is a hub centre for TAVI procedures in the Emilia-Romagna Region, and it is necessary to manage relationships with the spoke centres of the Region. Coordination and good communication among all the actors involved therefore becomes crucial for a new TAVI pathway to work effectively. Given this level of complexity, it is necessary to identify a role that will assume the responsibility of coordinating the pathway. A Clinical Valve Coordinator may help to manage the procedural programme for individual patients while maintaining seamless communication with the Heart Team throughout the patient care journey, making the pathway more streamlined [ 36 ]. One of the Clinical Valve Coordinator’s responsibilities is to ensure that all relevant screening results (e.g., CT scan, coronary angiography, blood tests) are distributed to all members of the Heart Team promptly to inform patient discussion and prevent delays in Heart Team recommendations [ 37 ]. In addition, the Clinical Valve Coordinator is in charge of scheduling the screening tests during the hospitalisation, gathering all the results for the Heart Team, scheduling the TAVI procedures, and preparing the mode of discharge of the patients after the procedure (McCalmont et al., 2021). Further tasks of the Clinical Valve Coordinator are to inform patients and caregivers about the TAVI pathway and manage communications among patients, caregivers, and the Heart Team. Finally, this individual could have a central role in managing relationships among the Hub centre, the spoke centres, and the rehabilitation facilities. In addition to knowing the TAVI pathway well, the Clinical Valve Coordinator should possess the skills of leadership, problem-solving, coordination, communication, and organisational design. A possible job description of the Clinical Valve Coordinator is available in Additional file 4. However, if on the one hand the process of innovation is complex, on the other hand the organisational interventions identified in this study can generate many positive impacts for patients, caregivers, healthcare workers, and the hospital. First of all, there are several advantages of an optimised TAVI pathway for the patients [ 38 ]. First, the waiting times for the CT scan, and therefore the patient’s inclusion in the TAVI pathway, are shorter; hospital admissions are reduced for cases in which coronary angiography is not necessary; the patient is better informed about and more aware of the entire pathway. Furthermore, patients who can follow the fast track could avoid the discomfort of a bladder catheter as well as a reduced risk of urinary infections; they can benefit from early mobilisation and return home sooner, avoiding the risk of delirium/confusion related to long hospitalisations for elderly patients. The caregivers, for their part, can have better knowledge of the pathway their relatives will follow and be more ready to accompany them in the rehabilitation process after discharge. As regards healthcare workers, the new pathway guarantees to free up time and resources that could be re-deployed elsewhere. In this sense, the new optimised TAVI pathway is a “capacity-enhancing innovation” that upon adoption releases capacity in the form of re-deployable resources enabling better care for more patients with existing resources. The Clinical Valve Coordinator may allow physicians to focus on the clinical aspect of the process and dedicate more time to patients. A well-coordinated pathway improves the organisational context and satisfaction of healthcare professionals [ 39 ]. Many studies have, in fact, shown that better coordination of processes, greater collaboration between professionals, a greater focus on clinical rather than bureaucratic activities, and the possibility of having greater resources available are all elements that increase the motivation of healthcare workers [ 39 – 41 ]. Finally, there are also many benefits for the hospital of adopting a “capacity-enhancing innovation”. In addition to having more satisfied patients, caregivers, and professionals, the healthcare organisation improves the overall quality of the service. Making the pathway more efficient not only generates significant cost savings, but also allows to free up resources (e.g., beds, hospital days, physicians’ time) that can be used to increase the productivity of the cardiology area or invested in other departments of the hospital (see results section). The advantages for the hospital are then reflected in a benefit at the level of the regional healthcare system, enabling improvements to the organisation of services in the area. Conclusion Since the first groundbreaking procedure carried out in 2002, TAVI has revolutionised the management of aortic stenosis, and to date, more than 1.5 million procedures have been performed worldwide in more than 70 countries [ 42 ]. However, if, on the one hand, the TAVI intervention is standardised throughout the world, on the other, the organisational model used by hospitals to manage TAVI patients varies [ 29 ]. This study showed a process of TAVI pathway optimisation aligned with the BENCHMARK best practices, highlighting both the organisational and economic impacts. The case study analysed can be useful to all hospitals seeking to undertake a process of improving their TAVI pathway. The case study of the University Hospital of Parma represents a successful case of ‘capacity enhancing innovation’ [ 43 ]. The results of this study demonstrated that rethinking organisational processes can create several advantages for both stakeholders and the hospital. In particular, the possibility of reducing the costs of a clinical path is not a secondary issue, especially in a historical period in which healthcare systems around the world have to face continuous tensions related to financing [ 44 ]. However, the research is not without limitations. First of all, the organisational solutions identified by the University Hospital of Parma cannot be generalised to all institutions. Although they can serve as inspiration for other hospitals, each individual hospital must define the organisational model that best takes account of its own demographic characteristics, experience, and qualifications. Furthermore, the change process described in this article is still at an early stage, and it will take time for the new process to be consolidated. Finally, the economic impact was estimated. The real economic savings can only be assessed in the medium term. However, the first data from patients who followed the optimised TAVI pathway (November–December 2023) show results in line with what was estimated by the prospective analyses carried out as part of our study. In this regard, future research could confirm the actual economic impact on the hospital one year later. Abbreviations TAVI Transcatheter Aortic Valve Implantation CT scan Computed Tomography Scan ICCU Intensive Coronary Care Unit. Declarations Ethics approval and consent to participate The AVEN Territorial Ethics Committee, with prot. n. 43459 of 10/31/202, approved this study. The General Director of the Parma Hospital, with resolution DELI0000896_2023, authorised this study. All interviewed gave their consent to participate in the study, after being informed that their participation was voluntary and that they were free to withdraw from the study at any time. The participants were all adults and they were guaranteed confidentiality. Consent for publication Not applicable. Availability of data and materials The datasets analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The research was carried out without funding. Authors' contributions SF designed and conducted the empirical study, wrote and revised the manuscript. LP wrote part of the background and revised the manuscript. GL, GB, LV revised the manuscript. All authors reviewed and approved the final manuscript. Acknowledgements We thank the many healthcare professionals from the University Hospital of Parma who have actively participated in the research by responding to interviews. References Øvretveit J. Total quality management in European healthcare. International journal of health care quality assurance. 2000 Apr 1;13(2):74-80. Andersson A, Hallberg N, Timpka T. A model for interpreting work and information management in process-oriented healthcare organisations. International Journal of Medical Informatics. 2003 Dec 1;72(1-3):47-56. Friesl M, Brielmaier C, Dobusch L. Taking individual choices seriously: A process perspective of self-selection in strategy work. Organization Theory. 2023 Jun;4(2):26317877231183986. Harris J. Managing state social work: Front-line management and the labour process perspective. Routledge; 2018 Tozzi V. La gestione per processi in sanità. CICLI DI VITA DEI FENOMENI, CICLI DI VITA DELLE POLITICHE. 2004:71. Davenport TH. Process innovation: reengineering work through information technology. Harvard business press; 1993. de Waal A, Sivro M. The relation between servant leadership, organizational performance, and the high-performance organization framework. Journal of Leadership & Organizational Studies. 2012 (2):173-90. George B, Walker RM, Monster J. Does strategic planning improve organizational performance? A meta‐analysis. Public administration review. 2019;79(6):810-9. Wood DA, Lauck SB, Cairns JA, Humphries KH, Cook R, Welsh R, Leipsic J, Genereux P, Moss R, Jue J, Blanke P. The Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: the 3M TAVR study. Cardiovascular Interventions. 2019 Mar 11;12(5):459-69. Butala NM, Wood DA, Li H, Chinnakondepalli K, Lauck SB, Sathananthan J, Cairns JA, Magnuson EA, Barker M, Webb JG, Welsh R. Economics of minimalist transcatheter aortic valve replacement: results from the 3M-TAVR economic study. Circulation: Cardiovascular Interventions. 2022 (10):e012168. Kuck KH, Leidl R, Frankenstein L, Wahlers T, Sarmah A, Candolfi P, Shore J, Green M. Cost-effectiveness of SAPIEN 3 transcatheter aortic valve implantation Versus Surgical aortic valve replacement in German severe aortic stenosis patients at Low Surgical Mortality Risk. Advances in Therapy. 2023 (3):1031-46. Clayton B, Morgan-Hughes G, Roobottom C. Transcatheter aortic valve insertion (TAVI): a review. The British journal of radiology. 2014;87(1033):20130595. Heathcote L, Srivastava T, Sarmah A, Kearns B, Sutton A, Candolfi P. A systematic review and statistical analysis of factors influencing the cost-effectiveness of transcatheter aortic valve implantation for symptomatic severe aortic stenosis. ClinicoEconomics and Outcomes Research. 2023:459-75. Goodall G, Lamotte M, Ramos M, Maunoury F, Pejchalova B, de Pouvourville G. Cost-effectiveness analysis of the SAPIEN 3 TAVI valve compared with surgery in intermediate-risk patients. Journal of Medical Economics. 2019;22(4):289-96. Lorenzoni V, Barbieri G, Saia F, Meucci F, Martinelli GL, Cerillo AG, Berti S, Candolfi P, Turchetti G. The cost-effectiveness of transcatheter aortic valve implantation: exploring the Italian National Health System perspective and different patient risk groups. The European Journal of Health Economics. 2021, 22(9):1349-63. Mennini FS, Meucci F, Pesarini G, Vandoni P, Lettino M, Sarmah A, Shore J, Green M, Giardina S. Cost-effectiveness of transcatheter aortic valve implantation versus surgical aortic valve replacement in low surgical risk aortic stenosis patients. International Journal of Cardiology. 2022;357:26-32. Reynolds MR, Lei Y, Wang K, Chinnakondepalli K, Vilain KA, Magnuson EA, Galper BZ, Meduri CU, Arnold SV, Baron SJ, Reardon MJ. Cost-effectiveness of transcatheter aortic valve replacement with a self-expanding prosthesis versus surgical aortic valve replacement. Journal of the American College of Cardiology. 2016; 67(1):29-38. Fagerlund BC, Stoinska-Schneider A, Lauvrak V, Juvet LK, Robberstad B. Health technology assessment of Transcatether aortic valve implantation (TAVI) as treatment of patients with severe aortic stenosis and intermediate surgical risk–Part 2. Health economic evaluation. McCalmont G, Durand E, Lauck S, Muir DF, Spence MS, Vasa‐Nicotera M, Wood D, Saia F, Chatel N, Lüske CM, Kurucova J. Setting a benchmark for resource utilization and quality of care in patients undergoing transcatheter aortic valve implantation in Europe—Rationale and design of the international BENCHMARK registry. Clinical Cardiology. 2021 O(10):1344-53. Gilard M, Eltchaninoff H, Iung B, Lefèvre T, Spaulding C, Dumonteil N, Mutuon P, Roussel C, Candolfi P, de Pouvourville G, Green M. Cost-effectiveness analysis of SAPIEN 3 transcatheter aortic valve implantation procedure compared with surgery in patients with severe aortic stenosis at low risk of surgical mortality in France. Value in Health. 2022;25(4):605-13. Dubois C, Adriaenssens T, Annemans L, Bosmans J, Callebaut B, Candolfi P, Cornelis K, Delbaere A, Green M, Kefer J, Lancellotti P. Transcatheter aortic valve implantation versus surgical aortic valve replacement in severe aortic stenosis patients at low surgical mortality risk: a cost-effectiveness analysis in Belgium. Acta Cardiologica. 2024;79(1):46-57. Eerdekens R, Kats S, Grutters JP, Green M, Shore J, Candolfi P, Oortwijn W, Harst PV, Tonino P. Cost-utility analysis of TAVI compared with surgery in patients with severe aortic stenosis at low risk of surgical mortality in the Netherlands. Cost Effectiveness and Resource Allocation. 2024;22(1):24. Eaton J, Mealing S, Thompson J, Moat N, Kappetein P, Piazza N, Busca R, Osnabrugge R. Is transcatheter aortic valve implantation (TAVI) a cost-effective treatment in patients who are ineligible for surgical aortic valve replacement? A systematic review of economic evaluations. Journal of medical economics. 2014;17(5):365-75. Rodríguez JM, Bermúdez EP, Zamorano JL, Burgos JM, Díaz-Fernández JF, del Blanco BG, Sarmah A, Candolfi P, Shore J, Green M. Cost-effectiveness of SAPIEN 3 transcatheter aortic valve implantation in low surgical mortality risk patients in Spain. mortality. 2023;4:5. Ghiasvand H, Khaleghparast S, Kachoueian N, Tirgarfakheri K, Mortazian M, Toloueitabar Y, Gorjipour F, Naghdi S. Transcatheter aortic valve implantation against conventional aortic valve replacement surgery in high-risk patients with aortic stenosis; a cost-effectiveness analysis. Health economics review. 2023;13(1):1. Barbanti M, van Mourik MS, Spence MS, Iacovelli F, Martinelli GL, Muir DF, Saia F, Bortone AS, Densem CG, van der Kley F, Bramlage P. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. EuroIntervention. 2019;15(2):147-54. Frank D, Durand E, Lauck S, Muir DF, Spence M, Vasa-Nicotera M, Wood D, Saia F, Urbano-Carrillo CA, Bouchayer D, Iliescu VA. A streamlined pathway for transcatheter aortic valve implantation: the BENCHMARK study. European heart journal. 2024 Jun 1;45(21):1904-16. Pibarot P. Transcatheter aortic valve replacement: benchmarking practices to optimize quality and outcomes. European heart journal. 2024:ehae174. Tchetche D, de Biase C, Brochado B, Mastrokostopoulos A. How to make the TAVI pathway more efficient. Interventional Cardiology Review. 2019 Feb;14(1):31. Eisenhardt KM. Building theories from case study research. Academy of management review. 1989;14(4):532-50. Yin RK. Case study research: Design and methods. Sage, London, 2009. Yin RK. Discovering the future of the case study. Method in evaluation research. Evaluation practice. 1994; (3):283-90. Bowen F, Newenham-Kahindi A, Herremans I. When suits meet roots: The antecedents and consequences of community engagement strategy. Journal of Business Ethics. 2010;95:297-318. Forcella F, Arnold RL, Sanchez R, Ghersa CM. Modeling seedling emergence. Field Crops Research. 2000;67(2):123-39. Banks J, Carson JS, Nelson BL, Nicol DM. Verification and validation of simulation models. Discrete-event system simulation, 3rd Edition, Prentice-Hall, Upper Saddle River (NJ). 2001:367-97. During SD. Nurse-led post-procedure protocol to facilitate safe next-day discharge home: Findings of the 3M TAVR study. Canadian Journal of Cardiology. 2019;35. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European heart journal. 2022;43(7):561-632. Bohmann K, Burgdorf C, Zeus T, Joner M, Alvarez H, Berning KL, Schikowski M, Kasel AM, van Mark G, Deutsch C, Kurucova J. The COORDINATE pilot study: impact of a transcatheter aortic valve coordinator program on hospital and patient outcomes. Journal of Clinical Medicine. 2022; 11(5):1205. Yeh TM, Pai FY, Huang KI. Effects of clinical pathway implementation on medical quality and patient satisfaction. Total Quality Management & Business Excellence. 2015;26(5-6):583-601. Vilma Z, Egle K. Improving motivation among health care workers in private health care organizations: A perspective of nursing personnel. Baltic Journal of Management. 2007; 2(2):213-24. Mascia D, Dello Russo S, Morandi F. Exploring professionals' motivation to lead: a cross-level study in the healthcare sector. The International Journal of Human Resource Management. 2015;26(12):1622-44. Cribier A. Invention and uptake of TAVI over the first 20 years. Nature Reviews Cardiology. 2022; (7):427-8. Veenstra GL, Dabekaussen KF, Molleman E, Heineman E, Welker GA. Health care professionals’ motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review. Health care management review. 2022 Apr 1;47(2):155-67. Panayides P. Enhancing innovation capability through relationship management and implications for performance. European Journal of Innovation Management. 2006; 9(4):466-83. Pratici L, Fanelli S, Zangrandi A. Not only funding: how healthcare organizations can contribute to National Health Service sustainability. International Journal of Public Administration. 2023; 46(13):971-81. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1Checklisttostratifythecoronaryrisk.docx Additionalfile2Checklistforafasttracktodischarge.docx Additionalfile3ClinicalValveCoordinator.docx Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 16 Jul, 2024 Editor assigned by journal 16 Jul, 2024 Submission checks completed at journal 16 Jul, 2024 First submitted to journal 15 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4741137","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":327694859,"identity":"d38974a6-67e7-416f-89c0-e10cb7fa187c","order_by":0,"name":"Simone Fanelli","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYDACZgjFD8SMBx4Y2EBFDAhrkWwAEgcSDNJgWvDpQdHCcBgmgFuLfDt34uOCCgYJ/tnNBw4kFJxP3M7Oe+wDQ8EfnFoMDvNuNp5xhkFC4s6xBKDDbifubOZLnoHPYQbMvNukedsY6hhu5BiAtWw4zGOM1y/yzSAt/xgk5G/kfwBqOUdYC8NhkJYGBgmDGzmgEDtAWAvYLzzHJCQMb6SBHJZsvOEwXzJDgoExbof1n934mKfGRkLuRvLDBx/+2MluOH/2MMOHP3K4HQYBEsgcHgaGBEIa0AAPiepHwSgYBaNguAMAWfFP9POlzUAAAAAASUVORK5CYII=","orcid":"","institution":"University of Parma","correspondingAuthor":true,"prefix":"","firstName":"Simone","middleName":"","lastName":"Fanelli","suffix":""},{"id":327694860,"identity":"5897d787-29d4-4cfc-ba67-56b2abf6b9bd","order_by":1,"name":"Gianluca Lanza","email":"","orcid":"","institution":"University of Parma","correspondingAuthor":false,"prefix":"","firstName":"Gianluca","middleName":"","lastName":"Lanza","suffix":""},{"id":327694861,"identity":"d8a4c803-25e8-46cf-92a4-5577411834f7","order_by":2,"name":"Lorenzo Pratici","email":"","orcid":"","institution":"University of Parma","correspondingAuthor":false,"prefix":"","firstName":"Lorenzo","middleName":"","lastName":"Pratici","suffix":""},{"id":327694862,"identity":"cd3ead76-c1f2-4569-8b59-02e5770a4776","order_by":3,"name":"Giorgio Benatti","email":"","orcid":"","institution":"Ospedale di Parma","correspondingAuthor":false,"prefix":"","firstName":"Giorgio","middleName":"","lastName":"Benatti","suffix":""},{"id":327694863,"identity":"2c32908d-d1e9-4566-a9b7-1530aefc7c39","order_by":4,"name":"Luigi Vignali","email":"","orcid":"","institution":"Ospedale di Parma","correspondingAuthor":false,"prefix":"","firstName":"Luigi","middleName":"","lastName":"Vignali","suffix":""}],"badges":[],"createdAt":"2024-07-15 06:44:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4741137/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4741137/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13021-z","type":"published","date":"2025-07-01T15:58:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62328429,"identity":"28169a56-c8a8-4ee7-a4d0-060a8f4de744","added_by":"auto","created_at":"2024-08-13 03:14:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73872,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe TAVI pathway in the University Hospital of Parma before the optimisation\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4741137/v1/7049d58f8c2cae7a6397f125.jpg"},{"id":86179206,"identity":"4bce34d7-c5ee-4454-b985-4e99ead056b6","added_by":"auto","created_at":"2025-07-07 16:17:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":985181,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4741137/v1/70a02aed-1a78-4d8d-8a84-a2a578dd5d81.pdf"},{"id":62328427,"identity":"ca414637-c341-4cc9-a657-ae09ee38b2fc","added_by":"auto","created_at":"2024-08-13 03:14:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14422,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1Checklisttostratifythecoronaryrisk.docx","url":"https://assets-eu.researchsquare.com/files/rs-4741137/v1/721734b61fbb86033889bd7a.docx"},{"id":62328428,"identity":"497e1ae1-468a-486d-ba49-6d543172baf7","added_by":"auto","created_at":"2024-08-13 03:14:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15013,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2Checklistforafasttracktodischarge.docx","url":"https://assets-eu.researchsquare.com/files/rs-4741137/v1/7b09afca8a1db361fe882828.docx"},{"id":62328426,"identity":"ccb85233-7da7-4f14-b3d6-f110c70c764d","added_by":"auto","created_at":"2024-08-13 03:14:59","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24651,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3ClinicalValveCoordinator.docx","url":"https://assets-eu.researchsquare.com/files/rs-4741137/v1/b94b543aceb21e398fd0c7f0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Economic impact of TAVI pathway optimisation: the experience of the University Hospital of Parma.","fulltext":[{"header":"Background","content":"\u003cp\u003eThe healthcare sector is strongly characterised by a high number of specialisations and medical professions, complex therapies, and equipment, and often different service units revolve around different organisations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. All these characteristics mean that opportunities for integration and coordination should be found while continuing to respect all fields of specialisation. Doing so allows knowledge to be transferred with high-grade professionalism and a high technological level in contexts such as hospitals [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince the 1990s, both studies and management experiences have paid increasing attention to the management of organisational processes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. International contributions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] recognise the \u0026ldquo;pathway perspective\" as an alternative to the functional approach insofar as organisations are understood not as sets of vertically integrated functional units, but as collections of interrelated processes that create value. In functional models, the governance of the production activity, whose management aims to achieve economies of scale, and hierarchical control systems drive the control of the value creation process rather than its management. In the pathway approach, value creation is seen as a non-hierarchical process that requires non-vertical co-ordination mechanisms (lateral coordination) of the chain of events that can transcend the boundaries of the organisation.\u003c/p\u003e \u003cp\u003eThe shift from functional to pathway-oriented organisational models represents a significant change in the perspectives of an organisation\u0026rsquo;s management, focusing on the management of pathways rather than structures and orienting strategic choices to increase value creation and enhance forms of coordination [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe debate about pathway-based management originated in the business world and can offer countless stimuli to improve the pathway management of healthcare organisations.\u003c/p\u003e \u003cp\u003eResearchers have offered different definitions of pathway. According to Davenport (1993) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], a pathway is a set of structured and measured activities designed to produce a specific output for a particular market or customer. The main characteristics of pathway can be noted in the pathway is associated with a spatial-temporal sequence of activities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the field of healthcare, organisational pathways (along with clinical competences and technology) are recognised as pivotal elements for achieving high levels of performance [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, it is crucial to acknowledge that no single set of organisational pathways can be deemed universally perfect for all organisational contexts [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is incumbent upon management to thoroughly examine the current pathways implemented within their organisations with the aim of pinpointing any critical issues and subsequently proposing better organisational and managerial solutions tailored to their specific organisational contexts. It is envisioned that such initiatives can enable resource optimisation and enhance the efficacy of patient care. Thus, each healthcare organisation must therefore undertake the task of identifying the most suitable pathway based on its own unique set of resources and requirements, and this imperative applies equally to the TAVI (Transcatheter Aortic Valve Implantation) pathway. As a matter of fact, the aim of our study was to analyse how to optimise, from an economic\u0026ndash;organisational perspective, the TAVI pathway, identifying the most critical aspects of the process and proposing alternative solutions to use the resources and the technologies in a better way. This article reports on a study conducted at the Cardiology Unit of the University Hospital of Parma, Italy.\u003c/p\u003e \u003cp\u003eEmpirical studies conducted in other healthcare settings have already demonstrated the feasibility of identifying TAVI organisational pathways that not only ensure heightened patient safety, but also yield organisational and managerial advantages [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, there is a paucity of evidence on the outcomes of TAVI pathway optimisation and there is a lack of studies that quantify the economic impact of TAVI pathway optimisation.\u003c/p\u003e\n\u003ch3\u003eTAVI pathway\u003c/h3\u003e\n\u003cp\u003eTAVI has emerged as a standard of care for patients suffering from symptomatic severe aortic stenosis after its introduction almost two decades ago. Previous studies have shown that TAVI generates greater economic and clinical benefits compared to other techniques [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and that it helps in reducing costs, resources usage, and waiting times [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Its implementation leads not only to increased productivity, but also to a reduction of indirect costs due to a general reduction of staff overload as well as the elimination of costs related to unnecessary procedures [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies concerning the cost-effectiveness of TAVI have been performed since the 2010s. Multiple cost-effectiveness analyses indicate that TAVI is more cost-effective than medical management for inoperable patients and highly cost-effective in comparison to surgical aortic valve replacement for high- and, intermediate-risk patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, around the world more and more studies have assessed the cost-effectiveness of TAVI in severe aortic stenosis patients at low risk of surgical mortality [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll these studies aimed to assess the economic value of TAVI when well implemented; however, as other researchers have claimed [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], organisational analyses of this technique have been lacking.\u003c/p\u003e \u003cp\u003eMcClamont \u003cem\u003eet al.\u003c/em\u003e (2014) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] were the first to discuss the clinical pathway to streamline patient care with the aim of improving standards of care by reducing the length of stay in hospital. Their analysis was a comprehensive study of organisational and economic aspects, but no clear conclusions were reached in terms of organisation, as data were lacking at the time the study was carried out due to challenges in data collection. Subsequently, other authors addressed the organisational aspects of the TAVI pathway [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecently, using a clear set of quality-of-care measures, Frank \u003cem\u003eet al.\u003c/em\u003e (2024) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] introduced the organisational aspect to the scholarly discourse by studying the implementation of a set ofbest practices within the BENCHMARK registry. This was a multicenter international registry enrolling patients with severe symptomatic aortic stenosis undergoing TAVI at 28 European centres. This study highlighted how the adoption of simple, standardised, TAVI-specific quality-of-care measures can help select patients for early discharge. In fact, the authors demonstrated that after the implementation of BENCHMARK practices mean length of stay was reduced from 7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0 to 5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 days (median 6 vs. 4 days; P\u0026thinsp;\u0026lt;\u0026thinsp;.001), without compromising patients\u0026rsquo; safety at 30-day follow-up.\u003c/p\u003e \u003cp\u003ePibarot (2024) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], in his editorial referred to Frank\u0026rsquo;s study, has also highlighted that the TAVI procedure has become more efficient with BENCHMARK and that the BENCHMARK study \u0026ldquo;represents by far the largest and most ambitious attempt at achieving and generalizing best practices in TAVI\u0026rdquo;. In particular, Pibarot states that the optimisation of TAVI pathways is definitely cost-effective and that represents a good investment for every hospital performing TAVI.\u003c/p\u003e \u003cp\u003eAnother comprehensive research on the organisational aspects of TAVI was performed by Tchetche \u003cem\u003eet al.\u003c/em\u003e (2019) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The authors discussed why clinicians need to make the TAVI pathway more efficient and described the most important steps to take, from screening to early discharge, including procedural optimisation. This study suggests that the core idea behind an efficient TAVI program is that it should ensure the ability to treat all patients who need the procedure from several aspects: optimisation, a minimalist approach during the procedure, and early discharge without compromising clinical outcomes. However, although Tcheche \u003cem\u003eet al.\u003c/em\u003e\u0026rsquo;s (2019) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] study highlighted important and innovative results from an organisational point of view, it contained little discussion of the potential impact of new organisational procedures.\u003c/p\u003e \u003cp\u003eThe actual research aims to focus on the importance of defining suitable ways to manage TAVI optimisation. In particular, this study aims to assess the potential impact of TAVI pathway optimisation in terms of organisational, human, material, and economic resources. Best practices and protocols from the BENCHMARK study were followed to define and implement the optimisation of the TAVI pathway in the University Hospital of Parma.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe research was conducted through a case study: the University Hospital of Parma, in the Emilia-Romagna Region, Italy.\u003c/p\u003e \u003cp\u003eCase study analysis is considered suitable for interpreting change in organisational processes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Yin (2009) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] argued that multiple sources should be used when building the \u0026ldquo;case\u0026rdquo;. Thus, setting up the framework of our methodological strategy, we used both documentary analysis and interviews. Research data were triangulated, as is usual in case study research, for ensuring validity [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Yin (1994) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and Bowen \u003cem\u003eet al.\u003c/em\u003e (2010) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] find that multiple methods are useful in qualitative research to triangulate results and reduce the impact of possible biases.\u003c/p\u003e \u003cp\u003eThe research consisted of three stages: 1. mapping of the current TAVI pathway; 2. identification of the organisational changes necessary to optimise it and implementation of the identified action with a multidisciplinary teamwork; 3. simulations of the organisational and economic impact of the optimisation process.\u003c/p\u003e \u003cp\u003eThe TAVI pathway optimization presented in this study, as well as the protocols introduced and changes implemented are aligned with the BENCHMARK Study [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], which represents by far the largest attempt at generalizing and standardizing TAVI practices.\u003c/p\u003e \u003cp\u003eThe first phase aimed to identify the TAVI pathway currently used in the hospital (before the optimisation process was implemented). For this purpose, internal documents, such as clinical pathways, internal reports, and organisational guidelines, were analysed. In addition, 27 semi-structured, in-depth, face-to-face interviews, lasting approximately 40 minutes each, were conducted with the key actors (16 physicians and 11 nurses) involved in the TAVI pathway in the hospital to triangulate the evidence provided by the documents.\u003c/p\u003e \u003cp\u003eThe four main topics discussed in the interviews were the professionals involved and their competencies; the activities carried out in the three phases of the TAVI pathway (pre-, peri-, and post-procedure); the role of caregivers; and any problems arising during the TAVI pathway. The main interview questions developed for this study are reported in Additional file 1 (see Round 1).\u003c/p\u003e \u003cp\u003eThe interviews were conducted between June and July 2023. The interviews were recorded, after which a team of three researchers analysed them to jointly collect the information to reduce the subjectivity of interpretation.\u003c/p\u003e \u003cp\u003eDuring the second phase, the organisational changes necessary to ensure effective implementation of the actions needed to optimise the pathway were identified and subsequently implemented. For this purpose, five working groups were defined, each one focused on a different phase of the process and with a specific goal to solve one or more critical issues detected in the TAVI pathway currently in use in the hospital (see phase 1). The groups were interdisciplinary, with members having different areas of expertise. At least one member of each working group was interviewed. Furthermore, all the documents (checklists, protocols, flow charts, etc.) developed by the working groups were analysed. Thus, a second round of interviews was conducted to match the evidence provided by the documents with the activities put in place by the groups. The objectives of the interviews were to understand the organisational solutions identified, highlight the responsibilities of the different professionals involved, assess the benefits of change actions, and identify possible resistance to change.\u003c/p\u003e \u003cp\u003eAll groups were active during the summer of 2023 (July and August), and the second round of interviews was conducted during September 2023 (Additional file 1 \u0026ndash; Round 2). The interviews were recorded and then analysed by the team of researchers.\u003c/p\u003e \u003cp\u003eIn the last phase, simulations of the organisational and economic impacts of the optimisation pathway were carried out by the University Hospital of Parma. Simulation models are very often used in the literature to study healthcare processes [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], because they represent a new process dynamically rather than statically, thus presenting stakeholders with a more realistic picture of the situation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In particular, in our study, the following issues were analysed: the potential increase in production capacity of the new process, the economic impact of the new use of structural resources (beds, operating room, anaesthesia hours, intensive care beds), and the organisational effect on the operating unit related to the pathway improvement. The costs and revenues of the TAVI activities, as well as the activity data, were provided by the hospital\u0026rsquo;s Management Control office. The data analysed refer to the 12-month period between July 2022 and June 2023. The sample analysed identified 25 out of 35 patients treated by the unit, representing those patients who provided consent to be involved in the study and eligible for the fast track. Patients were deemed eligible for the fast track if they had no clinical complications or emergency admissions.\u003c/p\u003e \u003cp\u003eData analysis was performed using Microsoft Excel software.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results are presented below for each phase described in the method section.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eBefore TAVI-Pathway optimisation\u003c/h2\u003e \u003cp\u003eThe first phase aimed to identify the TAVI pathway currently used in the hospital. During the first phase, internal documents were analysed. In particular, the clinical pathways of TAVI used for both planned outpatients and emergency situations were analysed. Furthermore, semi-structured interviews were conducted with the different healthcare professionals involved in the TAVI pathway. Of the interviewees, 16 were physicians (59%) and 11 were nurses (41%), while 15 were women (55%) and 12 were men (45%). The document analysis and interviews thus made it possible to define the TAVI pathway currently in use in the hospital.\u003c/p\u003e \u003cp\u003eThe TAVI pathway before the optimisation is represented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe pathway begins with the patient\u0026rsquo;s first access. When patients arrive at the hospital, they have already had an ultrasound scan and been referred by a specialist as a possible TAVI patient. Then, during the pre-admission, physicians explain the TAVI pathway. If the patient agrees, they are placed on the waiting list to receive invasive coronary angiography (second access) and then a CT scan (third access), these being the preliminary examinations for the TAVI procedure. Once the coronary angiography and CT scan reports are available, a multidisciplinary group of experts (Heart Team) discusses the cases on a weekly basis. The Heart Team defines when the patient will be treated, the type of TAVI device to be implanted, and the pathway to be followed. The Heart Team comprises several professionals, namely, general cardiologists, interventional cardiologists, cardiac surgeons, anaesthetists, and electrophysiologists. Once the TAVI procedure has been scheduled, the patient is admitted to the cardiology ward a few days before the procedure (2.16 days). After the procedure, the patient is admitted to the Intensive Coronary Care Unit (ICCU) and, if there are no complications, transferred to a rehab facility approximately 130 h later (5.53 days) or home approximately 120 h later (5.05 days) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe interviews made it possible to highlight several critical points linked to the current TAVI pathway described above. For convenience, these can be referred to as the three main phases of the pathway: pre-procedure, peri-procedure, and post-procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePre-procedure\u003c/h2\u003e \u003cp\u003eWith reference to the first phase, the first critical element identified concerned patient access. The waiting time between the first access and coronary angiography was about one month, while three weeks elapsed between the coronary angiography and the CT scan. According to some interviewees, such waiting times may be problematic for the organisation of activities, as the risk of the patient no longer being traceable is high. The large number of CT scan requests, not only for TAVI patients, but also for other indications, could create a bottleneck. Moreover, according to the interviewees, invasive angiography is an avoidable examination that could be replaced by the CT scan as first screening tool to rule in/rule out the presence of significant coronary artery disease.\u003c/p\u003e \u003cp\u003eIn addition, several professionals pointed out that some problems were arising from the first patient access: the selection of the patient, a fundamental moment in starting the whole pathway, sometimes was not taking place correctly (namely, problems of futility assessment may occur). The patient also often appears confused and inadequately informed. Informing patients and caregivers is the responsibility of physicians during the pre-admission phase. However, given the advanced age of the patient, the state in which the patient may be, and the facts that the patient is not always accompanied by a caregiver and the subject of communication is not standardised but depends on the physician on duty, the effectiveness of communication may be significantly reduced.\u003c/p\u003e \u003cp\u003eThe Heart Team also identified some criticalities. Key stakeholders, such as anaesthetists, geriatricians, and electrophysiologists, did not always attend Heart Team meetings. During the admission to the cardiology ward the day before the procedure, the patient was assessed by the anaesthetist, but this assessment did not always yield an adequate level of information. There have been cases in which the patient did not have all the information about the procedure (e.g., type of anaesthesia) or was not physically ready (e.g., urinary tract infection, had not discontinued medication), and therefore procedure might be postponed. There is a protocol for the TAVI pathway at the ward level, but this is not shared among all the professionals involved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePeri-procedure\u003c/h2\u003e \u003cp\u003eOnly one critical issue arose during the procedure, namely the excessive use of the bladder catheter even when this could be avoided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePost-procedure\u003c/h2\u003e \u003cp\u003eThe two main critical issues in the post-procedure phase concerned the days spent on the ward (ICCU) and the patient\u0026rsquo;s mobilisation, and these issues were found to be interrelated. The nursing staff on the ward were not properly trained on early mobilisation, which slowed the process down and makes not only mobilisation itself, but also the rehabilitation and discharge, less efficient. The lack of a checklist for early discharge increases the length of stay during hospitalisation, generating organisational and economic problems for the hospital and discomfort for patients. Finally, the lack of information for patients and caregivers on the rehab pathway out of the hospital and the lack of coordination with rehab facilities run by the local health authority may also represent sources of delay in discharge.\u003c/p\u003e \u003cp\u003eIn light of the pathway described above, several optimisation opportunities could be highlighted: (1) waiting time reduction, (2) coronary angiography bypass, (3) bladder catheter bypass (4) better selection of patients, (5) communication improvement, (6) early mobilisation and early discharge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAfter TAVI-Pathway optimisation\u003c/h2\u003e \u003cp\u003eTo identify organisational approaches to increase the level of performance of the TAVI pathway at the University Hospital of Parma, five working groups were created.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the goals and results of the groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWorking groups: members, goal, results.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMembers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGoal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrganisational action\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003epre-procedure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree cardiologists that work on pre-admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefine and structure educational materials to inform patients and caregivers. The goal of this activity was to provide all patients with clear and standardised information to avoid misunderstandings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThree educational materials were drawn up for patients and caregivers: one concerned aortic stenosis disease; one was related to TAVI and the diagnostic process; and one with a focus on the pre-discharge phase and describing follow-up and post-procedure recovery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThree cardiologists that work on pre-admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefine a checklist to stratify the coronary risk. The aim was to identify patients who can undergo CT scan while also avoiding coronary angiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA checklist (Additional file 2), with the increase of CT scan slots dedicated to TAVI patients, has an impact in terms of more productivity, waiting list reduction, and reduction of costs for unnecessary tests. These changes allow the organisation to achieve two different outcomes: reduction of patient no-shows between first access and CT scan and greater speed in bringing case discussion to the Heart Team. Physicians from the pre-admission had put in place a collaboration with Geriatrics so that after the first visit, patients identified as frail will be evaluated by Geriatrics to have a more comprehensive assessment useful for patient selection.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFour general and interventional cardiologists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBuild a checklist to evaluate patients eligible for a fast track to early discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePre-procedural criteria to include patients eligible for early discharge (Additional file 3) were identified. The checklist had two parts: one on clinical-anamnestic criteria evaluated by the cardiologist and the other on clinical criteria evaluated by the Heart Team.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003epost-procedure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo cardiologists and a nurse coordinator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefine a close monitoring and nurse-led early mobilisation protocol and create a pre-discharge checklist. The protocol allows the identification of patients eligible to be mobilised within 6 h after arrival in ICCU and to be discharged during the next 48 h. Patients who are eligible for early mobilisation could avoid a bladder catheter.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe protocol was made up of three different checklists. The first monitored patient conditions over time (at arrival, after 30 minutes, after 60 min, after 2 h, after 3 h, after 4 h, after 5 h, and after 6 h). The second concerned nurse-led early mobilisation to facilitate a progressive return to baseline status with monitoring of patient\u0026rsquo;s clinical conditions. The assessment will be conducted on a regular basis: 6\u0026ndash;7 h, 9 h, 10 h, and night rest.\u003c/p\u003e \u003cp\u003eThe third checklist evaluated patient conditions after 24 h, 36 h, and 48 h to evaluate the possibility of discharge.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo electrophysiologists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefine a flowchart to manage the conduction disorders.\u003c/p\u003e \u003cp\u003eThis protocol is used to standardise the decision process that could lead to permanent pacemaker implantation based on close monitoring of ECG.\u003c/p\u003e \u003cp\u003eStandardisation is crucial to create a consistent approach that does not depend on the physician on duty.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTwenty-four hours after the procedure, the patient will be monitored, and if there are no complications, they will be eligible for a standardised pathway (e.g., fast-track discharge).\u003c/p\u003e \u003cp\u003eIf any complications appear (any variations on ECG), the patient will be monitored regularly: 24 h for balloon-expandable valves and 48 h for self-expanding valves. When identifying the right valve, the Heart Team should take into consideration any pre-existing conduction disorder.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eTAVI pathway: the impact of the optimisation process\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the main figures for TAVI activities at the University Hospital of Parma for the period July 2022 \u0026ndash; June 2023.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eTAVI descriptive data for the University Hospital of Parma (2022\u003c/b\u003e\u0026ndash;\u003cb\u003e23)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge average (youngest; oldest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.21 (72; 89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay (min; max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.69 days (3; 105)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe organisational solutions highlighted in the previous paragraph outline a new TAVI pathway capable of generating a significant impact not only from an organisational point of view, but also from an economic point of view (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe optimisation process: organisational and economic impact\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritical issues\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOrganisational action\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOrganisational impact\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEconomic impact\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003epre-procedure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe waiting time between the first access and coronary angiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA checklist to stratify pre-TAVI coronary risk, also avoiding coronary angiography, was created\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduction of waiting lists.\u003c/p\u003e \u003cp\u003eReduction in the number of coronary angiographies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIncrease in the number of slots for coronary angiographies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe waiting time between coronary angiography and CT scan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAgreement with the imaging department to increase the number of TAVI-dedicated slots\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduction of waiting lists.\u003c/p\u003e \u003cp\u003eIncreased productivity of TAVI operations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIncrease in productivity and in revenues linked to TAVI operations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe selection of the patient does not take place correctly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA collaboration with geriatrics to better evaluate frail patients was started\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBetter patient selection helps avoid unnecessary procedures (futility assessment)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduction of unnecessary procedures and related costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe patient is often inadequately informed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEducational material about aortic stenosis, TAVI, and the diagnostic process was prepared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAll patients receive clear and standardised information. Misunderstandings are avoided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduction of the time spent by physician per patient during the pre-admission phase\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey figures do not always attend the Heart Team meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe Heart Team can seek advice from geriatricians if necessary. Anaesthetists regularly attend Heart Team meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA better assessment of the patient is made. A fast track for some patients can be identified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe best TAVI path to follow is defined for each patient, avoiding waste and inefficiencies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe assessment of the patient by the anaesthetist the day before the operation does not always yield an adequate level of information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnaesthetists are always involved in the Heart Team, so they know the patient in advance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdvance knowledge of the patient\u0026rsquo;s history reduces the likelihood of postponing TAVI procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduction of costs related to pre-procedural tests that must be repeated due to postponement of the of the surgical procedure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eperi-\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eprocedure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe excessive use of the bladder catheter, even when this could be avoided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients who are candidates for early mobilisation could avoid a bladder catheter.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduction in the number of bladder catheters\u003c/p\u003e \u003cp\u003eReduction in the number of infections and consequent prolonged length of stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduction of costs related to the use of the bladder catheter\u003c/p\u003e \u003cp\u003eReduction of infection costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003epost-procedure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelays in patient mobilisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA protocol to identify patients eligible to be mobilised within 6 h was created.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurse-led early mobilisation of the patient\u003c/p\u003e \u003cp\u003ePossibility of discharging the patient early\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduction of the days spent in ICCU and related costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe time spent by patients in the ICCU after the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre procedural criteria used to identify patients eligible for fast-track (pre procedure)\u003c/p\u003e \u003cp\u003ePre-discharge checklist to ensure a criteria-driven discharge decision making to be assessed at 24 and 48h (post procedure) - the effect of this second one is the reduction of ICCU days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduction of the number of days spent in ICCU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduction of the days spent in ICCU and related costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe lack of information for patients and caregivers on the rehab pathway out of hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEducational materials about follow-up and post-operative recovery were prepared.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBetter information for patients and caregivers on the post-procedural course\u003c/p\u003e \u003cp\u003eReduction of resistance to discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduction of the days spent in hospital and related costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows how optimising the TAVI pathway enables the organisation of the process to be improved, generating several economic savings at all stages of the path (pre-, peri-, and post-procedure). In order to evaluate the economic impact of the introduction of the new optimised TAVI pathway to a population of 25 patients (the number of planned patients without complications from July 2022 to June 2023, thus potentially eligible for the fast-track pathway) in one year is hypothesised below.\u003c/p\u003e \u003cp\u003eThe new pathway after the optimisation establishes that invasive coronary angiography is no longer performed on most patients (e.g., between \u0026minus;\u0026thinsp;70% and \u0026minus;\u0026thinsp;90%). At the same time, the reduction in waiting lists and increase in the number of CT scan slots dedicated to TAVI would probably lead to an increase in production of around 30%. The reimbursement rate for TAVI in the Emilia-Romagna Region was \u0026euro;28,518.\u003c/p\u003e \u003cp\u003eTherefore, 20 patients would avoid bladder catheter insertion (saving \u0026euro;1,500, given the cost of \u0026euro;75 per catheter); in terms of lengths of stay, the new pathway would allow patients to be admitted the day before the procedure (24 h) instead of the current average of 51 h (2.16 days); they would also be discharged after 48 h, if discharged home, or 24 h, if discharged to a rehab facility, instead of approximately 130 h later (5.53 days) when discharged to rehab facility or approximately 120 h later (5.05 days) if discharged home. It should be borne in mind that the cost of a day of hospitalisation in the ICCU is \u0026euro;852.\u003c/p\u003e \u003cp\u003eThe average cost reduction related to the optimisation of the pathway would be about \u0026euro;3,900 per patient, which would generate an overall cost reduction for 25 patients of about \u0026euro;97,000 per year (see details in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the main differences in terms of activities and costs before and after the TAVI-pathway optimisation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ldquo;Before\u0026rdquo; and \u0026ldquo;after\u0026rdquo; the \u003cem\u003eTAVI-Pathway optimisation\u003c/em\u003e: average patient\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePhase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eActivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003eDifferences\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eBefore\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026euro;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eAfter\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026euro;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoronary angiography*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo need in 80% of cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.16 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026euro;1,840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026euro;852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeri-Procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026euro;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026euro;23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo need in 70% of cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePost-procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStay if discharged home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.05 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026euro;3,442\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026euro;1,363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e80% of patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStay if discharged to another facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.27 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026euro;942\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026euro;170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20% of patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal costs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eBefore\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAfter\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u003cb\u003eCost reduction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAverage for 1 patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u0026euro;6,299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u0026euro;2,408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u0026euro;3,891\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAverage for 25 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u0026euro;157,489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u0026euro;60,203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u0026euro;97,276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Coronary angiography is a procedure performed before admission, so it is not part of reimbursement rate.\u003c/p\u003e \u003cp\u003eThe reduction in hospitalisation after TAVI procedures would free about 112 days of hospitalisation in the ICCU (from an average length of stay of about 7,5 days to 3 days) to be used to increase the number of TAVI procedures (if there is a waiting list) or by other operating units in the hospital. Evaluating potential revenues, if all these days were used to perform TAVI procedures with a reimbursement rate of \u0026euro;28,518, we can assume an average potential revenue of \u0026euro;1,148,000 (about 40 TAVI procedures).\u003c/p\u003e \u003cp\u003eFurthermore, the real economic advantage could be even more significant if a series of costs that are more difficult to evaluate are considered:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eReduction in time spent by physician per patient during the pre-admission phase;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReduction in costs related to pre-procedure examinations that must be repeated due to postponement of the procedure;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReduction of infections and their related costs, etc.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study show how the organisational solutions identified by the University Hospital of Parma can create new conditions for the efficiency and quality of the TAVI pathway. Efficiency is evident not only in the amount of economic savings, but also in the reduction of waiting times for patients, in the optimisation of the use of available resources, and in the increase in productivity for the hospital. A higher quality of service is achieved thanks to a better assessment of the patient's pre- and post-procedure conditions, the reduction of avoidable hospital days, a decrease in infection risks, and improved overall well-being for the patient.\u003c/p\u003e \u003cp\u003eHowever, the change of the pathway described here is characterised by a certain level of organisational complexity. Many actors are involved in the TAVI pathway. A first question concerns patients. TAVI patients are often very elderly, and communication with them is not easy. The active involvement of caregivers therefore becomes important. Furthermore, many healthcare professionals are involved, and they have different skills and act at different moments of the pathway. The University Hospital of Parma is a hub centre for TAVI procedures in the Emilia-Romagna Region, and it is necessary to manage relationships with the spoke centres of the Region. Coordination and good communication among all the actors involved therefore becomes crucial for a new TAVI pathway to work effectively. Given this level of complexity, it is necessary to identify a role that will assume the responsibility of coordinating the pathway. A Clinical Valve Coordinator may help to manage the procedural programme for individual patients while maintaining seamless communication with the Heart Team throughout the patient care journey, making the pathway more streamlined [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. One of the Clinical Valve Coordinator\u0026rsquo;s responsibilities is to ensure that all relevant screening results (e.g., CT scan, coronary angiography, blood tests) are distributed to all members of the Heart Team promptly to inform patient discussion and prevent delays in Heart Team recommendations [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In addition, the Clinical Valve Coordinator is in charge of scheduling the screening tests during the hospitalisation, gathering all the results for the Heart Team, scheduling the TAVI procedures, and preparing the mode of discharge of the patients after the procedure (McCalmont et al., 2021). Further tasks of the Clinical Valve Coordinator are to inform patients and caregivers about the TAVI pathway and manage communications among patients, caregivers, and the Heart Team. Finally, this individual could have a central role in managing relationships among the Hub centre, the spoke centres, and the rehabilitation facilities. In addition to knowing the TAVI pathway well, the Clinical Valve Coordinator should possess the skills of leadership, problem-solving, coordination, communication, and organisational design. A possible job description of the Clinical Valve Coordinator is available in Additional file 4.\u003c/p\u003e \u003cp\u003eHowever, if on the one hand the process of innovation is complex, on the other hand the organisational interventions identified in this study can generate many positive impacts for patients, caregivers, healthcare workers, and the hospital.\u003c/p\u003e \u003cp\u003eFirst of all, there are several advantages of an optimised TAVI pathway for the patients [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. First, the waiting times for the CT scan, and therefore the patient\u0026rsquo;s inclusion in the TAVI pathway, are shorter; hospital admissions are reduced for cases in which coronary angiography is not necessary; the patient is better informed about and more aware of the entire pathway. Furthermore, patients who can follow the fast track could avoid the discomfort of a bladder catheter as well as a reduced risk of urinary infections; they can benefit from early mobilisation and return home sooner, avoiding the risk of delirium/confusion related to long hospitalisations for elderly patients. The caregivers, for their part, can have better knowledge of the pathway their relatives will follow and be more ready to accompany them in the rehabilitation process after discharge.\u003c/p\u003e \u003cp\u003eAs regards healthcare workers, the new pathway guarantees to free up time and resources that could be re-deployed elsewhere. In this sense, the new optimised TAVI pathway is a \u0026ldquo;capacity-enhancing innovation\u0026rdquo; that upon adoption releases capacity in the form of re-deployable resources enabling better care for more patients with existing resources. The Clinical Valve Coordinator may allow physicians to focus on the clinical aspect of the process and dedicate more time to patients. A well-coordinated pathway improves the organisational context and satisfaction of healthcare professionals [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Many studies have, in fact, shown that better coordination of processes, greater collaboration between professionals, a greater focus on clinical rather than bureaucratic activities, and the possibility of having greater resources available are all elements that increase the motivation of healthcare workers [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, there are also many benefits for the hospital of adopting a \u0026ldquo;capacity-enhancing innovation\u0026rdquo;. In addition to having more satisfied patients, caregivers, and professionals, the healthcare organisation improves the overall quality of the service. Making the pathway more efficient not only generates significant cost savings, but also allows to free up resources (e.g., beds, hospital days, physicians\u0026rsquo; time) that can be used to increase the productivity of the cardiology area or invested in other departments of the hospital (see \u003cspan refid=\"Sec4\" class=\"InternalRef\"\u003eresults\u003c/span\u003e section). The advantages for the hospital are then reflected in a benefit at the level of the regional healthcare system, enabling improvements to the organisation of services in the area.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSince the first groundbreaking procedure carried out in 2002, TAVI has revolutionised the management of aortic stenosis, and to date, more than 1.5\u0026nbsp;million procedures have been performed worldwide in more than 70 countries [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. However, if, on the one hand, the TAVI intervention is standardised throughout the world, on the other, the organisational model used by hospitals to manage TAVI patients varies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study showed a process of TAVI pathway optimisation aligned with the BENCHMARK best practices, highlighting both the organisational and economic impacts. The case study analysed can be useful to all hospitals seeking to undertake a process of improving their TAVI pathway. The case study of the University Hospital of Parma represents a successful case of \u0026lsquo;capacity enhancing innovation\u0026rsquo; [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The results of this study demonstrated that rethinking organisational processes can create several advantages for both stakeholders and the hospital. In particular, the possibility of reducing the costs of a clinical path is not a secondary issue, especially in a historical period in which healthcare systems around the world have to face continuous tensions related to financing [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the research is not without limitations. First of all, the organisational solutions identified by the University Hospital of Parma cannot be generalised to all institutions. Although they can serve as inspiration for other hospitals, each individual hospital must define the organisational model that best takes account of its own demographic characteristics, experience, and qualifications. Furthermore, the change process described in this article is still at an early stage, and it will take time for the new process to be consolidated.\u003c/p\u003e \u003cp\u003eFinally, the economic impact was estimated. The real economic savings can only be assessed in the medium term. However, the first data from patients who followed the optimised TAVI pathway (November\u0026ndash;December 2023) show results in line with what was estimated by the prospective analyses carried out as part of our study. In this regard, future research could confirm the actual economic impact on the hospital one year later.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTAVI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTranscatheter Aortic Valve Implantation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT scan\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography Scan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICCU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Coronary Care Unit.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe AVEN Territorial Ethics Committee, with prot. n. 43459 of 10/31/202, approved this study. The General Director of the Parma Hospital, with resolution DELI0000896_2023, authorised this study.\u003c/p\u003e\n\u003cp\u003eAll interviewed gave their consent to participate in the study, after being informed that their participation was voluntary and that they were free to withdraw from the study at any time. The participants were all adults and they were guaranteed confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analysed during the current study are available from the corresponding author on reasonable request.\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was carried out without funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSF designed and conducted the empirical study, wrote and revised the manuscript. LP wrote part of the background and revised the manuscript. GL, GB, LV revised the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the many healthcare professionals from the University Hospital of Parma who have actively participated in the research by responding to interviews.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u0026Oslash;vretveit J. Total quality management in European healthcare. International journal of health care quality assurance. 2000 Apr 1;13(2):74-80.\u003c/li\u003e\n\u003cli\u003eAndersson A, Hallberg N, Timpka T. A model for interpreting work and information management in process-oriented healthcare organisations. International Journal of Medical Informatics. 2003 Dec 1;72(1-3):47-56. \u003c/li\u003e\n\u003cli\u003eFriesl M, Brielmaier C, Dobusch L. Taking individual choices seriously: A process perspective of self-selection in strategy work. Organization Theory. 2023 Jun;4(2):26317877231183986.\u003c/li\u003e\n\u003cli\u003eHarris J. Managing state social work: Front-line management and the labour process perspective. Routledge; 2018 \u003c/li\u003e\n\u003cli\u003eTozzi V. La gestione per processi in sanit\u0026agrave;. CICLI DI VITA DEI FENOMENI, CICLI DI VITA DELLE POLITICHE. 2004:71.\u003c/li\u003e\n\u003cli\u003eDavenport TH. Process innovation: reengineering work through information technology. Harvard business press; 1993. \u003c/li\u003e\n\u003cli\u003ede Waal A, Sivro M. The relation between servant leadership, organizational performance, and the high-performance organization framework. Journal of Leadership \u0026amp; Organizational Studies. 2012 (2):173-90.\u003c/li\u003e\n\u003cli\u003eGeorge B, Walker RM, Monster J. Does strategic planning improve organizational performance? A meta‐analysis. Public administration review. 2019;79(6):810-9.\u003c/li\u003e\n\u003cli\u003eWood DA, Lauck SB, Cairns JA, Humphries KH, Cook R, Welsh R, Leipsic J, Genereux P, Moss R, Jue J, Blanke P. The Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: the 3M TAVR study. Cardiovascular Interventions. 2019 Mar 11;12(5):459-69.\u003c/li\u003e\n\u003cli\u003eButala NM, Wood DA, Li H, Chinnakondepalli K, Lauck SB, Sathananthan J, Cairns JA, Magnuson EA, Barker M, Webb JG, Welsh R. Economics of minimalist transcatheter aortic valve replacement: results from the 3M-TAVR economic study. Circulation: Cardiovascular Interventions. 2022 (10):e012168.\u003c/li\u003e\n\u003cli\u003eKuck KH, Leidl R, Frankenstein L, Wahlers T, Sarmah A, Candolfi P, Shore J, Green M. Cost-effectiveness of SAPIEN 3 transcatheter aortic valve implantation Versus Surgical aortic valve replacement in German severe aortic stenosis patients at Low Surgical Mortality Risk. Advances in Therapy. 2023 (3):1031-46.\u003c/li\u003e\n\u003cli\u003eClayton B, Morgan-Hughes G, Roobottom C. Transcatheter aortic valve insertion (TAVI): a review. The British journal of radiology. 2014;87(1033):20130595.\u003c/li\u003e\n\u003cli\u003eHeathcote L, Srivastava T, Sarmah A, Kearns B, Sutton A, Candolfi P. A systematic review and statistical analysis of factors influencing the cost-effectiveness of transcatheter aortic valve implantation for symptomatic severe aortic stenosis. ClinicoEconomics and Outcomes Research. 2023:459-75.\u003c/li\u003e\n\u003cli\u003eGoodall G, Lamotte M, Ramos M, Maunoury F, Pejchalova B, de Pouvourville G. Cost-effectiveness analysis of the SAPIEN 3 TAVI valve compared with surgery in intermediate-risk patients. Journal of Medical Economics. 2019;22(4):289-96. \u003c/li\u003e\n\u003cli\u003eLorenzoni V, Barbieri G, Saia F, Meucci F, Martinelli GL, Cerillo AG, Berti S, Candolfi P, Turchetti G. The cost-effectiveness of transcatheter aortic valve implantation: exploring the Italian National Health System perspective and different patient risk groups. The European Journal of Health Economics. 2021, 22(9):1349-63. \u003c/li\u003e\n\u003cli\u003eMennini FS, Meucci F, Pesarini G, Vandoni P, Lettino M, Sarmah A, Shore J, Green M, Giardina S. Cost-effectiveness of transcatheter aortic valve implantation versus surgical aortic valve replacement in low surgical risk aortic stenosis patients. International Journal of Cardiology. 2022;357:26-32.\u003c/li\u003e\n\u003cli\u003eReynolds MR, Lei Y, Wang K, Chinnakondepalli K, Vilain KA, Magnuson EA, Galper BZ, Meduri CU, Arnold SV, Baron SJ, Reardon MJ. Cost-effectiveness of transcatheter aortic valve replacement with a self-expanding prosthesis versus surgical aortic valve replacement. Journal of the American College of Cardiology. 2016; 67(1):29-38.\u003c/li\u003e\n\u003cli\u003eFagerlund BC, Stoinska-Schneider A, Lauvrak V, Juvet LK, Robberstad B. Health technology assessment of Transcatether aortic valve implantation (TAVI) as treatment of patients with severe aortic stenosis and intermediate surgical risk\u0026ndash;Part 2. Health economic evaluation.\u003c/li\u003e\n\u003cli\u003eMcCalmont G, Durand E, Lauck S, Muir DF, Spence MS, Vasa‐Nicotera M, Wood D, Saia F, Chatel N, L\u0026uuml;ske CM, Kurucova J. Setting a benchmark for resource utilization and quality of care in patients undergoing transcatheter aortic valve implantation in Europe\u0026mdash;Rationale and design of the international BENCHMARK registry. Clinical Cardiology. 2021 O(10):1344-53.\u003c/li\u003e\n\u003cli\u003eGilard M, Eltchaninoff H, Iung B, Lef\u0026egrave;vre T, Spaulding C, Dumonteil N, Mutuon P, Roussel C, Candolfi P, de Pouvourville G, Green M. Cost-effectiveness analysis of SAPIEN 3 transcatheter aortic valve implantation procedure compared with surgery in patients with severe aortic stenosis at low risk of surgical mortality in France. Value in Health. 2022;25(4):605-13.\u003c/li\u003e\n\u003cli\u003eDubois C, Adriaenssens T, Annemans L, Bosmans J, Callebaut B, Candolfi P, Cornelis K, Delbaere A, Green M, Kefer J, Lancellotti P. Transcatheter aortic valve implantation versus surgical aortic valve replacement in severe aortic stenosis patients at low surgical mortality risk: a cost-effectiveness analysis in Belgium. Acta Cardiologica. 2024;79(1):46-57. \u003c/li\u003e\n\u003cli\u003eEerdekens R, Kats S, Grutters JP, Green M, Shore J, Candolfi P, Oortwijn W, Harst PV, Tonino P. Cost-utility analysis of TAVI compared with surgery in patients with severe aortic stenosis at low risk of surgical mortality in the Netherlands. Cost Effectiveness and Resource Allocation. 2024;22(1):24.\u003c/li\u003e\n\u003cli\u003eEaton J, Mealing S, Thompson J, Moat N, Kappetein P, Piazza N, Busca R, Osnabrugge R. Is transcatheter aortic valve implantation (TAVI) a cost-effective treatment in patients who are ineligible for surgical aortic valve replacement? A systematic review of economic evaluations. Journal of medical economics. 2014;17(5):365-75.\u003c/li\u003e\n\u003cli\u003eRodr\u0026iacute;guez JM, Berm\u0026uacute;dez EP, Zamorano JL, Burgos JM, D\u0026iacute;az-Fern\u0026aacute;ndez JF, del Blanco BG, Sarmah A, Candolfi P, Shore J, Green M. Cost-effectiveness of SAPIEN 3 transcatheter aortic valve implantation in low surgical mortality risk patients in Spain. mortality. 2023;4:5.\u003c/li\u003e\n\u003cli\u003eGhiasvand H, Khaleghparast S, Kachoueian N, Tirgarfakheri K, Mortazian M, Toloueitabar Y, Gorjipour F, Naghdi S. Transcatheter aortic valve implantation against conventional aortic valve replacement surgery in high-risk patients with aortic stenosis; a cost-effectiveness analysis. Health economics review. 2023;13(1):1.\u003c/li\u003e\n\u003cli\u003eBarbanti M, van Mourik MS, Spence MS, Iacovelli F, Martinelli GL, Muir DF, Saia F, Bortone AS, Densem CG, van der Kley F, Bramlage P. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. EuroIntervention. 2019;15(2):147-54.\u003c/li\u003e\n\u003cli\u003eFrank D, Durand E, Lauck S, Muir DF, Spence M, Vasa-Nicotera M, Wood D, Saia F, Urbano-Carrillo CA, Bouchayer D, Iliescu VA. A streamlined pathway for transcatheter aortic valve implantation: the BENCHMARK study. European heart journal. 2024 Jun 1;45(21):1904-16.\u003c/li\u003e\n\u003cli\u003ePibarot P. Transcatheter aortic valve replacement: benchmarking practices to optimize quality and outcomes. European heart journal. 2024:ehae174.\u003c/li\u003e\n\u003cli\u003eTchetche D, de Biase C, Brochado B, Mastrokostopoulos A. How to make the TAVI pathway more efficient. Interventional Cardiology Review. 2019 Feb;14(1):31.\u003c/li\u003e\n\u003cli\u003eEisenhardt KM. Building theories from case study research. Academy of management review. 1989;14(4):532-50.\u003c/li\u003e\n\u003cli\u003eYin RK. Case study research: Design and methods. Sage, London, 2009.\u003c/li\u003e\n\u003cli\u003eYin RK. Discovering the future of the case study. Method in evaluation research. Evaluation practice. 1994; (3):283-90.\u003c/li\u003e\n\u003cli\u003eBowen F, Newenham-Kahindi A, Herremans I. When suits meet roots: The antecedents and consequences of community engagement strategy. Journal of Business Ethics. 2010;95:297-318.\u003c/li\u003e\n\u003cli\u003eForcella F, Arnold RL, Sanchez R, Ghersa CM. Modeling seedling emergence. Field Crops Research. 2000;67(2):123-39.\u003c/li\u003e\n\u003cli\u003eBanks J, Carson JS, Nelson BL, Nicol DM. Verification and validation of simulation models. Discrete-event system simulation, 3rd Edition, Prentice-Hall, Upper Saddle River (NJ). 2001:367-97.\u003c/li\u003e\n\u003cli\u003eDuring SD. Nurse-led post-procedure protocol to facilitate safe next-day discharge home: Findings of the 3M TAVR study. Canadian Journal of Cardiology. 2019;35.\u003c/li\u003e\n\u003cli\u003eVahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European heart journal. 2022;43(7):561-632.\u003c/li\u003e\n\u003cli\u003eBohmann K, Burgdorf C, Zeus T, Joner M, Alvarez H, Berning KL, Schikowski M, Kasel AM, van Mark G, Deutsch C, Kurucova J. The COORDINATE pilot study: impact of a transcatheter aortic valve coordinator program on hospital and patient outcomes. Journal of Clinical Medicine. 2022; 11(5):1205. \u003c/li\u003e\n\u003cli\u003eYeh TM, Pai FY, Huang KI. Effects of clinical pathway implementation on medical quality and patient satisfaction. Total Quality Management \u0026amp; Business Excellence. 2015;26(5-6):583-601.\u003c/li\u003e\n\u003cli\u003eVilma Z, Egle K. Improving motivation among health care workers in private health care organizations: A perspective of nursing personnel. Baltic Journal of Management. 2007; 2(2):213-24.\u003c/li\u003e\n\u003cli\u003eMascia D, Dello Russo S, Morandi F. Exploring professionals\u0026apos; motivation to lead: a cross-level study in the healthcare sector. The International Journal of Human Resource Management. 2015;26(12):1622-44.\u003c/li\u003e\n\u003cli\u003eCribier A. Invention and uptake of TAVI over the first 20 years. Nature Reviews Cardiology. 2022; (7):427-8.\u003c/li\u003e\n\u003cli\u003eVeenstra GL, Dabekaussen KF, Molleman E, Heineman E, Welker GA. Health care professionals\u0026rsquo; motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review. Health care management review. 2022 Apr 1;47(2):155-67.\u003c/li\u003e\n\u003cli\u003ePanayides P. Enhancing innovation capability through relationship management and implications for performance. European Journal of Innovation Management. 2006; 9(4):466-83.\u003c/li\u003e\n\u003cli\u003ePratici L, Fanelli S, Zangrandi A. Not only funding: how healthcare organizations can contribute to National Health Service sustainability. International Journal of Public Administration. 2023; 46(13):971-81.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"economic impact, organisational process, healthcare management, management control, transfemoral TAVI, Clinical Valve Coordinator, capacity enhancing innovation","lastPublishedDoi":"10.21203/rs.3.rs-4741137/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4741137/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTranscatheter Aortic Valve Implantation (TAVI) has emerged as a standard of care for patients suffering from symptomatic severe aortic stenosis. However, organisational analyses and investigations of this intervention’s economic impact are lacking. This study aims to assess the potential impact of implementing a process designed to optimise the TAVI pathway regarding organisational, human, material, and economic resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe research is conducted through a case study. The methodology consisted of three stages: 1. mapping of the current TAVI pathway; 2. identification of the organisational changes necessary to optimise it and implementation of the identified action with a multidisciplinary teamwork; 3. simulations of the organisational and economic impact of the optimisation process. Data related to costs, revenues, and activities were provided by the hospital’s Management Control office. The data analysed refer to a 12-month period. The TAVI pathway optimization presented in this analysis is aligned with the best practices described in the BENCHMARK study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe analysis of the current TAVI pathway in the studied hospital highlighted several critical points during the three phases of the course (pre-procedure, peri-procedure, and post-procedure). The working groups identified five areas for TAVI pathway improvement: patient and family education, coronary risk stratification, conduction disorders management, fast-track discharge eligibility, nurse-led rapid mobilisation and early discharge.\u003c/p\u003e\n\u003cp\u003eThe organisational solutions highlighted by the working groups outline a new TAVI pathway capable of generating a significant impact not only from an organisational point of view, but also from an economic point of view. We estimated that in our cohort TAVI optimisation would have saved approximately 112 ICCU bed-days and have led to an average cost reduction of about €3,900 per patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis study showed a process of optimisation of the TAVI pathway highlighting the positive impacts for patients, caregivers, healthcare workers, and the hospital. A Clinical Valve Coordinator may help to manage the procedural programme for individual patients while maintaining seamless communication with the Heart Team throughout the patient care journey, making the process even more streamlined. The case study analysed can be useful to all hospitals wishing to undertake processes aimed at improving the TAVI pathway.\u003c/p\u003e","manuscriptTitle":"Economic impact of TAVI pathway optimisation: the experience of the University Hospital of Parma.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-13 03:14:52","doi":"10.21203/rs.3.rs-4741137/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-16T12:43:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-16T06:43:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-16T06:42:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-07-15T06:42:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e20d75cd-0509-4b49-acf5-bad125e10076","owner":[],"postedDate":"August 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:07:11+00:00","versionOfRecord":{"articleIdentity":"rs-4741137","link":"https://doi.org/10.1186/s12913-025-13021-z","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-07-01 15:58:26","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2024-08-13 03:14:52","video":"","vorDoi":"10.1186/s12913-025-13021-z","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13021-z","workflowStages":[]},"version":"v1","identity":"rs-4741137","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4741137","identity":"rs-4741137","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}