Same-Day Discharge After Elective PCI Safe, Preferred by Most Patients

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Select patients who undergo elective percutaneous coronary intervention (PCI) and are discharged the same day do just as well in terms of safety outcomes and coping ability as their counterparts who spend a night in the hospital, according to study results published in the March 2013 issue of Circulation: Cardiovascular Quality and Outcomes. Moreover, most patients prefer same-day discharge.

Investigators led by Michael E. Farkouh, MD, MSc, of Mount Sinai School of Medicine (New York, NY), randomized 298 patients undergoing elective PCI with femoral access at 2 centers to same-day (n = 150) or next-day (n = 148) discharge. The groups were similar with respect to sociodemographic and baseline clinical characteristics.

Seven days after PCI, same-day discharge proved noninferior compared with next-day discharge in terms of patients’ coping ability scores, the primary endpoint (79% vs. 77%; P for noninferiority < 0.001).

At 30 days, rates of clopidogrel adherence as well as emergency room visits, bleeding, and hospitalization were similar between the 2 groups. Chest pain was more common among next-day discharge patients (table 1).

Table 1. Thirty-Day Follow-up

At 30 days, only 9% of patients discharged the same day reported wishing they had stayed in the hospital longer, while 37% of those discharged the next day said they would have preferred to have been released earlier (P < 0.001). In addition, 80% of the same-day patients and 68% of the next-day patients reported that they would prefer same-day discharge if they ever underwent another PCI procedure.

“Same-day discharge compared with next-day discharge after PCI did not affect patient-centered and clinical outcomes,” the authors conclude. Although same-day discharge patients reported being less ready to go home after PCI, “levels of anxiety before discharge and coping and adherence to clopidogrel after discharge were not different across randomization arms,” they note, adding that neither were adverse outcomes, including rehospitalization, [MI], or death, which occurred only in rare instances.

Safe in Select Patients

In separate telephone interviews with TCTMD, Sorin Brener, MD, of Weill Cornell Medical College (New York, NY), and Carl L. Tomasso, MD, of the NorthShore University Health System (Skokie, IL), agreed that sending select patients home following a simple PCI procedure, even when a femoral approach is used, is safe and likely to become standard practice.

“With an appropriate program and training in place, this is a very doable strategy that appears to be safe, but there are some issues that have to be addressed,” Dr. Brener said. “We are concerned about compliance with antiplatelet therapy, and a night in hospital gives us the opportunity to work out details with the social workers and discharge coordinators and so on. . . . And you need to have a good program for follow-up.”

Careful patient selection based on clinical and psychosocial characteristics is crucial to make same-day discharge safe and reasonable, said Dr. Tommaso. “Certainly, if the patients have complex lesions or if they came to the hospital with ACS, you are not going to send that patient home [the same day],” he said. “If they are 80 years old and live 100 miles away, you’re not going to send them home. . . .  You have to take into account the social and family structure.”

Effect on Cost Disputed

Dr. Brener suggested that the main barrier to implementation of same-day discharge is that hospitals are reimbursed less for outpatient than inpatient procedures.

But Dr. Tommaso disagreed. Many hospitals, he said, put stable patients on 23-hour observation, with reimbursement unaffected by whether they go home the same day or the next day. On the other hand, he commented, the savings to the hospital of sending select PCI patients home the same day may not be significant. The study estimates a per-patient savings of $1,000, but the calculations do not reflect actual hospital billing practices or costs, he noted, adding that furthermore, several patients would need to go home the same day before nursing staff could be cut back, while other costs are minimal.

The real benefit of same-day PCI discharge may boil down to patient comfort, Dr. Tommaso said, adding, “I prefer to sleep in my own bed than a hospital bed.”