Same-Day Discharge After Peripheral Interventions Gets Mixed Results in Pilot Study

Discharging patients the same day after an endovascular peripheral arterial intervention appears feasible and safe, but, perhaps counterintuitively, results from a small trial suggest that patients may be more comfortable staying the night.

In a randomized study with just 19 total participants, patients discharged the same day of their procedure seemed less satisfied, as indicated by a lower perceived level of safety, a lower likelihood of considering having the procedure again, and a lower likelihood of referring friends and family for such a procedure, according to researchers led by Ashequl Islam, MD (Baystate Medical Center, Springfield, MA).

Those discharged on the day of their procedure also provided lower ratings for pain control, the investigators report in a study published online last week ahead of print in Catheterization and Cardiovascular Interventions.

That’s despite the fact that the vast majority of patients (89%) said before the procedure that they preferred same-day discharge and that only one procedure-related complication occurred (in the overnight group).

Islam et al say that “we believe that [same-day discharge] is a very realistic and attractive option after peripheral arterial interventions,” assuming the safety and cost-effectiveness of the approach are confirmed in other studies.

“Therefore it behooves providers to manage patients’ expectations with respect to pain control, and to reinforce the benefits and safety of [same-day discharge] after peripheral arterial interventions,” they write, adding that a larger RCT evaluating patient satisfaction should be performed before widespread adoption.

From my own experience, I know that most patients want to go home same day and they actually argue with us and get upset if they have to stay overnight. Mehdi Shishehbor

However, patients undergoing endovascular procedures are already commonly discharged on the day of their procedure, according to Mehdi Shishehbor, DO, PhD (University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH), who estimated that about 40% of such cases are done without an overnight stay.

He said he was surprised by the findings of this study because one of the benefits ascribed to same-day discharge—in addition to cost savings for the healthcare system—is improved patient satisfaction and quality of life.

Due to several limitations of the study—including the small sample size, the lack of statistical power, and the relatively uncomplicated patient population—and the discordance of the findings with prior data on same-day discharge following coronary interventions, Shishehbor said that he thought the lower patient satisfaction seen with same-day discharge was “just noise.”

“From my own experience, I know that most patients want to go home same day and they actually argue with us and get upset if they have to stay overnight,” he said.

Islam et al set out to examine the feasibility and safety of and patient satisfaction with same-day discharge, enrolling 19 patients who were undergoing elective, outpatient endovascular interventions at their center between 2011 and 2014. The patients were randomized to an overnight stay or same-day discharge if they were free from complications in the hours after the procedure and were able to ambulate.

All participants had hypertension, nearly all (95%) had CAD, 90% had hyperlipidemia, and 68% had diabetes. All had claudication and were in Rutherford class 1 to 3; most could not walk more than 100 feet. More than 80% of the procedures were performed in the superficial femoral or iliac artery and most (60%) involved vascular closure devices.

There was only one complication within the first 24 hours: an access-site hematoma in a patient randomized to stay overnight.

Based on blinded telephone interviews conducted at 48 to 72 hours and at 10 days, patients in both groups provided high ratings regarding various aspects of their experience. Lower ratings on some of the measures among those discharged on the day of their procedure were unchanged after adjustment for marital status and education.

“It is possible that better pain control and setting up more realistic expectations postprocedure could improve overall patient satisfaction, confidence, and willingness to undergo [same-day discharge] following peripheral arterial interventions,” the investigators say.

The Main Obstacle: Bleeding

Shishehbor said that the primary hindrance to greater use of same-day discharge in patients undergoing lower-extremity interventions are groin complications, mainly bleeding. That differs from the coronary space, where more serious complications may be seen in the first 24 hours, he said.

In response to concerns about groin complications, companies have introduced new devices that allow for radial access for a wider range of lower-extremity interventions. In the past, radial procedures in the lower-extremities were limited to iliac interventions, Shishehbor said.

“I think that these new devices and technologies will allow us to be able to be more aggressive in discharging these patients home same-day because the risk of sending them home is mainly related to groin complications, not so much the concern about having arrhythmias or having a stent thrombosis like we do in the heart,” he said, noting that he is involved in planning a national study to evaluate the safety of the radial approach for peripheral interventions.

As for same-day discharge, Shishehbor said, “I think the majority of [patients] would enjoy that, and it will improve their quality of life and their satisfaction, it will make it a more cost-effective system, and it will make it more efficient for the hospitals.”