Same-Day Discharge and Transradial Access: ‘Millions’ of Dollars in Cost Savings on the Table

Among stable patients undergoing elective PCI, a new cost-analysis shows that hospitals around the country could save millions of dollars by discharging at least 30% of people the same day and by using transradial access more often.

Randomized trials have shown that avoiding overnight stays is safe and preferred by patients. Likewise, several studies have demonstrated the benefits of transradial access—fewer complications, lower bleeding risk, and greater patient comfort—for a wide variety of PCI patients.

Yet “even in contemporary practice, there is still a huge gap and a really large deficiency in same-day discharge,” lead study author Amit Amin, MD, MSc (Washington University School of Medicine, St. Louis, MO), told TCTMD. Results from his team’s study, published in the February 27, 2017, issue of JACC: Cardiovascular Interventions, show just 5.3% of almost 280,000 elective PCI patients enrolled in the NCDR CathPCI Registry eligible for same-day discharge between 2009 and 2012 actually did not stay overnight. Of these, 23.1% were treated transradially, with 9% of the overall population treated via this access route.

Using Medicare claims files and propensity adjustment, the researchers found that using radial instead of femoral access saved $916 per patient and that sending patients home the same day as their procedure saved $3,502 compared with keeping them overnight. Also, the total adjusted cost for utilizing transradial access and same-day discharge was significantly lower compared with treating a patient transfemorally and keeping him or her overnight ($13,389 vs $17,076; P < 0.0001).

The study authors estimate that hospitals performing at least 1,000 annual PCIs could save $1 million by treating at least 30% of their patients with both transradial access and same-day discharge. By their calculations, this would also save the country $300 million each year.

Using a comprehensive and structured “patient-centered approach” comprised of education and pre-procedure risk assessment, Amin estimates that, at Barnes Jewish Hospital, St. Louis, where he practices, he personally sends home “over 90%” of his elective PCI patients on the day they are treated. “The patient satisfaction is just tremendous and the cost savings have been substantial with this approach,” he said.

While recognizing that the decision to discharge patients this quickly “is still a very personal one that depends on a lot of factors,” Amin said, he described 5% as “way too low.”

“It’s this ‘value’ concept of care that we strive for, where we have better outcomes, higher patient satisfaction, and then simultaneously as a secondary outcome, lower costs,” Amin commented. “That’s a win-win for all.”

Amin continued: “We have identified a mechanism for hospitals to improve their efficiency, lower costs, and improve PCI outcomes simultaneously. Hospitals that redesign their care pathways to perform more same-day, transradial PCIs can potentially save hundreds of thousands of dollars each year, with no change or even better outcomes. . . . In this day and age of healthcare reform and all the changes occurring, identifying high-value targets where better care can be delivered at lower cost is critically important.”

Not Foolproof

In an accompanying editorial, Joseph Ladapo, MD, PhD (David Geffen School of Medicine at UCLA, Los Angeles, CA), notes that even with adjustment, the issue remains that “patients most likely to undergo a transradial procedure and same-day discharge are the least complicated, lowest risk patients,” and he cautions against selection bias.

Acknowledging that using economic data to inform care decisions might not be foolproof, “studies like Amin et al’s are critical to informing professional society guidelines and helping physician, hospitals, and healthcare systems provide high-quality care while constraining growth in healthcare costs,” Ladapo writes. “And if the results from Amin et al bear out, studies like this will even help us to reduce healthcare costs.”

For his part, Amin said he does not see any issue with basing care decisions on cost data, but added that was not the point of this paper. “When we focus on devices or therapies that improve patient outcomes and reduce resource utilization then there’s always a reduction in cost,” he said. “But recommendations based on cost alone are not appropriate. Better patient care at a lower cost is what we are after and transradial with same-day discharge is one of the ways of doing that.”

‘Exciting’ Timing

Adhir Shroff, MD (University of Illinois at Chicago), who was not involved in the study but authored a literature review of same-day discharge after elective PCI last year, told TCTMD that “the timing of this paper is pretty exciting. As the whole bundled payment model is being instituted across the country, I think hospitals are looking for more and more opportunities to help improve some of the economics at least in the initial PCI procedure because they are aware that they are going to be responsible for any further episodes of care for the next several months.”

He emphasized, however, “that every patient is not going to be suitable to go home the same day,” claiming that this is an argument that “critics” of same-day discharge often turn to. Some veteran operators’ habits might be rooted in tradition, and they tend to keep elective PCI patients overnight because “that’s just the way [they’ve] always done things,” Shroff suggested. Additionally, naysayers might assert that sending a patient home so soon after a critical procedure “might minimize to a patient what they just have had done,” he said, adding that this logic is “a little paternalistic.”

So as long as an institution has a “vigorous education program” in place alongside their same-day discharge protocol, Shroff said he is fully supportive of this practice, admitting he sends 20-25% of his elective PCI patients home without an overnight stay. “The limitation is just an organizational issue, you know making sure those patients who are likely to be PCI are done earlier in the day so that they can recover and go home at a reasonable hour,” he commented.

“This article is adding to the literature that is calling into question the way we are practicing, and [asking if there are] opportunities for certain groups of patients to have a more facilitated early discharge,” Shroff concluded.