Same-Day Discharge Does Not Affect Death, Rehospitalization Risk After PCI

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Although patients undergoing elective percutaneous coronary intervention (PCI) typically are kept overnight following the procedure, a new study suggests the precaution may not always be necessary. New data published in the October 5, 2011, issue of the Journal of the American Medical Associationindicate that patients who go home the same day—even older ones—can achieve similar death and rehospitalization rates compared with those who stay for observation.

Researchers led by Sunil V. Rao, MD, of the Duke Clinical Research Institute (Durham, NC), examined data from 107,018 patients age 65 years or older who underwent elective PCI at 903 sites participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between November 2004 and December 2008.

Overall, the prevalence of same-day discharge was 1.25%, with the frequency varying by geographic region Most same-day discharges occurred in the Midwest and South (39% and 38%, respectively) and the fewest occurred in the Northeast (6.5%).

Patients Similar But Outcomes Vary

Procedural success and in-hospital bleeding complications were similar irrespective of whether patients were subsequently discharged the same day or later. Vascular complications were more common for same-day discharge patients than for overnight stay patients, although rates were low in both groups (0.75% vs. 0.25%; P < 0.001).

There were no differences between the groups in terms of death or rehospitalization rates, whether assessed at 2 days or at 30 days (table 1). Moreover, the median time to death or rehospitalization was equivalent between same-day discharge (13.0 days) and overnight stay (14.0 days; P = 0.96).

Table 1. Outcomes by Discharge Status  

After multivariable adjustment, factors associated with a reduced risk of 30-day death or rehospitalization included radial access, use of a vascular closure device, prior PCI, increasing ejection fraction, better renal function, increasing body mass index, and male sex.

Safety of Same-Day Discharge Confirmed

“What we found in this study is that same-day discharge appears to be just as safe with respect to early or late death or readmission compared with overnight observation in select low-risk patients,” Dr. Rao said in a telephone interview with TCTMD. The impetus for the study, he added, was that he and his colleagues discovered in the course of doing clinical research that same-day PCI is commonplace in many countries other than the United States.

Dr. Rao believes the implications of the findings may be far-reaching. “One advantage of sending patients home the same day obviously is that it frees up beds in the hospital,” he said. “This is also an advantage for referral centers that must transfer patients who ordinarily have to wait. By sending low-risk PCI patients home the same day, you make room for [the very] sick patients from a referral hospital who really do need a bed. The other issue is it reduces the overhead costs [related to monitoring and staffing].”

However, Dr. Rao acknowledged that the study raises the issue of whether same-day discharge is really necessary despite its apparent safety.

Patient preference also matters. “Some patients are more comfortable staying in the hospital after a procedure like this, but in our experience, the vast majority want to go home as soon as they can,” he reported. “We need to break our dependence on overnight observation in selected patients, particularly when it isn’t adding much.”

Dr. Rao pointed out, though, that the study was unable to gather “information on what type of support system patients had at home. It’s very important when you are doing same-day discharge that the patient has someone who can help them in case there is a problem, that they have contact information and that they know how to recognize when they do have a problem. This isn’t for every patient, and it isn’t for every center that is doing PCI.”

First Steps Toward Quality Improvement

David Holmes, MD, of the Mayo Clinic (Rochester, MN), and president of the American College of Cardiology, pointed out that the study is strengthened by the use of the NCDR’s CathPCI Registry, which is linked with administrative Centers for Medicare and Medicaid claims data to capture outcomes after discharge.

“Hospitals looking to implement a same-day discharge program for elective PCI patients will find this study to be beneficial, however, as the authors suggest, since this is the first study in the United States, the results from this study should be further explored,” Dr. Holmes noted in a written press release.

“With the current economic state, it is important to look for areas in the healthcare system where major cost-savings can be found and implemented, while also keeping the safety of the individual patient a top priority,” he added.

Study Details

Compared with the overnight group, those who had same-day discharge underwent shorter procedures using lower contrast volume. Most patients underwent procedures via the femoral approach, but transradial PCI use was higher in same-day discharge than in overnight patients at 3.1% vs. 1.6%, respectively (P < 0.001). The use of vascular closure devices also was higher among same-day discharge patients (65.0% vs. 50.1%; P < 0.001). In addition, fewer same-day discharge patients received glycoprotein IIb/IIIa inhibitors or bivalirudin.

Overnight patients were more likely to have undergone PCI for multivessel disease and less likely to have been treated for bifurcation lesions, but the overall risk levels of target lesions were similar between the 2 groups. In terms of hospital characteristics, same-day discharge patients were treated at smaller facilities with slightly lower annual PCI volumes.

Patients who were discharged the same day were similar to those who stayed overnight with respect to median age, sex, and race. There also were few differences in medical comorbidities, with the exceptions of hypertension and dyslipidemia being less common and prior PCI being more common among same-day discharge patients.

 

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Source:
Rao SV, Kaltenbach LA, Weintraub WS, et al. Prevalence and outcomes of same-day discharge after elective percutaneous coronary intervention among older patients. JAMA. 2011;306:1461-1467.

 

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