Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe and saves costs, but is infrequently and inconsistently used in the United States, results of an observational study suggest.
Greater use of SDD could save more than $550 million annually, say researchers, led by Amit P. Amin, MD, MSc, Washington University School of Medicine, St. Louis. They found that SDD was associated with a savings of $5128 per procedure, compared with non-SDD, after adjustment for interhospital variation in case mix and the propensity score.
Most of the savings with SDD were attributable to lower room and board costs and lower central supply costs.
"Taken together, our findings underscore a potentially large missed opportunity of SDD in the United States," they write.
Their findings were published online September 26 in JAMA Cardiology.
The researchers used the Premier Healthcare Database, an administrative claims database that includes about 20% of all acute care hospitalizations in the United States. They looked at 672,470 elective PCIs performed at 493 hospitals between January 2006 and December 2015.
Substantial hospital variation was noted. The unadjusted overall SDD rate was 9.1% (ranging from 0% to 83%), which corrected to 3.5% after adjustment for interhospital variation. This suggested, the authors say, that a few larger hospitals performing a larger number of SDD procedures skewed the unadjusted result upward.
Indeed, the median rate of SDD at the top decile of hospitals was 44.5%, compared with 2.2% at the non-top-decile SDD hospitals, which was where 88.74% of all elective PCIs were performed.
Applied nationally to the approximately 300,000 elective PCIs performed yearly, the authors suggest that a shift in practice nationwide to an SDD rate of 44.5% would be associated with savings of $577 million annually.
Using a series of mixed effects, hierarchical logistic regression models, they also looked at the safety of SDD, specifically at four outcomes — death, transfusion for bleeding, acute kidney injury (AKI), and acute myocardial infarction (AMI) — at 30 days, 90 days, and 1 year.
"From these results, we observed that SDD was not associated with a higher rate of rehospitalization for bleeding, AKI, AMI, or mortality after discharge," the authors note.
Length of Stay
"The data reinforce what we already suspected was the main contributor to costs in intervention, which is duration of hospital stay," said interventional cardiologist William A. Rollefson, MD, Arkansas Heart Hospital, Little Rock.
Rollefson thinks 44.5% is a conservative estimate of what's possible. He was not involved in this study, but recently published his own data showing SDD, compared with next-day discharge, after elective transradial PCI was safe and saved about $2600 per patient at 30 days.
"At our institution, since the implementation of the two-midnight rule, we are now averaging roughly 70% of our patients going home same day, so I absolutely think it's a very realistic goal to have about 50% of patients going home the same day as a national target."
The Centers for Medicare and Medicaid Services implemented the two-midnight rule in 2013. In brief, it requires practitioners to clearly designate whether a patient is expected to require a hospital stay that crosses two midnights.
"It is what has really ramped up interest in same-day discharge, because there is just absolutely no advantage to staying overnight and a lot of disadvantages to the institution financially. The clinicians get paid the same either way," said Rollefson.
He suggested that the reluctance to shift practice to shorter post-PCI stays was mostly an issue of clinicians and institutions being slow to change practice in the absence of a clear incentive to do so. "The mindset of interventionalists was that people needed to stay overnight because that's the way we've always done it."
The authors found that, overall, the rate of SDD steadily increased over time, from 0.4% in 2006 to 6.3% in 2015. More contemporary data from the National Cardiovascular Data Registry's CathPCI registry indicate that the SDD rate has risen still more, to 22.3% in the fourth quarter of 2017.
Importantly, the rates of adverse outcomes did not differ between patients released the same day and those with a longer hospital stay.
"It seems that acute complications of PCI occur within the first 4 hours and, after that, there's really no benefit in keeping people any longer," said Rollefson.
Transradial access independently increased the odds of SDD by 45% (P < .001), but the authors stress that the shift to transradial only partly explains the rising trend in SDD. In a sensitivity analysis that excluded the transradial cases, SDD among transfemoral elective PCI patients was still associated with a cost savings of $5095 per patient and similar safety.
The transradial approach does "facilitate" a same-day discharge, said Rollefson, but it's not strictly required. SDD is safe and feasible in many patients who have transfemoral access, but usually requires the use of a closure device, he said.
Amin receives grant support from the National Institutes of Health and Volcano corporation and MedAxiom Synergistic Healthcare Solutions, and consulting fees from Terumo and AstraZeneca. Rollefson reported no conflicts of interest related to this study.
JAMA Cardiol. Published online September 26, 2018. Abstract
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