Center Site, Volume Affect Uptake of Same-Day Discharge for Elective PCI

Hospital location and volume are the two biggest contributors to adoption of same-day discharge for elective PCI patients, a British study suggests.

Speaking with TCTMD, senior study author Mamas A. Mamas, BMBCh, DPhil (Royal Stoke Hospital, Stoke-on-Trent, England), said the findings are somewhat surprising.

“I would have predicted that perhaps it would have been patient characteristics or access-site practice. But actually, this study suggests that those were relatively unimportant,” he said. Instead, multiple center-related factors such as physical infrastructure within hospitals may be playing significant roles in whether they can, or are willing to, accommodate same-day discharge for PCI.

For example, whether the hospital has radial discharge lounges and staffing that can work on that unit, how constrained their bed capacity is, or whether the personnel makeup of the hospital is a particular demographic that is open to changes, all are important pieces of the puzzle. “It may be that hospitals that have older, more-established attendings are less likely to adopt change than newer, more-dynamic attendings,” Mamas observed.

In my view, the standard of care should be same-day discharge. It’s safe, it's cost-effective, it's what the patient wants. Mamas Mamas

As the study shows, the United Kingdom has seen rapid adoption of same-day discharge in elective PCI care, with rates increasing from 23.3% in 2007 to 58.2% in 2014.

Commenting for TCTMD, George A. Stouffer, MD (University of North Carolina at Chapel Hill), said while the United States is making strides in same-day discharge, it’s happening more slowly than in Britain. One of the important takeaways from the study, he added, is that it highlights the impact of multiple factors on sending patients home sooner rather than later, including where physicians work and where they trained.

“If you’re used to sending patients home then you continue to do that,” he noted. “If you're not used to it, you don't send them home no matter how low risk they are. It’s an interesting observation that parallels what we have seen with uptake of transradial access.”

Mamas and colleagues say the findings highlight the need for standardized guidelines and protocols for same-day discharge in uncomplicated cases.

No ‘One Size Fits All’

The study, published online March 10, 2020, in Circulation: Cardiovascular Interventions and led by Paraskevi Taxiarchi, MSc (University of Manchester, England), included data from the British Cardiovascular Intervention Society on all elective PCIs performed in England, Wales, and Scotland from 2007 to 2014. The percentage of patients with previous PCI or hypertension increased regardless of whether patients were discharged the same day or stayed overnight, while the percentage of those given glycoprotein IIb/IIIa inhibitors decreased. Patient characteristics indicative of higher risk, such as poor LVEF, multivessel disease and left main territory attempted, and CTO attempted were more common in the overnight-stay patients.

When clinical, procedural, and institutional characteristics were put into a model, the importance of Strategic Health Authorities—organizations within the National Health Service—eclipsed all other factors. Over the same period, transradial access increased in both the same-day discharge and overnight cohorts (from 26.2% to 71.7% and from 20.4% to 56.8%, respectively). Of note, the researchers found that from 2010 onward, the relative importance of radial access to the adoption of same-day discharge was significantly greater than the relative importance of all other clinical and procedural characteristics. But while access site was the dominant contributor to adoption in some regions of the UK, elsewhere it was center volume or a combination of factors.

The old system has worked really well for years, and it's not that we're fixing something that’s broken, we're just trying to make better something that's already working very well. George A. Stouffer

“What this really tells us, and what it should tell hospitals, is they have to look at what are the barriers in their particular healthcare environment and try to address those,” Mamas said. “It's not a one-size-fits-all situation.”

For Stouffer, the new data are encouraging and add to mounting evidence that most elective PCI patients can go home the same day.

“Thanks to the work of this group and others, we're so much better off than we were 5 or 10 years ago at understanding this whole area,” he noted. “We still need a little bit more understanding of who can't go home and we need motivators in place for docs to understand that in sending them home it’s actually to the patients’ benefit and their benefit. The old system has worked really well for years and it's not that we're fixing something that’s broken, we're just trying to make better something that's already working very well.”

Mamas added that while there is in many respects an “evidence-free zone” with regard to the safety of sending high-risk patients home the same day, data suggest that a significant proportion of them can be discharged safely.

“These patients either are not included in the literature or there are active contraindications from consensus documents that are perhaps not informed by evidence,” he observed. “In my view, the standard of care should be same-day discharge. It’s safe, it's cost-effective, it's what the patient wants.”