Same-Day Discharge After PCI Just as Safe as Overnight Stay, UK Study Finds
More research is needed to flag patients who should definitely remain overnight, an editorialist says.
Same-day discharge after elective percutaneous coronary intervention has become the dominant model for PCI care in the United Kingdom and a new analysis reassures that this approach is just as safe as spending a night in hospital post-PCI. The numbers, drawn from a large, retrospective analysis of UK data, also point to the increasing complexity of same-day-discharge cases, as well as substantial differences between regions, investigators say.
Comparing same-day discharge versus overnight stays, “you’ll obviously get better outcomes with same-day discharge,” senior author Mamas A. Mamas, BMBCh, DPhil (Royal Stoke Hospital, Stoke-on-Trent, England), noted to TCTMD. “That’s what the vast majority of people have done. . . . What we did was look at whether the outcomes predicted by the national risk model of same-day discharge cases are the same as those we observed.”
Researchers performed the same analysis for uncomplicated overnight stays. While early and 30-day mortality overall crept higher during the study period, reflecting the more complex patients being treated, there were no differences between patients treated and discharged the same day and patients who recovered overnight in-hospital.
“These findings provide reassurance that a change in same-day discharge practice toward higher-risk patients is safe and that changes toward a predominant same-day discharge model of care for elective PCI nationally is feasible, which has important economic implications for healthcare systems worldwide,” lead author Paraskevi Taxiarchi, MSc (University of Manchester, England), and colleagues conclude.
Same-Day Discharge as the ‘Dominant’ Strategy
The new study, published in the August 12, 2019, issue of JACC: Cardiovascular Interventions, involved 169,623 elective PCIs of varying complexity in England and Wales from 2007 to 2014. During that time, 41.6% of patients went home the same day as their procedures and 58.4% remained at the medical facility overnight. Same-day discharge increased noticeably over this period, from 23.5% in 2007 to 57.2% in 2014.
There was a fivefold differential among different regions of England and Wales. North East England experienced dramatic gains in same-day discharge after PCI, from 4% in 2007 to 64% in 2014. In Wales, 87% of elective PCIs resulted in same-day discharge as of 2014. In contrast, South West England experienced no increase in same-day discharge levels.
Mamas hypothesized that there could be various reasons for these variations, which he said came as a surprise. Some centers have established radial lounges to facilitate efficient PCI, and bed-poor National Health Service facilities have an incentive to send patients home sooner rather than later. On the other hand, Mamas noted, “if you join a unit where the practice is not same-day discharge, then it can often be very challenging [to change] that approach.”
If you join a unit where the practice is not same-day discharge, then it can often be very challenging [to change] that approach. Mamas A. Mamas
Future work in his research group will explore the drivers behind regional variations in practice. If same-day discharge after elective PCI becomes the standard of care in the UK and elsewhere, the authors argue, there’s a large potential to save money. A 2017 study showed that only 14% of US interventional cardiologists practice same-day discharge, and the 2019 AHA estimate for mean hospital charges for elective PCIs in the United States is $84,813.
For their analysis, Taxiarchi et al performed multiple logistic regressions to compare 30-day mortality rates between patients sent home on the same day and those who experienced an uncomplicated overnight stay after elective PCI. They also assessed whether mortality fell within ranges prepared by the British Cardiovascular Intervention Society (BCIS).
The strongest predictor of same-day discharge was radial access (OR 1.69; 95% CI 1.65-1.74). Overnight stays, in contrast, were predicted by numerous factors. They were more common for women, older patients, those undergoing more complex interventions, and those with PVD, prior MI or revascularization, renal problems (high creatine or dialysis), or valvular heart disease. Centers with more elective cases were more likely to keep patients overnight.
What we really need to know is which patients you can’t send home. George A. Stouffer
Patients at higher risk of dying after same-day discharge tended to be on a glycoprotein IIb/IIIa inhibitor, have poor left ventricular function, and have undergone multivessel or left main PCI.
One limitation of their data set, the researchers acknowledge, is that it does not include information about cases that were initially slated for same-day discharge but developed into overnight stays due to unanticipated uncomplications.
“The safety of same-day discharge in low-risk patients in now well-established,” George A. Stouffer, MD (University of North Carolina, Chapel Hill), and colleagues write in an accompanying editorial. That said, they note, several challenges remain, among them the need to reduce geographic variability. Commenting to TCTMD, Stouffer said that, in terms of research, “what we really need to know is which patients you can’t send home. . . . If we had more information on how to identify those patients, then I think it would raise the level of comfort that the people you are sending home are the right group.”
Taxiarchi P, Kontopantelis E, Martin GP, et al. Same-day discharge after elective percutaneous coronary intervention: insights from the British Cardiovascular Intervention Society. J Am Coll Cardiol Intv. 2019;12:1479-1494.
Stouffer GA, Means GT, Yeung M. To stay or not to stay: that is the question. J Am Coll Cardiol Intv. 2019;12:1495-1496.
- Mamas and Stouffer report no relevant conflicts of interest.