Same-Day Discharge Safe After Elective PCI, Canadian Study Affirms

Data on nearly 36,000 PCIs reinforce the safety message, prompting questions about why the practice isn’t more widespread.

Same-Day Discharge Safe After Elective PCI, Canadian Study Affirms

Same-day discharge is just as safe as overnight stays for patients who receive an elective PCI, and is more cost-effective, according to a population-based study from Canada. Despite these robust results, which reinforce similar findings in the United States, overnight stays remain more common than same-day discharges in both nations.

The observational study, published June 24, 2019, in the Journal of the American Heart Association, includes 8 years of data on 35,972 elective PCIs done at 17 centers in the Canadian province of Ontario. Post-PCI, 30% of patients were discharged on the day of their procedure and 70% remained overnight.

“The capacity of our hospital is always at its limits, and there are not enough beds,” explained senior author Dennis T. Ko, MD (ICES, Toronto, Ontario, Canada). “From our standpoint, this is a very important [message] to continue to advocate for patients not to stay an extra day in the hospital,” Ko emphasized to TCTMD.

This is a very important [message] to continue to advocate for patients not to spend an extra day in the hospital. Dennis T. Ko

Prior studies about the safety of same-day discharge after elective PCI focused on patients selected for being at low risk of complications. In contrast, the Ontario study covers an unselected sample of PCIs conducted on nearly all adult patients (18 years or older) from October 1, 2008, to March 31, 2016; patients whose overnight stays exceeded 1 day or who died during hospitalization were excluded, for example.

Ko along with lead author Mina Madan, MD (Sunnybrook Health Sciences Centre, Toronto, Canada), compared various measures of mortality and rehospitalization, as well as revascularization rates, between the two groups at 30 days and 1 year. In every instance same-day discharge patients fared as well as—or even better than—their overnight-stay counterparts.

 

Outcomes Based on Timing of Discharge

 

Same Day

Overnight

HR (95% CI)

Death or ACS Hospitalization

     30 Days

     1 Year

 

1.3%

6.5%

 

1.6%

7.6%

 

NS

0.85 (0.76-0.96)

Death

     30 Days

     1 Year

 

0.1%

1.9%

 

0.2%

1.9%

 

0.40 (0.19-0.84)

NS

Hospitalization for ACS

     30 Days

     1 Year

 

1.3%

4.7%

 

1.4%

5.9%

 

NS

0.79 (0.69-0.91)

All-Cause Hospitalization

     30 Days

     1 Year

 

5.8%

22.8%

 

6.4%

24.8%

 

NS

0.90 (0.85-0.95)

Revascularization

     30 Days

     1 Year

 

3.4%

10.3%

 

3.5%

11%

 

NS

NS

 

In addition to their conclusions about the safety of same-day discharge, the researchers observed widespread variation in practice throughout Ontario. Some PCI centers never discharged a patient on the same day, while the same-day discharge rate reached 87% in other places. Academic medical centers (40.1% vs 10.7%), PCI centers with cardiac surgery units (34.9% vs 9.4%), and centers with > 50% radial-access use (42.8% vs 25.9%) were especially likely to practice same-day discharge. In 2008, the overall rate of same-day discharge in Ontario was 17%. By 2015, it had grown to 45%.

“Some of our cath labs are further away from the city, so there may be some logistics reasons” for less same-day discharge in these centers, Ko hypothesized. “But I think ultimately it’s a culture of the hospital. We’ve gone through this at my hospital the last few years,” he explained. “Initially everybody was resistant, until we started putting some [safety-centered] indications in place.”

Such strategies are essential as healthcare transitions from a volume-based reimbursement paradigm to one focused on value. Amit P. Amin

Last year Amit P. Amin, MD (Washington University School of Medicine, St. Louis), and colleagues published a study in JAMA Cardiology that showed that same-day after elective PCI is also safe in the United States. The new Canadian study essentially mirrors these findings. In conversation with TCTMD, Amin observed: “I think things are changing. If you look at the NCDR CathPCI registry, we began almost at 0% and we’re now up to almost 30%.” Like Ko, Amin hopes to see an accelerated transition to same-day discharge after elective PCI.

Amin’s study showed that hospitals saved more than US $5,000 per PCI whenever they opted to skip an overnight stay. Similarly, the current study shows savings of more than Can $1,200 per same-day discharge. In a follow-up email to TCTMD, Amin observed that his US-based study was “an important opportunity to improve the value of percutaneous coronary intervention for patients undergoing elective percutaneous coronary intervention in the United States. Such strategies are essential as healthcare transitions from a volume-based reimbursement paradigm to one focused on value.”

Sources
Disclosures
  • Ko reports no relevant conflicts of interest

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