Meta-Analysis Finds No Clear Answer for Same-Day Discharge After PCI

Same-day discharge after uncomplicated percutaneous coronary intervention (PCI) appears to produce the same outcomes as overnight hospitalization, according to a meta-analysis published online January 23, 2013, ahead of print in JACC: Cardiovascular Interventions. But evidence for the approach, derived from a slate of randomized and observational studies, is extremely mixed and therefore inconclusive.

Researchers led by Olivier F. Bertrand, MD, PhD, of Laval University (Quebec, Canada), identified 13 studies (5 randomized and 8 observational) published between 1999 and 2011 that examined outcomes in 111,830 patients according to discharge timing after uncomplicated PCI.

Reported lengths of stay for same-day discharge ranged between 4 and 11 hours, and the average stay for overnight hospitalization was 1 day. Yet patients experienced similar levels of total complications, MACE, and rehospitalization in both randomized and observational studies irrespective of when they were discharged (table 1).

Table 1. Outcomes at 30 Days After PCI

Results remained consistent when the researchers excluded an observational study with a sample size of 107,018 patients, the largest in the meta-analysis.

Study populations, endpoint definitions, and treatment protocols varied. For example, 1 study included a proportion of patients treated for unstable angina. Eleven studies specified unfractionated heparin as the anticoagulant of choice. Both radial and femoral access routes were used, though the latter was far more common. Multivessel PCI was performed in 16% of cases and 37% of patients had type B or C lesions.

Current Evidence Insufficient

“In this systematic review and comprehensive meta-analysis, we show that many carefully selected and risk-stratified groups of patients undergoing elective or ad hoc PCI for low-intermediate risk ACS have been managed successfully with a [same-day discharge] strategy,” the researchers conclude. “Still, due to the low event rate, the significant variation in the definition of outcomes across studies, and wide confidence intervals around the pooled point estimates, a definitive resolution of a statistically significant hazard or benefit to the [same-day discharge] approach cannot be determined based on the totality of presently available data.”

To be adequately powered, a randomized controlled trial would require a “very large” sample size of more than 17,000 patients, they say, adding, “Until such a trial is completed, [same-day discharge] after uncomplicated PCI seems a reasonable approach in selected patients.”

In a telephone interview, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), cautioned, “You could take the opposite view and say, ‘If the event rates are low, how do you know it’s safe?’” Earlier discharge, for example, could result in underdetection of events, he noted.

Dr. Bertrand acknowledged that a sufficiently large trial is unlikely to happen. He told TCTMD in a telephone interview, “I assume it will never be done. We have to live with what we have.”

Kreton Mavromatis, MD, of the Emory University School of Medicine (Atlanta, GA), however, suggests in an accompanying editorial that it might be feasible.

“Such a study could be funded with the cost-saving associated with same-day discharge, and data collection could be facilitated by catheterization laboratory registries. . . . Meanwhile, on the basis of the currently available data, high-volume PCI centers with critical needs could reasonably develop same-day discharge programs, with the careful monitoring and publication of their outcomes,” he writes. “These types of efforts would facilitate the controlled dissemination of same-day discharge after PCI while simultaneously promoting the refinement of its implementation.”

Importantly, earlier discharge requires adequate triage, emergency contingency planning, and follow-up planning on the part of clinicians, Dr. Mavromatis advises.

Dr. Bertrand agreed that a “safety net” is crucial. “Usually we have a nurse calling the patient the next day to insure that there is no delayed bleeding [or other problem]. You have to reassure the patient [and] provide counseling about medications [as well as cardiac rehabilitation and risk modification],” he advised, noting that patients do not have to physically be in a hospital to benefit from this counseling.

Why the Reluctance?

Only 1.25% of patients undergoing elective PCI are discharged the same day as their procedure in the United States, Dr. Mavromatis notes, explaining that the resistance toward shorter stays “might relate to residual concerns over safety and medico-legal risk, the unrecognized cost benefit of same-day discharge, and an under-appreciation of the potential for increased patient satisfaction related to avoiding an overnight stay in the hospital.”

Beyond those factors, Dr. Bertrand and colleagues mention that health care providers may worry that same-day discharge “may not provide enough time to educate patients about their underlying disease and/or their PCI procedure.”

In a telephone interview, Carl L. Tommaso, MD, of Skokie Hospital (Skokie, IL), suggested that the rarity of radial access in the United States may partially explain the low rates of same-day discharge there, while more frequent radial PCI has translated to same-day discharge becoming “near routine in some parts of Europe, Asia, and Canada,” according to the paper.

Transradial PCI can help facilitate same-day discharge “because of less potential for bleeding,” Dr. Tommaso said, though ischemic complications are also a concern. “What happens if someone has chest pain? What happens if they have a stent thrombosis? Those sorts of things, which are very rare, decrease considerably after 24 hours,” he added. “But every now and then you have a patient who you felt could have gone home, who [in fact] bleeds or has chest pain during the night, and you’d like to have that patient there.”

Interventional cardiologists are also creatures of habit, Dr. Tomasso added. “Don’t forget that when we first started putting stents in and had [to give patients warfarin], they were in the hospital 3, 4, 5 days [and] we would bring all our diagnostic patients in the night before,” he said.  Change, Dr. Tomasso noted, will require ensuring that clinicians are “comfortable with what they’re doing.”

Furthermore, the savings of $1,000 per patient cited by the editorial is “a relatively small proportion” of the overall costs, he concluded. “We all have to be stewards of health care [costs,] but as physicians, we have to take optimal care of our patients. Some patients can go home the same day, and others shouldn’t.”

Change Is Afoot

Dr. Kirtane, however, pointed out that practice patterns are already changing.

The Centers for Medicare and Medicaid Services (CMS) “has pretty much issued the dictum that for the majority of uncomplicated PCI procedures, they are only going to pay for outpatient stays,” he said. This shift has “absolutely” begun to affect patients, he reported, as CMS has begun to review—and deny payment for—hospital stays that have already taken place. Patients on private insurance, meanwhile, may pay more in the form of copays associated with outpatient care, since inpatient hospital admissions are often fully covered.

Historically, Dr. Bertrand explained, “there was clearly a disincentive from the US perspective [due to the country’s reimbursement system based on diagnosis-related groups.] If [patients got] out of the hospital on the day of the procedure, the hospital [was not] reimbursed the same way. We are witnessing now a complete change in the way US hospitals will be managed.”

 

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Sources:
1. Abdelaal E, Rao SV, Gilchrist IC, et al. Same-day discharge compared with overnight hospitalization after uncomplicated percutaneous coronary intervention. J Am Coll Cardiol Intv. 2013;Epub ahead of print.

2. Mavromatis K. Same-day discharge after percutaneous coronary intervention: Are we ready? J Am Coll Cardiol Intv. 2013;Epub ahead of print.

 

 

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