Among selected low-risk Medicare patients who underwent an elective percutaneous coronary intervention (PCI; procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries), same-day discharge was rarely implemented, but was not associated with an increased risk of being rehospitalized or having a higher risk of death at 2 days or at 30 days, than patients who remained in the hospital overnight, according to a study in the October 5 issue of JAMA.
“Percutaneous coronary intervention is one of the most commonly performed cardiac procedures with more than 1 million episodes of care annually among Medicare recipients. Risks associated with PCI are highest within the first 24 to 48 hours after the procedure and include periprocedural myocardial infarction [MI; heart attack], acute stent thrombosis [blood clot formation within the stent], bleeding, or renal failure,” according to background information in the article. “However, short- and long-term outcomes after PCI have improved because of the evolution in device technology and pharmacotherapy. Despite this improvement, patients are usually observed overnight in the hospital after elective PCI to monitor for PCI-related complications.” The safety of same-day discharge among older individuals undergoing this procedure is not known. Same-day discharge would increase bed availability for the hospital and reduce medical expenses.
Sunil V. Rao, M.D., of the Duke Clinical Research Institute, Durham, N.C., and colleagues conducted a study to examine the prevalence of same-day discharge among older individuals following PCI and the rates of death or rehospitalization. The study included data from 107,018 patients 65 years or older undergoing elective PCI procedures at 903 sites participating in the CathPCI Registry between November 2004 and December 2008 and were linked with Medicare Part A claims. Patients were divided into 2 groups based on their length of stay after PCI: same-day discharge or overnight stay. The primary outcomes measured were rehospitalization or death occurring within 2 days and by 30 days after PCI.
The researchers found that prevalence of same-day discharge was 1.25 percent (n = 1,339 patients), with significant variation across facilities. There was no significant difference in the rates of procedural success between the 2 groups. Patient characteristics were similar between the 2 groups, although same-day discharge patients underwent shorter procedures with less multivessel intervention. Patients who were discharged home the same day were more often categorized in the lowest quintile of predicted risk for death or rehospitalization, while there were approximately equal proportions of lower- and higher-risk patients observed overnight.
“There were no significant differences in the rates of death or rehospitalization at 2 days (same-day discharge, 0.37 percent vs. overnight stay, 0.50 percent or at 30 days (same-day discharge, 9.63 percent vs. overnight stay, 9.70 percent). Among patients with adverse outcomes, the median [midpoint] time to death or rehospitalization did not differ significantly between the groups (same-day discharge, 13 days vs. overnight stay, 14 days). After adjustment for patient and procedure characteristics, same-day discharge was not significantly associated with 30-day death or rehospitalization,” the authors write.
The researchers note that despite the apparent safety of same-day discharge for selected patients, the present analysis demonstrates that this approach is rarely practiced among sites represented in the National Cardiovascular Data Registry. “This may reflect reluctance on the part of clinicians to discharge patients the same day as the PCI procedure because of concerns over early post-PCI complications. Although these concerns are well founded, the rates of vascular or bleeding complications were extremely low (less than 1 percent) among the patients in our analysis, with no clinically significant differences between groups.”
“These data suggest that a proportion of low-risk patients currently observed overnight may be eligible for same-day discharge without an increase in early or intermediate-term adverse events.”
The authors add that according to published guidelines, same-day discharge can be considered for patients undergoing PCI who have low-risk clinical features, successful procedures without prolonged post-procedure use of parenteral (by injection) antithrombotic agents, and adequate social support.