Same-day discharge after percutaneous coronary intervention (PCI) generally saves healthcare dollars without hurting patient outcomes, a literature review found.
Arguing against the many exclusions for same-day discharge recommended in the 2009 Society for Cardiovascular Angiography and Interventions (SCAI) consensus statement, the totality of “the available evidence supports the safety of same-day discharge in selected patients after PCI,” Adhir Shroff, MD, MPH, of the University of Illinois at Chicago, and colleagues wrote online in JAMA Cardiology.
“Greater adoption of same-day discharge programs after PCI has the potential to improve patient satisfaction, increase bed availability, and reduce hospital costs without increasing adverse patient outcomes,” they wrote.
And those goals, it seems, may be increasingly within reach for many PCI scenarios.
“Due to advancements in technique, pharmacology, and technology, PCI is much safer and is commonly practiced throughout the world,” they wrote. What’s more, according to Shroff’s group, a prior estimate had predicted that the U.S. health care system would save $200-$500 million per year if half of the patients undergoing PCI were discharged the same day.
Ian C. Gilchrist, MD, of Hershey Medical Center in Hershey, Pa., and a co-author of the review, agreed that “a lot has changed in the way care can be delivered.” Unlike bypass surgery, which used to require weeks or months of recovery, “PCI can be done during the daylight hours,” he told MedPage Today in a phone interview.
“That pretty much can be done on most routine patients across the spectrum. I think that’s something that not all clinicians, especially those outside of the interventional field, understand. They’re still thinking back to last decade’s approach,” Gilchrist said.
One particular barrier to widespread early release is “physician inertia,” according to the authors. Given the hazards of staying in the hospital, however — where infection, accidents, drug errors have been commonly reported — they suggested that clinicians might overcome this by realizing that “the patient may be safer at home than in the hospital.”
Currently, the authors wrote, SCAI’s “conservative recommendations would exclude most patients now undergoing PCI regardless of their procedural outcome from same-day discharge. Indeed, the limitations of these exclusion criteria were illustrated in a case series of 100 consecutive patients discharged safely on the same day as their PCI during a period just predating the publication of the 2009 guidelines. Only 15% of these patients actually fit the definitions for appropriate same-day discharge, with most having features considered higher risk by the consensus document.”
Shroff’s literature review was performed on studies published between 1995 and 2015.
Nowadays, “a priori factors based on age and other preexisting conditions should not necessarily present a barrier to same-day discharge unless those conditions necessitate hospitalization,” the authors wrote.
Gilchrist added that “the paper also highlights that just because you can send a patient home earlier doesn’t mean that the care of the person is done earlier. All the places that send patients home quickly typically have safety nets set up: patient are contacted the following day, and instructions given on what to do.”
Shroff’s group suggested that key to every successful same-day discharge are: the accurate assessment of suitability for early release, excellent procedural outcomes, rapid and reliable stabilization of vascular access, reliable provision of dual antiplatelet therapy, and postprocedural patient education (including routine early follow-up and tracking).
Overnight observation can still be appropriate in a situation where the patient has “no social support at home,” where no one to take care of them or look in on them, Gilchrist said.
The same goes for patients in whom complications arose during PCI and those who may have heart attacks, he noted.
The authors concluded that “promoting early discharge for stable PCI recipients will benefit patients, caregivers, medical centers, and payers. Same-day discharge after low-risk cases is the next step in the evolution of PCI.”
Shroff and Gilchrist cited no relevant relationships with industry.
Shroff A, et al “Same-day discharge after percutaneous coronary intervention: current perspectives and strategies for implementation” JAMA Cardiol 2016; DOI: 10.1001/jamacardio.2016.0148.