A decade-long analysis of more than 800,000 patients undergoing elective procedures in almost 2,000 U.S. hospitals shows that an increase in same-day discharge following elective percutaneous coronary intervention (PCI) did not result in worse 30-day mortality or rehospitalization.
The findings could be an opportunity to cut costs without compromising patient outcomes, authors of the study, led by Steven M. Bradley, MD, MPH, from the Minneapolis Heart Institute, said. It was published online Monday ahead of the Aug 9. issue of JACC: Cardiovascular Interventions.
Despite increasing attention on improving healthcare value by optimizing patient outcomes, there has remained a lack of insights on contemporary use of same-day discharge following elective PCI, the researchers noted.
These cost-cutting measures are “particularly pertinent” for common and high-cost procedures like PCI, they added, noting that almost 500,000 PCI procedures are performed each year in the U.S. at an estimated cost of $5 billion.
The study, therefore, set out to evaluate trends in same-day discharge from hospitals and patient outcomes by running a sequential cross-sectional analysis of 819,091 patients undergoing elective PCI at 1,716 hospitals in the U.S. National Cardiovascular Data Registry CathPCI Registry from July 1, 2009, to December 31, 2017. The study excluded patients who stayed for more than 1 night after PCI, as well as those who did not receive stents.
A total of 114,461 patients (14%) were discharged the same day as the PCI procedure. The rate of same-day discharges grew over time, from 4.5% of the total in the third quarter of 2009 to 28.6% of the total in the fourth quarter of 2017, and was higher for radial-access procedures (growing from 9.9% to 39.7%) than for femoral access (growing from 4.3% to 19.5%).
Patients discharged the same day had a mean age of 65.7 ± 10.4 years, were majority male (75.4%), had mean body mass index of 30.3 ± 6.2 mg/kg, 12.4% were not white, and 72.4% had at least some of the cost covered through private health insurance, 53.4% had at least some cost covered by the federal Medicare plan and 8% had Medicaid-covered costs.
Of the same-day discharged patients, 31.9% had prior myocardial infarction, 12% prior congestive heart failure, 1.7% prior valve surgery, and 85.7% had hypertension, while 25.5% were insulin-dependent diabetics.
Risk-adjusted 30-day mortality did not change over-time, the researchers found, with 36 of those discharged the same day (0.2%) dying within 30 days compared to 463 (0.2%) of those discharged the next day.
Compared with next-day discharge, there was no significant association between same-day discharge and 30-day mortality (adjusted odds ratio [OR]: 1.03; 95% confidence interval [CI]: 0.73-1.46; P = 0.86). There was also no interaction observed between same-day discharge and the calendar year in association with 30-day mortality (P for interaction = 0.88).
Of the total 11,977 patients (5.6%) rehospitalized within 30 days of discharge, 806 (4.9%) came from the same-day discharge group and 11,171 (5.7%) from the group discharged the next day.
Risk-adjusted rehospitalization – which decreased over time – also dropped more quickly for those discharged the same day (P for interaction < 0.001).
Although same-day discharge was associated with a higher rate of 30-day rehospitalization in unadjusted in risk-adjusted analysis (OR: 1.69; 95% CI: 1.40-2.03) from 2009 to 2010, rehospitalization rates overall dropped over time and dropped more quickly for those discharged the same day (P for interaction < 0.001) to a low in 2014 of 3%, compared to 4.2% for next-day discharge.
Nevertheless, despite same-day discharge not resulting in raised risk, there remained wide hospital-level variation in the use of same-day discharge throughout the study period (median odds ratio adjusted for year and radial access: 4.15).
This could represent an opportunity to reduce costs without compromising patient outcomes, the researchers concluded.
In an accompanying editorial, Deepak L. Bhatt, MD, MPH, and Jonathon G. Sung MBChB, from Harvard Medical School, agreed that the adoption of same-day discharge where appropriate could make elective PCI “even more patient friendly and more affordable” as demand for these procedures rises with the aging population and increasing prevalence of coronary artery disease.
They also alluded to widely recorded patient preference for staying out of hospital and remaining at home.
“This important study further establishes the safety of same-day discharge and demonstrates its underuse in many centers across the country, hopefully leading to a change in practice at these centers in the near future,” the editorialists concluded.
Bradley SM, Kaltenbach LA, Xiang K et al. Trends in Use and Outcomes of Same-Day Discharge Following Elective Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2021;14:1655–66.
Bhatt DL, Sung JG. Same-Day Discharge After Elective PCI: Are We in for a Home Run? JACC Cardiovasc Interv 2021;14:1667-9.
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