A study published in the October 5 issue of JAMA shows that selected low-risk Medicare patients who underwent an elective percutaneous coronary intervention (PCI), such as balloon angioplasty or stent placement were rarely discharged the same day even though there is no increased risk of being readmitted to hospital or having a higher risk of death 2 or 30 days after the procedure compared with patients who remain in hospital overnight.
Background information in the articles states:
“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. 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.”
It is unknown whether same-day discharge amongst older people who undergo this type of surgery would be safe. Same-day discharge would mean more available hospitals beds and reduced medical expenses.
Sunil V. Rao, M.D., of the Duke Clinical Research Institute, Durham, N.C., and team researched mortality and rehospitalization rates of individuals aged 65 years or older, who underwent PCI and were discharged from hospital the same day.
They assessed data from 107,018 patients who underwent 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. The researchers categorized patients into 2 groups; those discharged the same day and those who were hospitalized overnight with the primary outcomes being measured in terms of rehospitalization or death occurring within 2 days and by 30 days after PCI.
Findings revealed that 1.25% of patients (n=1,339) were discharged the same day with substantial differences across facilities. The rates of procedural success were comparative between the two groups.
Although both groups included patients with similar characteristics, those discharged the same day underwent shorter procedures with less multi-vessel intervention. Those discharged the same day were more frequently classified into the lowest fifth category of predicted mortality risk or rehospitalization compared with equal numbers of lower and higher risk patients observed overnight.
The authors write:
“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 researchers point out that their analysis shows that sites presented in the National Cardiovascular Data Registry rarely practice same-day discharge in selective patients even though the safety is apparently. They write:
“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.”
In a concluding statement the authors say that in line with published guidelines, same-day discharge can be considered for patients undergoing PCI with low-risk clinical features as well as for those who underwent successful procedures that have no prolonged post-procedure use of injecting antithrombotic agents and have adequate social support.
Written by Petra Rattue