LOS ANGELES – Selected patients can safely undergo percutaneous coronary intervention and go home later the same day, according to experience with a series of 13 patients treated at one U.S. center.
The 13 patients had no cardiac or access-site complications during their first day after leaving the hospital, and by sending patients home 4-6 hours after their PCI the hospital where they were treated gained $1,884 of added margin per patient compared with hospitalizing them overnight, Dr. Quinn Capers IV said at the annual scientific sessions of the American Heart Association.
Hospitals run up fewer direct costs and patients prefer it, said Dr. Capers, an interventional cardiologist at Ohio State University in Columbus. Another key feature of his program is limiting same-day discharge to patients who undergo PCI via radial-artery access. Although other U.S. groups have had positive experiences with same-day discharges following PCI by femoral-artery access (JAMA 2011;306:1461-7), "I feel more comfortable sending home patients after radial-artery access than after femoral access," Dr. Capers said.
The 13-patient experience that Dr. Capers reported from Ohio State is dwarfed by some other programs. For example, Dr. Ian C. Gilchrist, who cochaired the session in which Dr. Capers presented his paper, spoke about his program’s experience with 300-400 PCI patients who went home within a few hours after their procedure.
"We do about 85% of our elective PCI patients same-day," said Dr. Gilchrist, an interventional cardiologist and professor of medicine at Pennsylvania State University, Hershey. "We start off assuming that just about every elective PCI patient is a good candidate to go home the same day," he said in an interview. "Early on I was worried [about same-day discharge], but once we started doing it I realized that it really works." Among the 300-plus patients treated this way by Dr. Gilchrist and his associates, there was one patient who developed a complication in the first 24 hours he was home that potentially would have been identified sooner by keeping the patient hospitalized.
"Our main criteria [for same-day discharge] have been good social support for patients and a relatively nontraumatic procedure. Patients love it. The data on safety and other aspects of PCI speak to the ability to send these patients home after just a few hours of observation," he said.
"We have a nurse practitioner talk with each patient before they come to the hospital to learn more about them, let them know there is a possibility that they can go home the same day, and to ask whether they have good social support. Most patients who don’t go home same day are those with more complicated procedures than we expected and those who don’t have someone who can keep an eye on them during their first night home. We do not a priori exclude patients because of their age, renal function, diabetes, or lung disease.
"About 98% of our same-day patients received radial-artery PCI," Dr. Gilchrist added. "I feel more comfortable sending patients home after a radial intervention. The only transfemorals we have done same day were patients who had a repeat PCI and went home same day the first time and who we couldn’t treat transradially for the repeat procedure. They insisted on going home the same day even after their femoral PCI."
Interventional cardiologists at Ohio State began offering same-day discharge post-PCI to selected patients in 2010. They limit the option to elective patients with preserved left ventricular and renal function and no significant left main or triple vessel disease. Patients also have to live within a 30-minute drive from the hospital and must be willing to return the next day for a brief follow-up assessment. The 13 patients ranged in age from 46 to 83 years.
Dr. Capers and his associates analyzed the direct costs and margins from these 13 patients and for 50 similar patients who had overnight stays in the months before same-day discharge became available. The analysis showed that the contribution margin per patient, calculated by subtracting direct costs from net revenue, was $5,667 for each of the 13 same-day discharges and $3,833 for each of the 50 patients who remained overnight at the hospital following their PCI, a difference of $1,834 per patient in favor of same-day discharges.
Dr. Capers said that he had no disclosures. Dr. Gilchrist has received honoraria from Terumo Medical.
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