NEJM: Hospitals may benefit from same-day PCI discharge
Sunil V. Rao, MD, of the Duke Clinical Research Institute in Durham, N.C., and colleagues evaluated the prevalence and outcomes of same-day discharge for older patients by linking data from the multicenter National Cardiovascular Data Registry’s CathPCI Registry to administrative data from the Centers for Medicare & Medicaid Services (CMS).
After applying exclusion criteria, they identified 107,018 patients 65 years old and older who underwent an elective PCI procedure between November of 2004 and December 2008 at one of 903 facilities.
Primary endpoints included death or rehospitalization for any cause within two days and 30 days. To determine predicted risk of death or rehospitalization, they divided patients in each group into quintiles of risk.
Of the total number of patients, 1,339 were discharged within a day of the procedure. Patient characteristics were similar between the two groups, although the researchers noted that same-day discharge patients underwent shorter procedures using less contrast volume, and were less likely to undergo multivessel PCI. Patients in the overnight group were evenly distributed across the risk quintiles while the proportion of patients in the same-day discharge group increased as risk decreased.
The researchers reported no significant difference between the two groups in the incidence of death or rehospitalization at two days and 30 days, a result Rao said was surprising. “Given that a proportion of these patients are doing so well with these procedures that they can go home the same day was a remarkable finding,” he said. “That is a major achievement.”
The small proportion of patients who were discharged within a day was not a surprise, though, he added. In their participation in previous international studies, Rao said that he and colleagues realized that same-day discharge was more common in other countries, where small studies indicated the practice was safe and cost effective.
In their paper, the researchers noted that Medicare reimbursement favors the inpatient model, but Rao emphasized that physician preference may be the driver behind overnight stays. “The reason most of the patients are staying overnight is because physicians are genuinely worried about their patients and want them to do well,” he said. “It is ingrained in us that overnight observation facilitates that. What our study showed is that operators should be reassured. Their outcomes are excellent.”
Medicare’s higher reimbursement for overnight stays reflects the disease burden of the patient group, he added. Patients who qualified for same-day release overall were at low risk for complications and had procedures that went well in the operator’s estimation.
Nonetheless, about 20 percent of overnight patients fell in the low-risk quintile in the risk prediction model, providing an opportunity for hospitals to improve margins through efficient allocation of resources and by freeing up hospital beds.
“It’s a two-fold advantage, potentially,” Rao said. “It may provide lower costs because you are not expending resources on a patient who doesn't need them, and then you can accept the really sick patient. It is an increased-availability and reduced-cost strategy.”
The authors noted several limitations to the study. The data did not capture critical information about same-day discharges such as the patient’s home environment, social support networks and hospital protocols for educating outpatients. The study was observational and subject to selection bias.
Rao added in the interview that use of a registry also may bias results because registry participants already tend be focused on improving patient outcomes.
Rao reiterated that same-day discharge is appropriate only for a select group of PCI patients, and that a randomized trial or demonstration based on prospective data was needed to confirm their results. “We need to make sure that we make policy decisions based on good prospective data,” he said. In the meantime, hospitals may use their findings to support the practice of same-day discharges for low-risk patients.