Outpatient Percutaneous Coronary Interventions

Safety, Feasibility and Economic Analysis of Same Day Discharge Following Elective Percutaneous Coronary Intervention

Background

Advances in percutaneous coronary intervention (PCI) has made the possibility of facilitating same day discharge (SDD) of patients undergoing intervention. We sought to investigate the feasibility, safety and economic impact of such a service.

Methods

We retrospectively collected data on all patients undergoing outpatient PCI at our institution over a 12-month period. We included in-hospital and 30-day major adverse cardiac events (MACE), vascular complications, acute kidney injury and any re-hospitalisations. We analysed the cost effectiveness of SDD compared to overnight admission post PCI and staged PCI following diagnostic angiography.

Results

A total of 147 patients undergoing PCI with 129 patients deemed suitable for SDD (88%). Mean age was 65.7 years. Most patients had type C lesions (60.3%); including 4 chronic total occlusions (CTOs). At 30-day follow-up there were no MACE events (0%). There were 10 (7.8%) re-hospitalisations of which majority (70%) were non cardiac presentations. We also included cost analysis for an elective PCI with SDD, which equated to $2090 per patient (total of $269 610 for cohort). Elective PCI with an overnight admission was $4440 per patient (total of $572 760 for cohort), an additional $2350 per patient (total $303 150). Total cost of an angiogram followed by a staged PCI with an overnight stay was $4700 per patient (total $606 300).

Conclusion

SDD is safe and feasible in the majority of patients that have elective coronary angiography that require PCI. SDD leads to a significant reduction in total cost and hospital stay of patients undergoing elective PCI.

Trends in Use and Outcomes of Same-Day Discharge Following Elective Percutaneous Coronary Intervention

OBJECTIVES

The aims of this study were to describe trends and hospital variation in same-day discharge following elective percutaneous coronary intervention (PCI) and to evaluate the association between trends in same-day discharge and patient outcomes.

BACKGROUND

Insights on contemporary use of same-day discharge following elective PCI are limited.

METHODS

In a sequential cross-sectional analysis of 819,091 patients undergoing elective PCI at 1,716 hospitals in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009, to December 31, 2017, overall and hospital-level trends in same-day discharge were assessed. Among the 212,369 patients who linked to Centers for Medicare and Medicaid Services data, the association between same-day discharge and 30-day mortality and rehospitalization was assessed.

RESULTS

A total of 114,461 patients (14.0%) were discharged the same day as PCI. The proportion of patients with same-day discharge increased from 4.5% in the third quarter of 2009 to 28.6% in the fourth quarter of 2017. From 2009 to 2017, the rate of same-day discharge increased from 4.3% to 19.5% for femoral-access PCI and from 9.9% to 39.7% for radial-access PCI. Hospital-level variation in the use of same-day discharge persisted throughout (median odds ratio adjusted for year and radial access: 4.15). Risk-adjusted 30-day mortality did not change over time, while risk-adjusted rehospitalization decreased over time and more quickly for same-day discharge (P for interaction <0.001).

CONCLUSIONS

In the past decade, a large increase in the use of same-day discharge following elective PCI was not associated with worse 30-day mortality or rehospitalization. Hospital-level variation in same-day discharge may represent an opportunity to reduce costs without compromising patient outcomes.

[Safety and clinical-cost effectiveness of percutaneous coronary interventions with overnight hospitalization]

New methods and treatment plans for patients with chronic coronary artery disease after endovascular interventions are currently introduced into clinical practice. It allows reducing hospital stay down to 24 hour, with discharge the next morning. This approach is called overnight stay. Using a similar strategy increases the availability of various types of endovascular interventions, shorter waiting lists, and cut the cost of treatment due to a reduced hospital stay.

Same-Day Discharge After Elective Percutaneous Coronary Interventions in Ontario, Canada

Background

To manage overcrowding and bed shortages in Canadian hospitals, same‐day discharge (SDD) after percutaneous coronary intervention (PCI) has emerged as a solution to improve resource utilization. However, limited information exists regarding current trends, hospital variation, and safety of SDD PCI in Canada.

Methods and Results

We evaluated outpatients undergoing elective PCI in Ontario, Canada, from October 2008 to March 2016. SDD was defined when patients were discharged on the day of PCI, and non‐SDD was defined as those patients who had 1 overnight stay. The primary outcome was 30‐day all‐cause death or hospitalization for acute coronary syndrome. Inverse probability of treatment weighting with propensity score was used to account for differences in baseline and clinical characteristics between SDD and non‐SDD groups. Among 35 972 patients who underwent elective PCI at 17 PCI centers in Ontario, 10 801 patients (30%) had SDD PCI and 25 121 patients (70%) had non‐SDD PCI. Substantial hospital variation for SDD PCI was observed, ranging from 0% to 87% during the study period. In the propensity‐weighted cohort, SDD patients had no significant difference in 30‐day rates of death or hospitalization for acute coronary syndrome (1.3% versus 1.6%; hazard ratio: 0.84 [95% CI, 0.65–1.08]; P=0.17) compared with non‐SDD patients. SDD and non‐SDD patients also had no significant difference in 30‐day rates of mortality or coronary revascularization.

Conclusions

In this large population‐based cohort of elective PCI patients, we demonstrated the safety of SDD PCI. Increased adoption of this strategy could lead to improved bed‐flow efficiency and substantial savings for the Canadian healthcare system without comprising outcomes.

See Editorial Patel and Banerjee

Comparison short time discharge with long time discharge following uncomplicated percutaneous coronary intervention for Non-ST elevation myocardial infarction patients

BACKGROUND

The rational length of stay following non-complicated percutaneous coronary intervention (PCI) for Non-ST elevation myocardial infarction (NSTEMI) patients remains controversial. Few studies have examined the impact of early discharge on short-term outcomes in NSTEMI patients, but short-time discharge is not uncommon in real world practice. This study examined the impact of short time discharge following non-complicated PCI on 30-day net adverse clinical events in NSTEMI patients.

METHODS

This retrospective study enrolled 1424 consecutive patients with NSTEMI diagnoses who underwent non-complicated PCI. Of these patients, 432 were discharged early (< 24 h), whereas the remaining 992 NSTEMI patients underwent routine discharge. The primary end points of the study were the net adverse clinical events including major adverse cardiac or cerebral events or access site vascular/bleeding complications within 30 days. The differences between the two groups were analyzed after propensity score matching to reduce selection bias.

RESULTS

The incidence of crude 30-day net adverse events was numerically higher in the long-time discharge group at 11.6% (115/992) compared with 8.6% (37/432) in the short-time discharge group, although this difference was not significant (P = 0.09). This difference was mainly due to lesser radial access selected in the long-time discharge group (827/932, 83.4% vs. 387/432, 89.5%, P < 0.0005). After PS matching to balance the access difference, there was no significant difference in the incidence of the events mentioned above between two groups.

CONCLUSIONS

If an NSTEMI patient undergoes PCI without any procedural or hospital complications, short-time discharge after successful PCI would be feasible and safe in selected NSTEMI patients.

Implementing Same Day Discharge Following Percutaneous Coronary Intervention: A Process Evaluation

BACKGROUND

The safety and effectiveness of same day discharge (SDD) following percutaneous coronary intervention are well demonstrated; however, the uptake of this model of care is low.

PURPOSE

The aim was to examine the effectiveness of implementing SDD using a process evaluation methodology.

METHODS

This study was undertaken in a cardiac services department of a tertiary teaching hospital in southeast Queensland, Australia. It was anticipated before the implementation that 120 patients could be discharged the same day in a 6 months' time period. Patient selection process and guideline adherence were assessed along with patients' and relatives' satisfaction.

RESULTS

During implementation, 22 patients were discharged home the same day. It was found that staff did not follow the guideline consistently, with an overall adherence of 77.3%.

CONCLUSION

The uptake of SDD was low in this implementation. The study is important as it provides direction for future improvement both in the criteria and the implementation process.

Phenotype of Same-Day-Discharge Patients After Percutaneous Coronary Intervention

BACKGROUND

Overnight observation is the standard of care for uncomplicated elective percutaneous coronary intervention (PCI). However, same-day discharge (SDD) is reportedly safe using predetermined criteria and patient risk categories. Characteristics of patients with SDD have not yet been described.

OBJECTIVE

The purpose of this study was to describe the phenotype of patients appropriate for SDD after PCI without predetermined criteria and patient risk categories.

METHODS

Analysis of PCI registry data was conducted on patients (n = 2174) who underwent elective and nonelective PCI between January 2012 and June 2014. Preliminary analysis included descriptive statistics, t tests, and χ tests. All variables were analyzed using random forest plot to determine importance of predictors of SDD followed by confirmatory logistic regression.

RESULTS

Random forest plot indicated 6 predictors of SDD. Confirmatory logistic regression using a model with all 6 predictors indicated that the model was able to distinguish between patients with SDD and overnight observation after PCI and was statistically significant (χ(7.12, N = 2174) = 511.12, P < .005). Strongest predictors of SDD were stable angina (odds ratio, 5.93 [95% confidence interval, 1.316-26.712]; P = .020) followed by non-ST elevation myocardial infarction/high-risk unstable angina (odds ratio, 1.66 [95% confidence interval, 1.239-2.225]; P = .001). Readmission within 24 hours of SDD after PCI was low at 0.91%.

CONCLUSIONS

Age, access site, complexity, and number of lesions stented did not preclude SDD. A broader range of patients, particularly patients in higher risk categories (non-ST elevation myocardial infarction and unstable angina), are candidates for SDD.

Early discharge compared with ordinary discharge after percutaneous coronary intervention - a systematic review and meta-analysis of safety and cost

Aim

We aimed to summarize the pooled effect of early discharge compared with ordinary discharge after percutaneous coronary intervention (PCI) on the composite endpoint of re-infarction, revascularization, stroke, death, and incidence of rehospitalization. We also aimed to compare costs for the two strategies.

Methods

The study was a systematic review and a meta-analysis of 12 randomized controlled trials including 2962 patients, followed by trial sequential analysis. An estimation of cost was considered. Follow-up time was 30 days.

Results

For early discharge, pooled effect for the composite endpoint was relative risk of efficacy (RRe)=0.65, 95% confidence interval (CI) (0.52–0.81). Rehospitalization had a pooled effect of RRe=1.10, 95% CI (0.88–1.38). Early discharge had an increasing risk of rehospitalization with increasing frequency of hypertension for all populations, except those with stable angina, where a decreasing risk was noted. Advancing age gave increased risk of revascularization. Early discharge had a cost reduction of 655 Euros per patient compared with ordinary discharge.

Conclusion

The pooled effect supports the safe use of early discharge after PCI in the treatment of a heterogeneous population of patients with coronary artery disease. There was an increased risk of rehospitalization for all subpopulations, except patients with stable angina. Clinical trials with homogeneous populations of acute coronary syndrome are needed to be conclusive on this issue.

Systematic oral hydration with water is similar to parenteral hydration for prevention of contrast-induced nephropathy: an updated meta-analysis of randomised clinical data

Background

Contrast-induced nephropathy (CIN) is the third most common cause of hospital-acquired kidney injury and is related to increased long-term morbidity and mortality. Adequate intravenous (IV) hydration has been demonstrated to lessen its occurrence. Oral (PO) hydration with water is inexpensive and readily available but its role for CIN prevention is yet to be determined.

Methods

PubMed, EMBASE and the Cochrane Central register of controlled trials (CENTRAL) databases were searched until April 2015 and studies were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. All randomised clinical trials with head-to-head comparison between PO and IV hydration were included.

Results

A total of 5 studies with 477 patients were included in the analysis, 255 of those receiving PO water. The incidence of CIN was statistically similar in the IV and PO arms (7.7% and 8.2%, respectively; relative risk 0.97; 95% CI 0.36 to 2.94; p=0.95). The incidence of CIN was statistically similar in the IV and PO arms in patients with chronic kidney disease and with normal renal function. Rise in creatinine at 48–72 h was lower in the PO hydration group compared with IV hydration (pooled standard mean difference 0.04; 95% CI 0.03 to 0.06; p<0.001; I²=62%).

Conclusions

Our meta-analysis shows that systematic PO hydration with water is at least as effective as IV hydration with saline to prevent CIN. PO hydration is cheaper and more easily administered than IV hydration, thus making it more attractive and just as effective.

Outcome and safety of same-day-discharge percutaneous coronary interventions with femoral access: a single-center experience

BACKGROUND

Ongoing development in percutaneous coronary intervention (PCI) techniques and closing devices facilitates same-day-discharge in patients undergoing uncomplicated PCI procedures. We examined the safety and outcome in low-risk patients discharged the same day as PCI with femoral access was performed.

METHODS

From January 1, 2010, through December 31, 2010, the outcomes of same-day discharge in 355 (19.6%) of in total 1,809 patients undergoing PCI were analyzed. Composite end point included major adverse cardiac or cerebral events and/or bleeding/vascular complications within 24 hours and 30 days. Major adverse cardiac and cerebral events were defined as cardiac death, myocardial infarction, stroke, coronary artery bypass grafting, or repeat PCI.

RESULTS

The mean age of the study population was 64.5 years (40.0-93.0 years), 17.3% of the patients were ≥75 years old. The indication for PCI was: stable angina pectoris (n = 277, 78.0%) and unstable angina pectoris/non-ST-segment elevation myocardial infarction (n = 78, 22.0%). In all patients femoral access was used, and the puncture site was closed with the closing-device AngioSeal. No major adverse cardiac and cerebral events were seen within 24 hours or 30 days except in 1 patient who had target lesion revascularization done as PCI 4 days post-procedure. Three patients had bleeding/vascular complications; 2 patients were re-admitted within 24 hours due to access-site hematomas, which were treated with manual compression and bed-rest regimes. One patient developed a pseudoaneurysm within 12 hours post-procedure.

CONCLUSIONS

Same-day-discharge after uncomplicated PCI using femoral access is safe when patients are properly selected. The strategy may improve and benefit health costs in the future.