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

Same-Day Discharge After Catheter Ablation of Atrial Fibrillation in the United States

BACKGROUND

Patients undergoing atrial fibrillation (AF) ablation have historically been hospitalized overnight or longer postprocedure. National rates of same-day discharge (SDD) following AF ablation remain unknown.

METHODS AND RESULTS

The NCDR (National Cardiovascular Data Registry) AF Ablation Registry was used to identify index procedures from January 1, 2016 to June 30, 2023. Patients were stratified by postprocedure disposition: (1) SDD, (2) overnight hospitalization (<1 day), or (3) >1 day hospitalization. Rates, clinical factors, and hospital-level variation associated with SDD were analyzed. Among 139 391 patients who underwent AF ablation across 197 hospitals, 51 622 (37.0%) underwent SDD, 78 220 (56.1%) were hospitalized overnight, and 9549 (6.9%) for >1 day postprocedure. SDD rates increased from 0.99% in Q1 2016 to 62.3% in Q2 2023 (P<0.0001), surpassing overnight hospitalization in Q1 of 2021. The likelihood of SDD increased significantly over time (odds ratio [OR], 1.26 per quarter-year [95% CI, 1.26-1.26]) with substantial variation across hospitals (median OR, 4.12 [95% CI, 3.48-4.79]). Those discharged the same day were less likely of Black race (OR, 0.71 [95% CI, 0.65-0.78]) and to have persistent AF (OR, 0.85 [95% CI, 0.82-0.88]) and cardiomyopathy (OR, 0.87 [95% CI, 0.84-0.91]). In total, major and overall complication rates were 0.70% and 2.13%, respectively. Major and overall complication rates were 0.03% and 0.19% for SDD and 0.24% and 0.98%, respectively, for overnight hospitalization.

CONCLUSIONS

Rates of SDD following AF ablation markedly increased over time, corresponding with onset of the COVID-19 pandemic, with substantial hospital variation. SDD patients had fewer comorbid conditions and were less likely to have persistent AF. Postprocedural complication rates with SDD were low and comparable with patients hospitalized overnight.

The Quality of Veterans Healthcare Administration Cardiovascular Care

A total of 9 million veterans receive care in a unique healthcare system, the Veterans Healthcare Administration (VHA), with nearly 50% reporting at least one cardiovascular disease. Despite evidence for high quality of health care in the VHA, more veteran care is being moved to the non-VHA community. An assumption of this shift in care is that the quality of non-VHA care is at least comparable to VHA care. This paper reviews the quality of cardiovascular care delivered by the VHA in comparison to community care, which is care delivered in non-VHA facilities by non-VHA providers and is authorized and paid for by VHA, examining quality metrics and highlighting novel national care programs. The critical examination of this data is valuable for deriving health care policy, sharing novel and effective quality initiatives throughout the healthcare sector, and will help veterans and their providers make important healthcare decisions.

Prevalence, trends, and outcomes of same-day discharge following elective percutaneous coronary intervention: a retrospective observational cohort study using routinely collected health data

AIMS

To identify the prevalence, trends, and outcomes of same-day discharge (SDD) following elective percutaneous coronary intervention (PCI) among six public hospitals in Queensland, Australia.

METHODS AND RESULTS

A retrospective observational research design was used. A total of 4387 cases were obtained from the Queensland Cardiac Outcomes Registry and National Hospital Cost Data Collection. The two data sets were linked using identifiable data items. Patients were those who had elective PCI between December 2012 and December 2019 either discharged the same day of the procedure or the next day. Data were analysed using descriptive and inferential statistics. The overall SDD prevalence was 6.5%, with a trend increasing from 0.2% in 2013 to 9.0% in 2019. The prevalence varied at the individual hospital level. Two hospitals did not perform SDD during the study period. The remaining hospitals demonstrated variability in SDD prevalence, with the highest from one hospital being 28.2% in 2019. Almost all SDD patients experienced no complications during or following PCI within 24 h. Compared with next-day discharge, SDD reduced the length of stay by 18 h and conferred an average of $3695 cost-savings per patient.

CONCLUSION

There was limited implementation of SDD in the six public hospitals contributing data to this study. Improvement in the SDD rate could result in better hospital resource utilization and reduce low-value care. Hence, strategies to implement and promote SDD are warranted.

Impact of a dedicated radial lounge on same-day discharge percutaneous coronary intervention

BACKGROUND

The same-day discharge (SDD) program after elective percutaneous coronary intervention (PCI) is a safe strategy that allows for the optimization of hospital resources. However, the lack of adequate infrastructure and a specially targeted care model may limit its implementation. Our center developed an outpatient care model based on an area designed for percutaneous procedures called radial lounge (RL).

AIMS

Evaluate the efficacy and safety of the RL care model: (1) SDD rate, (2) patient experience, (3) major adverse cardiac events (MACEs) (in-hospital, 30-day, and 1-year mortality and intervention), and (4) vascular access complication.

SECONDARY OBJECTIVE

Impact of RL SDD rate on total elective SDD-PCI volume.

METHODS

We conducted a retrospective observational cohort study at a cardiovascular hospital, including consecutive patients undergoing elective PCI between 2015 and 2022 who were admitted to the conventional hospitalization area (CHA) or the RL about the stated objectives. Patient experience was assessed using the Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

RESULTS

A total of 5466 elective PCI procedures were included: 2102 in the RL and 3364 in the CHA. The SDD rate was 85.2% in the RL group and 54% in the CHA. After the implementation of RL, a significant increase in the volume of elective SDD-PCI was observed and patient satisfaction improved significantly (p < 0.005) with CHA. Finally, a greater amount of MACEs were not observed in the RL.

CONCLUSIONS

The PCI program in RL proved to be safe and effective. It showed a higher rate of SDD and a significant improvement in patient experience was observed without affecting safety.

The safety of same-day discharge following percutaneous coronary intervention in regional Australia

BACKGROUND

Same-day discharge (SDD) following percutaneous coronary intervention (PCI) has proven safe, and global adoption of this strategy has been increasing rapidly. These data are predominantly derived from high-volume, metropolitan centres with a relative paucity of data from regional and remote settings.

AIMS

The primary objective of this study was to evaluate the outcomes of a same-day, criteria-led discharge strategy following elective transradial PCI in a regional setting.

METHODS

This is a retrospective, single-centre cohort study. Consecutive outpatients aged ≥18 years presenting for elective transradial invasive coronary angiography between March 2019 and February 2024 were included in the analysis. We report the primary composite outcome of 30-day all-cause mortality and unplanned hospital readmission and compare proportions between those who were discharged on the day of their procedure with those admitted overnight in hospital and discharged the next day.

RESULTS

A total of 555 eligible patients were identified, of which 330 (60%) were discharged on the day of their procedure. The composite primary end-point occurred in seven (2%) of the SDD patients and in six (3%) of the overnight admission patients (relative risk = 0.80; 95% confidence interval = 0.27-2.34; P = 0.68). No significant differences were seen in rates of readmission, or in other clinical outcomes assessed, including death, myocardial infarction, stroke and vascular complications or bleeding.

CONCLUSION

In a regional setting, SDD following elective transradial PCI, in select patients, is a safe approach which was not associated with higher rates of unplanned readmission or adverse clinical outcomes.

[Outpatient PCI in France: data from the France PCI registry]

Percutaneous coronary intervention (PCI) is the preferred method of revascularization for chronic coronary syndromes. Outpatient PCI has demonstrated, in addition to its reliability and safety, the comfort of patients and the reduction of costs that weigh on our healthcare systems. Nevertheless, it remains largely underutilized in France, with significant disparities between centers, particularly between private and public ones. This article provides an overview of outpatient PCI in France based on the France PCI registry and allows us to position ourselves in relation to our European neighbors.

[Outpatient coronary angiography and percutaneous coronary interventions before and after the COVID-19 pandemic: experience of the Versailles hospital centre]

BACKGROUND

Same day discharge (SDD) diagnostic coronary angiography and percutaneous coronary interventions (PCIs) are increasingly performed, and indications extend to more complex procedures and more fragile patients. We report the evolution of SDD interventional cardiology activity in our centre since 2016, particularly before and after the COVID-19 pandemic. Secondarily, we analysed the feasibility and safety of SDD PCI.

MATERIALS AND METHODS

We analysed the number and percentage of SDD coronary angiograms and PCIs (elective or ad hoc), during 4 periods of 11 months each, from September 2016 to July 2024. Periods 1 and 2 took place before COVID-19, periods 3 and 4 after. We also compared the rate of complications and conversion to hospitalisation between periods 1-2 and 4.

RESULTS

A total of 9587 procedures were analysed, including 1558 SDD procedures. The total number of SDD interventional cardiology procedures increased progressively over the 4 periods, from 146 SDD procedures (7.5%) in 2016-2017 to 620 (27.2%) in 2023-2024. This increase included both diagnostic coronary angiograms (respectively: 10.9%; 12.2%; 33.6% then 28.9%) and PCIs (respectively: 0.9%; 5.6%; 16.1% then 24.4%). In the immediate post-COVID-19 period, a significant increase, uncorrelated with the natural progression, was observed for SDD diagnostic coronary angiography and ad-hoc PCI. There were no deaths or serious complications, the rate of minor complications (1.1%) and conversion to conventional hospitalisation (4.5%) were low.

CONCLUSION

Provided a careful patient selection and rigorous organisation, SDD coronary angiography and PCI can safely be performed. The increase in the SDD interventional procedures, favoured by organisational (COVID-19) or economic constraints, need to be amplified.

[Same-day discharge for left main artery PCI: how to process?]

The steady development of same-day discharge (SDD) PCIs in recent years means that, by 2024, we will be able to tackle increasingly complex lesions, including those of the left main artery. This strategy is supported by the literature, but requires an appropriate patient selection (based on medical and social criteria) and precise assessment of the anatomical complexity of the lesion and the foreseeable risks of the PCI. Strict adherence to pre-established service protocols for patient preparation and follow-up, as well as the establishment of clinical and paraclinical criteria for discharge to a conventional hospital unit, are essential to the success of an SDD PCI program.

Physician Transfer Versus Patient Transfer for Mechanical Thrombectomy in Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Physician transfer is an alternate option to patient transfer for expedient performance of mechanical thrombectomy in patients with acute ischemic stroke.

METHODS AND RESULTS

We conducted a systematic review to identify studies that evaluate the effect of physician transfer in patients with acute ischemic stroke who undergo mechanical thrombectomy. A search of PubMed, Scopus, and Web of Science was undertaken, and data were extracted. A statistical pooling with random-effects meta-analysis was performed to examine the odds of reduced time interval between stroke onset and recanalization, functional independence, death, and angiographic recanalization. A total of 12 studies (11 nonrandomized observational studies and 1 nonrandomized controlled trial) were included, with a total of 1894 patients. Physician transfer was associated with a significantly shorter time interval between stroke onset and recanalization with a pooled mean difference estimate of -62.08 (95% CI, -112.56 to -11.61]; P=0.016; 8 studies involving 1419 patients) with high between-study heterogeneity in the estimates (I2=90.6%). The odds for functional independence at 90 days were significantly higher (odds ratio, 1.29 [95% CI, 1.00-1.66]; P=0.046; 7 studies with 1222 patients) with physician transfer with low between-study heterogeneity (I2=0%). Physician transfer was not associated with higher odds of near-complete or complete angiographic recanalization (odds ratio, 1.18 [95% CI, 0.89-1.57; P=0.25; I2=2.8%; 11 studies with 1856 subjects).

CONCLUSIONS

Physician transfer was associated with a significant reduction in the mean of time interval between symptom onset and recanalization and increased odds for functional independence at 90 days with physician transfer compared with patient transfer among patients who undergo mechanical thrombectomy.

Same-day discharge after percutaneous coronary procedures-Structured review and comprehensive meta-analysis

INTRODUCTION

Percutaneous coronary intervention is a well-established revascularization strategy for patients with coronary artery disease. The safety and feasibility of performing these procedures on a same-day discharge basis for selected patients has been studied in a large number of mostly nonrandomized trials. An up to date literature review should focus on trials with radial access, representing the current standard for coronary procedures in Austria and other European countries.

METHODS

The aim of this consensus statement is to review the most recent evidence for the safety and feasibility of performing same-day discharge procedures in selected patients. A structured literature search was performed using prespecified search criteria, focusing on trials with radial access procedures.

RESULTS

A total of 44 clinical trials and 4 large meta-analyses were retrieved, spanning 21 years of clinical evidence from 2001 to 2022. The outcome data from a wide range of clinical settings were unanimous in showing no negative effect on early (24 h) or late (30 day) major adverse events after same-day discharge coronary procedures. Based on nine prospective trials a comprehensive meta-analysis was compiled. Using 1‑month major adverse events data the pooled odds ratio of same-day discharge versus overnight stay procedures was 0.66 (95% confidence interval, CI 0.35-01.24; p = 0.19; I2 0%), indicating a noninferiority in carefully selected patients.

CONCLUSION

Outcome data from same-day discharge coronary intervention trials with radial access confirm the robust safety profile showing no increase in the risk of major adverse events compared to overnight stay.

Same-day discharge after percutaneous coronary procedures-Consensus statement of the working group of interventional cardiology (AGIK) of the Austrian Society of Cardiology

INTRODUCTION

Percutaneous coronary intervention is a well-established revascularization strategy for patients with coronary artery disease. Recent technical advances such as radial access, third generation drug-eluting stents and highly effective antiplatelet therapy have substantially improved the safety profile of coronary procedures. Despite several practice guidelines and a clear patient preference of early hospital discharge, the percentage of coronary procedures performed in an outpatient setting in Austria remains low, mostly due to safety concerns.

METHODS

The aim of this consensus statement is to provide a practical framework for the safe and effective implementation of coronary outpatient clinics in Austria. Based on a structured literature review and an in-depth analysis of available practice guidelines a consensus statement was developed and peer-reviewed within the working group of interventional cardiology (AGIK) of the Austrian Society of Cardiology.

RESULTS

Based on the available literature same-day discharge coronary procedures show a favorable safety profile with no increase in the risk of major adverse events compared to an overnight stay. This document provides a detailed consensus in various clinical settings. The most important prerequisite for same-day discharge is, however, adequate selection of suitable patients and a structured peri-interventional and postinterventional management plan.

CONCLUSION

Based on the data analysis this consensus document provides detailed practice guidelines for the safe operation of daycare cathlab programs in Austria.

Outcomes of same-day discharge following percutaneous coronary intervention in a rural population

BACKGROUND

Same-day discharge (SDD) following percutaneous coronary intervention (PCI) is safe, yet the nationwide rate of SDD remains low. The impact that residing in a rural area has on the safety of SDD is unknown.

OBJECTIVE

To investigate the safety of SDD compared to next-day discharge (NDD) among PCI patients living in a largely rural area.

METHODS

There were 3502 outpatient elective PCIs at a tertiary care center between January 1, 2011 and December 31, 2017. Data from the National Cardiovascular Data Registry CathPCI Registry® and the electronic medical records were obtained for patient demographics, procedural characteristics, and procedural outcomes. Data from the initial PCI in each 365-day period were included in the analysis for each patient. Rural-Urban Commuting Area codes 4-10 were used to define rural status.

RESULTS

A total of 2099 (59.9%) PCIs met the inclusion criteria (63% rural). The overall rate of SDD increased over time (4.7% in 2011 to 39.6% in 2017) as radial access increased (14.2% in 2011 to 59.9% in 2017). In this population, a total of 329 PCIs had SDD (15.7%; median (interquartile range) age 66.0 (14.0) years, 20.1% female, 52.3% rural status). Compared to NDD, SDD patients had less hyperlipidemia, atrial fibrillation, congestive heart failure, history of coronary artery bypass graft, and more radial access. SDD was noninferior to NDD for 30-day readmission but had a decreased 1-year (adjusted odds ratio [aOR]: 0.20, 95% confidence interval [CI]: 0.05-0.81, p = 0.024) and 5-year (aOR: 0.43, 95% CI: 0.28-0.66, p < 0.001) all-cause mortality compared to NDD. Rural status did not predict outcomes.

CONCLUSIONS

SDD in patients in rural areas does not have a significantly higher rate of 30-day readmission. SDD patients had lower odds of 1- and 5-year mortality when compared to NDD. Future studies prospectively evaluating the safety of SDD in this population are warranted.

Same-Day Discharge After Elective Percutaneous Transcatheter Cardiovascular Interventions

Percutaneous transcatheter interventions have evolved as standard therapies for a variety of cardiovascular diseases, from revascularization for atherosclerotic vascular lesions to the treatment of structural cardiac diseases. Concomitant technological innovations, procedural advancements, and operator experience have contributed to effective therapies with low complication rates, making early hospital discharge safe and common. Same-day discharge presents numerous potential benefits for patients, providers, and health care systems. There are several key elements that are shared across the spectrum of interventional cardiology procedures to create a successful same-day discharge pathway. These include appropriate patient and procedure selection, close postprocedural observation, predischarge assessments specific for each type of procedure, and the existence of a patient support system beyond hospital discharge. This review provides the rationale, available data, and a framework for same-day discharge across the spectrum of coronary, peripheral, and structural cardiovascular interventions.

Characteristics and short-term outcomes of outpatient and inpatient cardiac catheterizations: A descriptive study using a nationwide claim database in Japan

BACKGROUND

Most previous studies on outpatient cardiac catheterization have been conducted in Western countries, but Japanese studies are rare. We aimed to describe patient characteristics and short-term clinical outcomes of outpatient cardiac catheterization compared to those of inpatient cardiac catheterization in Japan.

METHODS

We conducted a retrospective cohort study using data from the JMDC Claims Database. We identified all adult patients aged ≥18 years who underwent cardiac catheterization between April 2012 and October 2021. We investigated patient characteristics and clinical outcomes (i.e. all-cause mortality, stroke, acute kidney injury, bleeding, vascular complications, percutaneous coronary intervention, and total healthcare costs) within 2, 7, and 30 days between patients who underwent outpatient cardiac catheterization (outpatient group) and those who underwent inpatient cardiac catheterization (inpatient group).

RESULTS

Of the 37,002 eligible patients (57.6 % <60 years old, and 80.2 % male), 1853 (5.01 %) underwent outpatient cardiac catheterization. The outpatient group was more likely to be male, have more comorbidities, and be performed at non-university hospitals than the inpatient group. The proportion of patients who underwent right heart catheterization and imaging was lower in the outpatient group. There were no significant differences in 7-day major complications between the two groups (all-cause mortality, 0.0 % versus 0.0 %, p = 0.57; acute kidney injury, 0.0 % versus 0.1 %, p = 0.10, bleeding, 0.5 % versus 0.9 %, p = 0.052; vascular complication, 0.0 % versus 0.1 %, p = 0.23, respectively). The 30-day total healthcare costs were lower in the outpatient group than in the inpatient group (mean 3212 US dollars versus 3955 US dollars, p = 0.003).

CONCLUSIONS

Approximately 5 % of cardiac catheterizations were performed in an outpatient setting. Given the low adverse event risk observed in this study, it may be a reasonable option to widen outpatient cardiac catheterization to include potential populations in Japan, warranting further studies.

Safety and feasibility of same-day discharge following catheter ablation of atrial fibrillation: what is known and what needs to be explored?

Catheter ablation of atrial fibrillation (AF) is the most effective rhythm control strategy and its role in the treatment of AF patients has been strengthened by recent guidelines. An increasing AF prevalence and the resulting demands on interventional electrophysiology call for improved resource allocation through both technical innovations and streamlined workflows and patient pathways. Same-day discharge is already established in the context of other electrophysiological interventions; however, its broad implementation in the practice of AF ablation is pending for several reasons, despite the fact that the body of evidence is growing and the majority of reports propagate early discharge to be feasible and safe under certain conditions. This review article is intended to provide an overview of the existing data, classify these into the specific study context, and to show limitations and open questions.