Neither 30-day mortality nor rehospitalization were increased by same-day discharge after elective percutaneous coronary intervention (PCI), a practice that has increased over the past 10 years, according to a recent study published in JACC: Cardiovascular Interventions.
“In a large, national, U.S. PCI registry of nearly 820,000 patients undergoing elective PCI, the use of same-day discharge increased more than 5-fold from 4.5% in 2009 to 28.6% in 2017. This increase in same-day discharge began prior to the implementation of reimbursement rules intended to dissuade short inpatient hospitalizations. However, the rate of increase in same-day discharge was greater following changes in reimbursement rules,” wrote researchers led by Steven M. Bradley, MD, MPH, of the Minneapolis Heart Institute, and fellow researchers.
To assess associations between same-day discharge and 30-day mortality and rehospitalization, Bradley and colleagues used the National Cardiovascular Data Registry CathPCI Registry to identify 819,091 patients who had undergone elective PCI at 1,716 hospitals. They excluded patients with a hospital stay of more than 1 night and those who did not receive stents.
In all, 14.0% were discharged the same day as PCI, with an increase in same-day discharge from Q3 2009 to Q4 2017 (4.5% to 28.6%, respectively). Same-day discharge was given to less patients with femoral access vs radial for all time points.
Between 2009 and 2017, the rate of same-day discharge increased from 4.3% to 19.5% in patients undergoing femoral-access PCI, and from 9.9% to 39.7% for radial-access PCI. Throughout all time points, variations in hospital level use of same-day charge persisted (median OR adjusted for year, radial access: 4.15), but risk-adjusted 30-day mortality remained consistent over time and risk-adjusted rehospitalization decreased overall, and more rapidly for patients with same-day discharge (P for interaction ˂0.001).
After adoption of CMS’ two-midnight rule, researchers saw an immediate 1.7% increase in same day discharges (95% CI: 0.8%-2.6%), and the rate of these continuously increased thereafter by 0.8% per quarter.
Hospital level median rate of same-day discharge increased from 2009 to 2017 (1.5% to 15.4%, respectively). Again, the range of same-day discharge by hospital was greater in patients who underwent radial access PCI compared with femoral access, but when “adjusted for year and access site, median OR was 4.15, representing a 4-fold increase in the odds of same-day discharge between randomly selected hospitals even after accounting for year and radial access,” noted Bradley et al.
In all, 212,369 patients were linked to data from the Centers for Medicare and Medicaid Services, of whom 0.2% died within 30 days of discharge, compared with 0.2% of patients discharged the next day. Upon unadjusted analysis, researchers found no significant associations between same-day discharge and 30-day mortality in this population (OR: 0.92; 95% CI: 0.66-1.30; P=0.42). The same was true for risk adjusted analysis (OR: 1.03; 95% CI: 0.73-1.46; P=0.86).
Among these Medicare patients, 5.6% were rehospitalized within 30 days of discharge, with a rehospitalization rate of 4.9% in patients with same-day discharge, compared with 5.7% among those discharged the next day.
Over time, associations between same-day discharge and rehospitalization changed, and decreased after 2010. During 2009-2010, same day discharge was associated with a higher 30-day rehospitalization rate in both unadjusted (8.6% versus 6.2%; OR: 1.54; 95% CI: 1.28-1.86) and risk adjusted analyses (OR: 1.69; 95% CI: 1.40-2.03). By 2014, this had decreased to 3.0% for same-day discharge and 4.2% for next-day discharge.
“Percutaneous coronary intervention (PCI) has become an increasingly common cardiac procedure in the United States. According to data from the National Cardiovascular Data Registry CathPCI Registry, the volume of PCI in the United States increased from 550,872 in 2013 to 637,650 in 2017. Approximately one third of these cases were performed on an elective basis. Advances in the devices and techniques of PCI have improved the safety and efficacy of the procedure. In selected patients, same-day discharge has become possible, and overnight in-hospital observation can be avoided. By reducing unnecessary hospital stays, both patients and hospitals could benefit,” wrote Deepak L. Bhatt, MD, MPH, Jonathan G. Sung, MBCHB, both of Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, in an accompanying article.
“The investigators are to be congratulated for an excellent analysis of this clinically important topic. The study has several strengths, including a large multicenter cohort followed over a long study period, during which a clear trend of change was observed. The availability of real-world mortality data should help promote a good practice that is being gradually adopted throughout the country,” concluded Bhatt and Sung.
Study limitations include the absence of data from hospitals not participating in the NCDR’s registry, the limitation of patient outcomes to Medicare patients, the lack of access to cost data, and failure to assess hospital-level characteristics.
Bradley et al added, “Finally, the present findings suggest that the use of same-day discharge in clinical practice has not compromised patient outcomes of mortality or rehospitalization. This does not reflect all potential outcomes of importance to patients. Nor does this equate to same-day discharge being safe and equivalent to overnight stay for all patients undergoing elective PCI. Continued research is needed to define the thresholds of safety in the application of same-day discharge for PCI.”
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Analysis finds no increases in 30-day mortality or rehospitalization in patients undergoing elective PCI, as well as no significant association between same-day discharge and risk-adjusted 30-day mortality among Medicare-matched patients.
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The proportion of elective PCIs with same-day discharge increased from 4.5% in 2009 to 28.6% in 2017.
Liz Meszaros, Deputy Managing Editor, BreakingMED™
This study was supported by the American College of Cardiology’s NCDR.
Bradley serves as an associate editor for JAMA Network Open.
Bhatt is an advisory board member for Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Janssen, Level Ex, Medscape Cardiology, MyoKardia, Novo Nordisk, PhaseBio, PLx Pharma, and Regado Biosciences; is a member of the boards of directors of the Boston VA Research Institute, the Society of Cardiovascular Patient Care, and TobeSoft; is chair of the American Heart Association Quality Oversight Committee; is a member of data monitoring committees for the Baim Institute for Clinical Research (formerly the Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), the Cleveland Clinic (including for the ExCEED trial, funded by Edwards Lifesciences), Contego Medical (chair, PERFORMANCE 2), the Duke Clinical Research Institute, the Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), and the Population Health Research Institute; has received honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org; vice chair, ACC Accreditation Committee), the Baim Institute for Clinical Research (formerly the Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee, funded the by Boehringer Ingelheim; AEGIS-II executive committee, funded by CSL Behring), Belvoir Publications (editor-in-chief, Harvard Heart Letter), the Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), the Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (editor-in-chief, Journal of Invasive Cardiology), the Journal of the American College of Cardiology (guest editor, associate editor), K2P (co-chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (continuing medical education steering committees), MJH Life Sciences, the Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and US national coleader, funded by Bayer), Slack Publications (chief medical editor, Cardiology Today’s Intervention), the Society of Cardiovascular Patient Care (secretary/ treasurer), and WebMD (continuing medical education steering committees); is deputy editor of Clinical CardiologyCardiovascular Intervention: A Companion to Braunwald’s Heart Disease
Sung reported no relevant disclosures. Cat ID: 308 Topic ID: 74,308,730,308,914,192,925Author
