May 6th, 2013
Meta-analysis Finds Same-Day Discharge for Low-Risk PCI May Be Feasible
Larry Husten, PHD
Although elective PCI for most low-risk patients is extremely safe, overnight observation is still standard practice in the U.S., largely due to the lack of evidence demonstrating that same-day discharge is safe. Now a new meta-analysis, published online in the Journal of the American College of Cardiology, provides support for same-day discharge in carefully selected low-risk patients.
Kimberly Brayton and colleagues analyzed data from 37 studies, 7 of which were randomized trials and 30 of which were observational studies. Among the 2,738 patients who were randomized to either same-day discharge or overnight observation, there was no difference in the primary composite endpoint of death, MI, and target lesion revascularization or in the rate of major bleeding and vascular complications. Among 10,065 patients who were included in observational studies, the pooled rate of the primary composite endpoint and the rate of major bleeding and vascular complications occurred at the very low rates of 1% and 0.68%.
In their discussion, the authors write that it was “important to note that patients with significant comorbidities were excluded from most of these studies.” Patients with low LVEFs or with chronic kidney disease “are unlikely to be ideal candidates for same-day discharge even when PCI is elective.” Hospitals seeking to develop a same-day discharge program “should develop formal criteria for identification of appropriate patients as well as a system for close follow-up.” Currently, they point out, PCI guidelines do not incorporate recommendations for same-day discharge. They conclude:
Although larger studies are needed to provide definitive comparisons of same-day discharge vs. overnight observation, in aggregate the data… support consideration of programs for same-day discharge in carefully selected patients.”
I asked Brayton to comment on whether same-day discharge is likely to become common practice in the near future:
It appears that there are two separate issues to consider for routine implementation of same-day discharge – safety and cost. Our study indicates that same-day discharge is safe for a large number of relatively low-risk patients undergoing PCI (mostly elective), and that it would be reasonable for most programs to consider instituting a protocol allowing same-day discharge of appropriate patients. However, cost considerations are considerably more complex. In general, the potential cost-savings of same-day discharge depend on two factors – a program having sufficient volume of low risk patients to justify the up-front costs of implementing a change in protocol, and the ability of a program to successfully recapture the resources liberated by same-day discharge, either through a decrease in staffing or through reallocation of the freed resources for use for another patient. Programs are heterogeneous enough, and the reimbursement structure fluid enough, that it is hard to predict how common the practice will become, even if data supporting the safety of same-day discharge continue to accrue.
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