Same-day discharge after PCI not associated with higher risk for death, rehospitalization

Rao S. JAMA. 2011;306:1461-1467.

Issue: November 2011

Among selected low-risk Medicare patients who underwent an elective percutaneous coronary intervention, same-day discharge was rarely implemented, but was not associated with an increased risk for death or rehospitalization at 2 days or at 30 days when compared with patients who remained in the hospital overnight, according to a recent study published in the Journal of the American Medical Association.

“Risks associated with PCI are highest within the first 24 to 48 hours after the procedure,” according to background information in the article. “However, short- and long-term outcomes after PCI have improved because of the evolution in device technology and pharmacotherapy. Despite this improvement, patients are usually observed overnight in the hospital after elective PCI to monitor for PCI-related complications.”

Sunil V. Rao, MD, of the Duke Clinical Research Institute, and colleagues examined the prevalence of same-day discharge among older individuals following PCI and the rates of death or rehospitalization. The study included data from more than 107,000 patients aged 65 years and older who underwent elective PCI procedures at 903 sites participating in the CathPCI Registry between November 2004 and December 2008; these data were linked with Medicare Part A claims. Patients were divided into two groups based on length of stay at the hospital after PCI: same-day discharge or overnight stay.

Overall, the prevalence of same-day discharge was 1.25% (n=1,339), with significant variation across facilities. Rates of procedural success were not significantly different between the two groups. Patient characteristics were similar with same-day discharge vs. overnight stay, although same-day discharge patients underwent shorter procedures with less multivessel intervention. Patients who were discharged the same day as surgery were more often categorized in the lowest quintile of predicted risk for death or rehospitalization, while there were approximately equal proportions of lower- and higher-risk patients observed overnight, according to a JAMA press release.

The researchers found no significant differences in rates of death or rehospitalization at 2 days (same-day discharge 0.37% vs. overnight stay 0.5%) or at 30 days (same-day discharge 9.63% vs. overnight stay 9.7%). Additionally, median time to death or rehospitalization did not differ significantly between the two groups in patients with adverse outcomes (same-day discharge 13 days vs. overnight stay 14 days). When the researchers adjusted for patient and procedure characteristics, same-day discharge was not associated with death or rehospitalization at 30 days.

The researchers noted, however, that despite the apparent safety of same-day discharge for selected patients, this approach is rarely practiced at sites represented in the National Cardiovascular Data Registry. “This may reflect reluctance on the part of clinicians to discharge patients the same day as the PCI procedure because of concerns over early post-PCI complications. Although these concerns are well founded, the rates of vascular or bleeding complications were extremely low (less than 1%) among the patients in our analysis, with no clinically significant differences between groups,” the researchers wrote.

They added, that according to published guidelines, same-day discharge can be considered for patients undergoing PCI who have low-risk clinical features, successful procedures without prolonged postprocedure use of parenteral (by injection) antithrombotic agents, and adequate social support.

Disclosures: Dr. Rao received consulting fees from Terumo Medical, The Medicines Company, AstraZeneca and Zoll and has received research funding from Ikaria, Sanofi-Aventis and Terumo Medical.

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