This article is more than 5 years old. Information may no longer be current.
Same-day discharge after PCI yields benefits for patients, providers, payers
Click Here to Manage Email Alerts
In an era where health care systems are being forced to behave more like businesses, the implementation of same-day discharge programs for patients undergoing PCI may not only improve patient satisfaction but also improve reimbursement, avoid penalties to institutions for inappropriate inpatient stays and cut overall health care costs.
“In 2016, CVD accounted for about $555 billion of the $3.3 trillion overall health care costs. By 2035, the burden of CVDs is going to be $1.1 trillion,” Amit P. Amin, MD, MS, assistant professor of medicine at Washington University School of Medicine in St. Louis, said during a presentation at the American College of Cardiology Scientific Session in March.
As the population ages, physicians are seeing more patients with comorbid conditions and the complexity of cases is increasing, which require physicians and hospitals to invest in more expensive technologies as well as increased staffing costs related to various initiatives from Medicare and other payers, Amin noted.
Payers are also feeling the burden. Consequently, CMS is not only decreasing reimbursement for certain procedures, such as PCI, but the agency now mandates that a portion of the financial risk be transferred to providers, saddling hospitals with a poor economic outlook. By 2025, more than half of the hospitals in the United States are projected to have negative margins, he said.
However, amid these challenges are opportunities, Amin added. The volume of patients with CVD is expected to increase and uptake of procedures within a more complex subset of patients, such as chronic total occlusion PCI, is growing.
“There is also an increase in growth of our patient services, such as elective PCI, and therein lies opportunities,” Amin said. “If we can streamline processes to account for or take advantage of these trends, then perhaps we could still be very viable in this health care environment.”
Promising solutions
For interventional cardiologists, use of the transradial approach, as opposed to the transfemoral approach, may offer a way to streamline these processes, according to Amin. For instance, in one small study published in JACC: Cardiovascular Interventions in 2013 involving five hospitals, Amin and colleagues found an $830 difference favoring transradial PCI over transfemoral PCI after adjustment for confounders of costs, bleeding and other complications.
Furthermore, in a more recent study published in JACC: Cardiovascular Interventions in 2017 evaluating costs associated with access site and same-day discharge in Medicare patients for elective PCI, Amin and colleagues found a $3,600 difference favoring transradial PCI with same-day discharge vs. transfemoral PCI with non-same-day discharge after adjustment for all comorbidities.
Same-day discharge is also associated with higher patient satisfaction and, when a patient-centered approach that accounts for risks is taken, can result in lower complication rates, Amin noted.
“In this era, converting from transfemoral to transradial access can have a large economic impact,” he said. “But independent of access site, if you can align the care you deliver in the cath lab and processes toward same-day discharge, then a same-day discharge program can result in large cost savings.”
Same-day discharge, which is essentially discharge on the same calendar day as the PCI procedure, can be worrisome for interventional cardiologists who are not only concerned about stent thrombosis, bleeding and vascular complications but also about hospital readmissions, which can result in a penalty for the hospital, according to Sunil V. Rao, MD, professor of medicine at Duke University Health System and the Duke Clinical Research Institute and a member of the Cardiology Today’s Intervention Editorial Board.
“The issue, though, is that as we increase inpatient stay, there are risks inherent to the patient. This is a little bit of a different way of looking at it: We’re worried about the risks to the patient if we send them home, but what about the risks if the patient stays in the hospital?” he said during a presentation at the ACC Scientific Session.
These risks include medical errors, hospital-acquired infections and, particularly for older patients with mental status issues, delirium, Rao noted. Additionally, same-day discharge satisfies patients who may want to spend the night in their own homes while also freeing up hospital beds at centers who are struggling with a lack of bed availability for those who truly need inpatient care.
Building a same-day discharge program
There are a number of questions to consider before establishing a same-day discharge program, such as how long a patient should be monitored, according to Rao.
Two studies have shown that most complications occur within 6 hours after PCI, suggesting that a 6-hour post-procedure observation period is reasonable. In one study, some events occurred after 24 hours, but this would be outside the typical overnight observation period anyway, he noted. Additionally, several studies have demonstrated no significant difference in 30-day death, complications or rehospitalization after PCI in patients who had same-day discharge vs. standard overnight observation.
“A successful same-day discharge program depends on what we call the three Ps: the patient, the procedure and the program,” Rao said.
For instance, the patient should be cognitively intact or have adequate social support at home and be medically stable after the procedure. The procedure should be successful and without significant complications. There should also be no requirement for prolonged IV antithrombotics, according to Rao. All of this should occur within the context of a program that allows for education of the patients around the procedure.
“For many of these patients, this is the first time they’ve had a diagnosis of coronary disease,” he said. “There has to be education about what to watch out for in terms of complications and they should be provided a number to call for help if they have any issues overnight.”
Rao also noted that patients should leave with the necessary medications, as they may not fill the prescriptions on their own.
It is also important to remember, he said, that a radial approach may be the best way to avoid vascular complications, but it is not necessary to build a same-day discharge program.
“The real issue is reducing complications. At the end of the day, it’s about making sure the access site and the patient are stable,” Rao said, noting that adequate post-procedure hemostasis is essential for safe same-day discharge. – by Melissa Foster
Reference:
Alasnag MA, et al. Session 606: Transradial Mini-Symposium. Presented at: American College of Cardiology Scientific Session; March 10-12, 2018; Orlando, Fla.
Disclosures: Amin reports he has received a research grant from the Volcano Corporation and he is a consultant for AstraZeneca, Terumo and The Medicines Company. Rao reports he has financial ties with Amgen, Boehringer Ingelheim, Cardiovascular Systems Inc., Corindus and Medtronic.