NEW YORK (Reuters Health) – As long as eligibility criteria are strictly followed, it is safe to let “real world” patients undergoing percutaneous coronary intervention go home on the same day as the procedure, physicians at Mount Sinai Hospital, New York, report in JACC: Cardiovascular Interventions for August.
“Like every procedure in medicine, even PCI is becoming an ambulatory procedure in selected patients,” commented Dr. Samin K. Sharma.
Dr. Sharma and colleagues note that, although same-day discharge after PCI is probably safe for low-risk, stable patients, data to guide the selection of appropriate patients are scarce. “Most of the reported studies on same-day discharge have strict inclusion criteria and hence do not truly reflect a real-world population.”
To address this issue, the investigators looked at outcomes of 2400 patients discharged on the same day after an uncomplicated PCI. Eligibility criteria included:
–Elective PCI for stable angina or crescendo angina or detection of asymptomatic coronary stenosis.
–Successful PCI with or without the use of a bolus dose of glycoprotein IIb/IIIa inhibitors
–Residual stenosis <30%
–Left ventricular ejection function >30%
–No post-procedural chest pain
–No vascular complications
–PCI performed before 3 PM to allow 8 hours of observation before discharge
–Unsuccessful but uncomplicated PCI
–Completion of a 200-m walk
Certain patients were not candidates, such as those with uncontrolled diabetes, hemodynamic instability, cases of complex PCI, or those with compromised post-PCI care.
PCI was performed via the femoral approach in 99.5% of the same-day discharge patients, and the interventional procedure was successful in 97% of the cases.
At day 30 of follow-up, there were no deaths, MIs, or strokes in any of the patients.
“Overall incidence of 30-day readmission was low (28 patients, 1.17%),” Dr. Sharma and colleagues found. Nineteen readmissions were due to cardiac reasons and 9 due to noncardiac reasons.
Summing up, Dr. Sharma said in an email to Reuters Health, “After making and adhering to the discharge protocol for uncomplicated cases, ambulatory PCI can safely be done in about 25-30% of PCIs (of approximately 1 million PCIs in the USA). At Mount Sinai Hospital, currently 26% of all PCIs are Ambulatory.”
He and his colleagues conclude that same-day discharge improves patient comfort and reduces utilization of hospital resources. “Ambulatory PCI works very well for patients by getting them back with the family and is preferred by many,” said Dr. Sharma.
On the cost issue, he noted, the main problem in the US is reimbursement. “Hospital are reimbursed at an average of $8000 (total payment) for ambulatory PCI as compared to $18,000 for in-hospital PCI. Therefore there is little incentive for ambulatory PCI and rather it may be detrimental to the hospital finances.”
However, he added, many insurers are now approving patients for only ambulatory PCI, and require a second approval if a patient has to stay in the hospital. “This policy will continue to change the way PCIs are done in the US (and) certainly will go a long way in reducing the health care cost of heart patients in the USA.”
J Am Coll Cardiol Intv 2010;3:851-858.
