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Same-Day Discharge for Elective PCI Patients Cuts Hospital Costs

 |  By cclark@healthleadersmedia.com  
   October 05, 2011

Hospitals could dramatically improve patient flow and save money by discharging low-risk elective percutaneous coronary intervention patients 12 hours earlier rather than keeping them through the night, according to a report in the Journal of the American Medical Association.

The researchers, led by Sunil V. Rao, MD, of Duke Clinical Research Institute in Durham, NC, examined an American College of Cardiology database of 107,018 Medicare patients who were kept up to 23 hours after their PCI procedures. The population was separated into five groups based on their risk of complications and rehospitalizations.

They discovered that earlier, or "same-day" discharge, say after a five- or six- hour recovery from the procedure, is safe for the lowest risk group of patients. Unfortunately, hospitals' current practice is to send home on the same day fewer than 2% of the patients who fit in this category.

The researchers estimated that some 20% of patients who are now kept overnight, but discharged within 24 hours, can safely be discharged much earlier, Rao said, freeing up bed space and labor resources for other, sicker patients.

"The bottom line is that PCI has evolved to the point where it's a very efficacious and safe procedure, and same-day discharge for elective PCI patients is an efficient care strategy that may fit into the protocols of major medical centers that are thinking about increasing efficiency," Rao said in a telephone interview.

Under their proposed model, "If an elective patient has a successful PCI procedure, didn't require prolonged intravenous medications, perhaps has the procedure radially (through the wrist rather than through the groin)...has someone to go home to, has all their medications and is educated on what to look for, that's an ideal candidate who can go home that day," he said.

He does not, however, advise discharging patients after 7 p.m.

Ralph G. Brindis, MD, a co-author and the immediate past president of the American College of Cardiology, added that recent improvements in revascularization procedures have made them much safer.

"In the early days of angioplasty, some 3 to 4% of patients who received coronary stents needed emergency bypass, but that's clearly no longer the case," Brindis said in a telephone interview. "That's now down to .1%"

Additionally, older anticoagulation medicine regimens put patients at higher risk of bleeding, catheter sizes were much larger than those in use today, and closure devices were much less sophisticated.

Brindis added that PCI is increasingly performed through the wrist, through procedure developed in part by Rao, which also reduces risk of bleeding. "As recently as a year and a half ago, 3% were done through the wrist, but in recent months that rate has risen to 10-15%."

Lastly, he predicted that patient experience scores will likely go up for patients who don't have to spend the night in a hospital.

Even though PCI is safer than ever, most hospitals still keep most low-risk patients overnight. And while Rao or Brindis emphasized that their findings should be confirmed by other studies, perhaps a Medicare demonstration project, the potential savings to hospitals and use of resources is enormous.

Brindis, an interventional cardiologist at Kaiser Permanente, Oakland in Northern California, calculated a "back-of-the-envelope" estimate of the saving: Of 700,000 patients who undergo a PCIs each year, one-third are elective, and about 20% of those might be sent home in the afternoon or early evening on the day of their procedure, rather than waiting in observation that night.

"That could potentially free up 35,000 beds for other patients," he suggested. "And if the average cost of a bed day is $1,000 to $2,000, well, that would be significant."

Medicare reimburses hospitals for PCI patients who stay overnight, but not 24 hours, at the same rate as someone who stays only 12 or 10 hours.

Rao said that economies will be more important to hospitals after the implementation of accountable care organizations and bundled payments.

"If we ever get to the point with bundled payments, which it looks like it's probably going to happen, the faster you get the patient out, the more margin there is for the hospital. But they shouldn't do it unless it's safe," Rao said.

Rao added, "Ours is not a call to widely implement same-day discharge. But what centers need to do is examine their own practices. If they've got a patient they're keeping overnight, and they realize that their rates of events within that 23-hour period are low, probably zero – and they're incredibly low in our study – they probably need to look at these elective patients and send them home the same day."

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