The Missed Opportunity of Same-Day Discharge in the United States

Cath Lab Digest talks with Amit P. Amin, MD, MSc, Washington University School of Medicine, Barnes Jewish Hospital, Center for Value and Innovation, Washington University School of Medicine, St. Louis, Missouri.

In this interview, we are joined again by Dr. Amin from Barnes Jewish Hospital. His seminal work on cath lab economics has proven to be extremely valuable in helping hospitals understand the economic value of same-day discharge in the elective percutaneous coronary intervention (PCI) population. His breakdown of direct, indirect, and total costs are providing new insight as to where costs could be better managed or avoided. In a healthcare environment that has acknowledged care variation as an opportunity to assess costs, his publication is a must-read for any cath lab program. —  Gary Clifton, Vice President, Terumo Business Edge

Can you describe your study?

This study, published online September 26^th in JAMA Cardiology¹, talks about the missed opportunity of same-day discharge in the United States. Our data source was the Premier Healthcare Database, which tracks about 20% of all hospitalizations in the United States, so it is one of the largest populations that you can study. From the database, we looked at about 700,000 percutaneous coronary intervention (PCI) patients undergoing an elective stent or angioplasty procedure from the years 2005 to 2015 at about 500 U.S. hospitals. We focused on overnight stay and same-day discharge, which was defined as discharge the same day of PCI, and found that <5% of elective PCI patients underwent same-day discharge. We also looked at the temporal trend in same-day discharge, and it was increasing, but it increased quite slowly, such that from 2005 until 2015 it only went from 1% to 10%. A large proportion of elective PCI patients are fairly stable and we feel that this population represents a large, missed opportunity for same-day discharge in the United States. 

What were the economic benefits found with same-day discharge?

We found there was approximately $5,100 cost savings per PCI procedure when accounting for all the comorbidities, case mix, and the varying practices and patient types at different hospitals. Accounting for these clinical and hospital variables, we still found about a $5100 savings associated with same-day discharge of elective PCI patients. We have published before (from the American College of Cardiology’s National Cardiovascular Data Registry [ACC-NCDR] CathPCI Registry) on the savings associated with same-day discharge.² This was a much larger study and it included department-level costs as well. We found a large reduction in “room and board” costs due to a shorter length of stay associated with same-day discharge, accounting for the vast majority of savings. As hospitals continue to struggle with their margins and Medicare invites hospitals to participate in bundled payments, the savings offered with same-day discharge could be a game-changer for hospitals offering PCI. Some of the savings result from transradial access and reduced complications, but more importantly, as costs for room and board go down, the associated expenses of necessary equipment and supplies also concomitantly reduce, resulting in these cost savings. A fundamental economic principle is that processes that enable you to save resources almost always result in financial gains. Same-day discharge is no different; it follows that principle.

Were patients tracked for readmissions?

That’s a great question. We looked at downstream readmissions and there was no excess association with readmission after same-day discharge. Among same-day discharge (vs non same-day discharge) patients, there was no higher risk of death, bleeding, acute kidney injury (AKI), or acute myocardial infarction (AMI) at 30, 90, or 365 days. So, in the patients selected for same-day discharge, it was safe as well as very effective in saving costs. 

Is there a standard level of use for same-day discharge across the U.S.?

We found a large variation in hospital practices regarding same-day discharge. Some hospitals discharged their patients the same day 80% of the time, while others were at 0%. There are several ways to quantify variation, and we used a mixed model, with a statistical concept called median incidence rate ratio, which revealed almost a four hundred-fold percent variation across hospitals, for statistically identical patients. Patients had a 400% variation in whether they would be discharged the same day or not, based on the hospital they went to. We looked at top-decile hospitals who are discharging patients the same day, and their rate of same-day discharge was about 40%. We then compared the outcomes of patients undergoing same-day discharge at these hospitals versus the non-top decile hospitals, which revealed no difference in outcomes. This means it was just as safe to go home at the hospitals who were discharging half their patients the same day versus those hospitals who were keeping patients overnight. This is a strong point of the study — that it demonstrates the potential safety in discharging elective PCI patients at least 45-50% of the time, because some hospitals are doing it safely, while other hospitals are lagging behind. 

Did any of the hospitals with higher rates of same-day discharge share any particular characteristics?

The Premier Healthcare Database anonymizes the hospitals, but we do have some basic characteristics available. Most of the hospitals who are discharging patients the same day were larger centers in more urban areas. We specifically did not explore hospital characteristics. 

In terms of economic value, this will certainly be something people can bring to their administrators. Do you think physicians themselves have been convinced?

Not everyone is convinced. There is clear, randomized evidence that same-day discharge can be safe in certain elective PCI patients. If it is done thoughtfully and carefully, most patients can be discharged the same-day safely, provided the PCI is of a high quality, that there are no concerns about the procedure, risks of complications are thoroughly understood and mitigated, patients are reliable in taking their medications, have enough support at home, and if follow-up processes are in place. Since such a program isn’t set up at most hospitals, what happens is that care is more reflexive — and the reflex is to admit these patients overnight. 

The PCI procedure itself has improved dramatically over the last decade. Abrupt vessel closure has disappeared, anticoagulants and antiplatelet agents are safe, and stent design and wire technology is spectacular! Overall, contemporary PCI has become a very controlled procedure. Transradial access, closure devices, and adjunctive technologies such as intravascular imaging have all made the PCI procedure even safer. And yet, we have not really capitalized upon these improvements and translated them into an economic advantage. 

What about the role of radial access?

Transradial access, of course, has an important role to play; it reduces bleeding and vascular complications, and although we have made rapid strides in the uptake of transradial PCI, the proportion of same-day discharge is still lagging behind. 

Once physicians decide on radial access and the case goes smoothly, then bleeding and vascular complications are unlikely after radial access. If there are no concerns, then a 6-hour window of observation is sufficient for most patients. If complications were to occur, they usually occur early after PCI, and this 6-hour window should be a sufficient timeframe of observation for most patients. Once the physician decides to proceed with transradial access, I believe the next natural step is an explicit awareness that this patient is unlikely to bleed, and if the PCI went well, considering same-day discharge after a few hours of observation…but right now, that is not happening.

A large proportion of same-day discharges in our study were also femoral. Femoral same-day discharge is still safe if we can use safe anticoagulants and perform successful access-site closure using closure devices. We showed that in another study from Barnes-Jewish Hospital³, where a substantial proportion of our same-day discharges after PCI were actually femoral, but we were still able to discharge them the same day, provided such precautions with femoral access were met. Obviously if someone has a groin complication or bleed, they won’t be going home the same day, but that story unfolds in the cath lab holding area, where we observe these patients very closely.

What would you like physicians to conclude from your study?

Physicians and hospitals should not only take a look at the evidence in the literature but also their own practice, and decide if they want to evolve their discharge practices. The PCI procedure in the elective setting is quite safe, especially after transradial access. If the procedure was successful, and no complications are anticipated, then same-day discharge should be considered, because the patients love it, it increases patient satisfaction, and health care costs are reduced. But we are not advocating same-day discharge for all elective patients. Obviously there are some complex patients who need overnight observation. The decision to discharge the same day should be a very cognitive, well-informed decision. It requires an upfront investment, usually in health information technology resources to enable objective risk stratification, and a nurse or a dedicated person to accelerate processes such as ambulation and hydration, to ensure delivery of dual antiplatelet medications, and to assess patients’ social support. Close scrutiny after discharge is critically important with phone calls and mandatory follow-up in provider offices and clinics. 

For a typical lab that does a lot of complex PCI, what percentage of your patients go home the same day?

I practice at Barnes Jewish Hospital, which is a large, urban, academic, tertiary care medical center, and our volumes and complexity are comparable to those expected at such academic medical centers. Despite this, we discharge close to 70-80% of our patients home the same day. That’s the point I am making — that even if you have performed a left main PCI or a bypass graft PCI in an elderly lady, as long as you are careful, same-day discharge is possible. We have published on a patient-centered approach,³ where we proactively predict ahead of time which patients are likely to bleed or have other complications such as acute kidney injury (AKI). We run ACC-NCDR CathPCI prediction models to obtain patient-specific risks of complications at the time of consent. This allows our interventionists to review these risks and plan their PCI procedure not solely around the anatomic complexity, but also factoring in these individualized risks. In someone at a high risk of bleeding, we may decide to go radial and use a safe anticoagulation strategy. In someone at a high risk for AKI with a creatinine of 2.1 mg/dl, we can predict how much dye can be safely used. If we can stay within these limits, then we can still consider sending the patient home the same day. 

Following is the process we have established at Barnes Jewish Hospital in follow-up for same-day discharge patients. Every single patient discharged same day gets a phone call the next morning of the procedure, to make sure that they are doing well. We set up the expectation with patients to respond to this phone call; that it is an important call. On this phone call, a specially trained nurse with a script checks in with the patient and will ask the patient all the relevant questions: Is the groin site ok? Is the radial site ok? Any nausea? Any chest pain? Any shortness of breath? Are you taking your antiplatelet medications? For the high-risk patients (risk measured objectively) we arrange a mandatory follow-up within 1 week of the PCI with their primary cardiologist or primary physician. This risk-based approach has allowed us to improve the quality of our care, prevent readmissions, and actually follow patients in a meaningful way such that we increase patient satisfaction and prevent adverse outcomes.

Does AKI show up close to the procedure?

AKI typically shows up in 48 to 72 hours after the procedure, so even with overnight observation, you are not going to capture AKI. In my practice, we avoid AKI by staying within planned contrast limits and we have a mandatory protocol for follow-up. In the high-risk patients, we send them with a lab order for a basic metabolic panel (BMP) lab test in a week’s time, which is followed up.  

Does Centers for Medicare & Medicaid Services (CMS) reward facilities that can implement same-day discharge?

Currently, I do not believe so. However, we hope CMS will take a close look at our study, because in the past, CMS policies have been the catalysts that incentivize hospitals and physicians to not only improve quality of care, but also reduce healthcare costs. Same-day discharge after elective PCI could be one such catalyst. 

What do you see as the path forward?

I believe we have reached a tipping point with transradial access. It is expected to exponentially increase in the U.S., soon we should be matching our European and Asian colleagues with respect to the rate of transradial access. I believe same-day discharge will also increase at most hospitals. Papers such as these will continue to bridge the gap between the evidence and practice.Physicians and hospital administrators will become increasingly aware of the data, the economic advantage, and greater patient satisfaction with same-day discharge. It is a win-win for all: patients win, hospitals win, and it is safe, so why shouldn’t we do it?

References

1. Amin AP, Pinto D, House JA, et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol. 2018 Sep 26. doi: 10.1001/jamacardio.2018.3029. [Epub ahead of print]
2. Amin AP, Patterson M, House JA, et al. Costs associated with access site and same-day discharge among Medicare beneficiaries undergoing percutaneous coronary intervention: an evaluation of the current percutaneous coronary intervention care pathways in the United States. JACC Cardiovasc Interv. 2017 Feb 27;10(4):342-351. doi: 10.1016/j.jcin.2016.11.049.
3. Amin AP, Crimmins-Reda P, Miller S, et al. Novel patient-centered approach to facilitate same-day discharge in patients undergoing elective percutaneous coronary intervention. J Am Heart Assoc. 2018 Feb 15;7(4). pii: e005733. doi: 10.1161/JAHA.117.005733.