SAME DAY DISCHARGE FOR PCI

When angioplasty became established, being minimally invasive, many of us felt that we should be able to discharge our patients after 4-6 hours of observations, even more so with all the wonderful stents that we now have. This had not worked out to be so. I am aware of a few centers who do day cases ( same day discharge ), but this is by and large few and far in between.
In the Oct 5th issue of the Journal of the American medical Association ( JAMA ), Dr Sunil Rao ( a Radialist ), has published a paper comparing event rates between same day discharge PCI and next day discharge PCI, and found no difference in the 2-30days event rates. Their data were taken from the Medicare Registry ( as most patients are Medicare patients ). They reviewed a cohort of 107,018 patients, aged >65years, of which 1339 had same day discharged, and found no difference in the event rates.

Two-day and 30-day rates of death and rehospitalization (adjusted for risk)

Outcome	Same-day discharge, n=1339 (%)	Overnight stay, n=105 679 (%)	p
2-d death or rehospitalization	0.37	0.50	0.51
2-d death	0.07	0.02	0.10
2-d rehospitalization	0.30	0.48	0.30
30-d death or rehospitalization	9.63	9.70	0.94
30-d death	0.30	0.22	0.53
30-d rehospitalization	9.56	9.60	0.96

These numbers must give some comfort to those who are doing day cases. It is fair to say that when you discharge PCI patients on the same day, you have to be very selective. I suppose these are straightforward maybe single of double vessel angioplasty, in the context of simple disease, without much co-morbidity. Despite that, the operator is still taking a chance.
I have not discharge patients on the same day routinely, as I do not derive a cost advantage for the risk that I take. In the mid-90s, when I was stenting a lot, I contemplated a same day discharge strategy, so I spoke to the hospital administrator, to see if same day discharge patients could have their hospital bills reduced by 30-50%, reasoning that I will save a bed for the hospital, and so the hospital can have a higher turn over. He was not interested and did not think so. Then if the day case and overnight stay cases have the same cost, there is no benefit to my patients, for the small risk that I take. So, whenever I do a colleague of the relatives of paramedics, who can abserve for puncture site bleeds, I would ask them if they wish to have a same day discharge. Those who agree, will be discharge the same day.
I suspect that until hospital beds become scarce and expensive, same day discharge for PCI, although feasible in many cases, will not become routine. In USA, hospital beds are expensive and scarce.

With this posting, I leave to go to Kuching to conduct ICF 2011 this weekend. Will write about it when I return.