Pressure on US hospitals to cut costs is fueling a new trend, sending patients home as little as 2 days after primary percutaneous coronary intervention after a serious heart attack. Most US patients go home in 4 to 5 days. A new study finds the short stay is usually safe and the research will likely add momentum to the trend.
The length of stay (LOS) for patients hospitalized after primary percutaneous coronary intervention (PPCI) following a serious heart attack has been dropping in the US.
Patients now are discharged as little as 48 hours after a ST-segment elevation myocardial infarction (STEMI). The trend has been fueled by pressure on hospitals to cut costs.
According to a new report from Weill Cornell Medical College/New York-Presbyterian Hospital Greenberg Division of Cardiology, the trend toward short stays appears to be safe for “selected”patients. That could add to pressure to discharge these patients quickly, perhaps even treating PPCI as an outpatient procedure for billing purposes. (Outpatient care is less lucrative for hospitals and for Medicare beneficiaries often comes with an obligation to pay more of the cost.)
Writing in the Journal of the American College of Cardiology Rajesh Swaminathan, MD and colleagues reported on 30-day outcomes for three groups of these patients. All were 65 or older.The researchers compared outcomes for those who had a short LOS (3 days or less) a medium LOS (4 to 5 days) or long (5 or more days.) In all there were 33,920 patients, all tracked in the CathPCI Registry dataset and treated from 2004 to 2009.
Most (46.3%) were in the medium LOS group.
They found no significant difference in all-cause mortality, major adverse cardiac events, readmission for myocardial infarction or unplanned revascularization in the medium LOS group and the short LOS group.
“Patients discharged as early as 48 hours after PPCI have outcomes similar to patients who stay in the hospital for 4 to 5 day,” they concluded. “Early, but not very early (less than 48 hours) discharge may be safe among selected older patients with STEMI,” Swaminathan wrote.
Keeping patients longer is a way to monitor for arrhythmias and other health threats post-STEMI, and thought to improve outcomes, he noted. In fact, he said, “Median LOS is shortest in the US compared with other countries.”
For a subset of patients discharged even earlier, a same-day or next-day discharge, going home quickly was risky. These 1,244 patients had a 30-day mortality rate twice that of patinets discharged after 3 or 4 days of hospitalization. But these may have been patients who left against medical advice or who were transferred to other facilities because they were sicker, he noted.
“These limitations significantly affect the ability to make any conclusions ab out the small subset of patients discharged after a very short LOS.
There is also widespread regional variation, with shortest stays in the West (35% of patients) and a low rate of short stays in the Northeast (16% of patients).
Professional societies have not set recommendations on the best LOS. Coupled with a lack of a large randomized trial to see how patients fare the information gap, “leaves clinicians with incomplete evidence with which to make decisions,” Frederic Resnic, MD, and Sachin Shah MD, wrote in an accompanying editorial.
But they also commented that the research showed shorter stays are generally justified and that “there is probably an opportunity to apply this practice more broadly, thereby achieving significant health care cost savings while maintaining the quality of STEMI care.”