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Same-Day Discharge in the US
Ready for Prime Time?
Ian C Gilchrist, MD, FACC, FSCAI
Professor of Medicine
Pennsylvania State University
Heart & Vascular Institute
Hershey, PA
2nd Advanced International Masterclass

AIM-RADIAL 2013
CME Disclosure Statement
AIM-RADIAL 2013

Nothing
Hospitalization Safe?
AIM-RADIAL 2013

<http://antiquescientifica.com/archive7.htm>copyrighted ©1982-2012 Alex Peck
Hazard of Hospitalization

AIM-RADIAL 2013

Model from all 206,489 pts in Victoria, Australia 2005/6

Predicted Probability of Adverse Event (%)

30

Risk of an overnight hospital stay

Skin Ulcers

25

20

0.4

Infections

15

11.1
10

Adverse
Drug
Reactions

5

3.4
0

1

2

3

4

5

Nights in the Hospital
Hauck K, Zhao X. Med Care. 2011 Dec;49(12):1068-75

6

7
Drivers of Same Day Care
AIM-RADIAL 2013

Minimize Cost

Hospital
Hazards

Improved PCI

Reimbursement

Same
Day PCI
AIM-RADIAL 2013

Bleeding

Ischemia

Education
Risks Same Day Discharge?
AIM-RADIAL 2013

Ischemic Deaths
>4 hrs post-PCI rare*
•

Access Site Bleeding
rare TRI, low TFI

•
•

•

Education
* Gibson, PROTECT-TIMI-30 Substudy, Am J Cardiol 2009;104:36-40.
* Cutlip, Multicentered coronary stent trials, Circulation 2001;103:1967-1971
Same Day v Overnight
30 Day Outcome

AIM-RADIAL 2013

Odds Ratio
Mantel-Haenszel Random effect, 95% CI

Hospitalization

MACE

Complications
RCT
n=5
Subtotal
(95% CI)

Observational
n=8
Subtotal
(95% CI)

Total (95% CI)
0.01

0.1

Same Day

1
Favors

10

100

Overnight

0.01

0.1

Same Day

1
Favors

10

100

Overnight

0.01

0.1

Same Day

1
Favors

10

100

Overnight

Despite analysis of >110,000 patients, unable to resolve a difference
A non-inferiority design with a sample size of > 320,000 patients needed for certainity
JACC: Cardiovascular Interventions 2013; 6(2):99-112.
AIM-RADIAL 2013

Timely Balance

Mitchell MD Circ Cardiovasc Qual Outcomes. 2012;5:454-462.
Evolution Cath Lab Procedures
AIM-RADIAL 2013

2010’s
Admit day of
Cath/PCI &
Discharge

2000’s
Admit day of
Cath/PCI
Discharge day after PCI
1990’s
Admit day of cath
PCI next day
1980’s Discharge day after PCI
Admit day before
Dx Procedure
Discharge day after cath

Driven by:
Technical Improvements
Patient Satisfaction
Efficacy
Payer Demands
“No Place Like Home”
AIM-RADIAL 2013

Dorothy-Wizard of Oz

After a well placed stent

Thank you
The Wizard of Oz. Metro-Goldwyn-Mayer, 1939

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Gilchrist IC - AIMRADIAL 2013 - Outpatient in the US

  • 1. Same-Day Discharge in the US Ready for Prime Time? Ian C Gilchrist, MD, FACC, FSCAI Professor of Medicine Pennsylvania State University Heart & Vascular Institute Hershey, PA 2nd Advanced International Masterclass AIM-RADIAL 2013
  • 3.
  • 5. Hazard of Hospitalization AIM-RADIAL 2013 Model from all 206,489 pts in Victoria, Australia 2005/6 Predicted Probability of Adverse Event (%) 30 Risk of an overnight hospital stay Skin Ulcers 25 20 0.4 Infections 15 11.1 10 Adverse Drug Reactions 5 3.4 0 1 2 3 4 5 Nights in the Hospital Hauck K, Zhao X. Med Care. 2011 Dec;49(12):1068-75 6 7
  • 6. Drivers of Same Day Care AIM-RADIAL 2013 Minimize Cost Hospital Hazards Improved PCI Reimbursement Same Day PCI
  • 8. Risks Same Day Discharge? AIM-RADIAL 2013 Ischemic Deaths >4 hrs post-PCI rare* • Access Site Bleeding rare TRI, low TFI • • • Education * Gibson, PROTECT-TIMI-30 Substudy, Am J Cardiol 2009;104:36-40. * Cutlip, Multicentered coronary stent trials, Circulation 2001;103:1967-1971
  • 9. Same Day v Overnight 30 Day Outcome AIM-RADIAL 2013 Odds Ratio Mantel-Haenszel Random effect, 95% CI Hospitalization MACE Complications RCT n=5 Subtotal (95% CI) Observational n=8 Subtotal (95% CI) Total (95% CI) 0.01 0.1 Same Day 1 Favors 10 100 Overnight 0.01 0.1 Same Day 1 Favors 10 100 Overnight 0.01 0.1 Same Day 1 Favors 10 100 Overnight Despite analysis of >110,000 patients, unable to resolve a difference A non-inferiority design with a sample size of > 320,000 patients needed for certainity JACC: Cardiovascular Interventions 2013; 6(2):99-112.
  • 10. AIM-RADIAL 2013 Timely Balance Mitchell MD Circ Cardiovasc Qual Outcomes. 2012;5:454-462.
  • 11. Evolution Cath Lab Procedures AIM-RADIAL 2013 2010’s Admit day of Cath/PCI & Discharge 2000’s Admit day of Cath/PCI Discharge day after PCI 1990’s Admit day of cath PCI next day 1980’s Discharge day after PCI Admit day before Dx Procedure Discharge day after cath Driven by: Technical Improvements Patient Satisfaction Efficacy Payer Demands
  • 12. “No Place Like Home” AIM-RADIAL 2013 Dorothy-Wizard of Oz After a well placed stent Thank you The Wizard of Oz. Metro-Goldwyn-Mayer, 1939

Hinweis der Redaktion

  1. &lt;http://antiquescientifica.com/archive7.htm&gt;copyrighted ©1982-2012 Alex PeckA G.I. severely wounded at Iwo Jima is prepared for surgery.
  2. 206,489 medical inpatients in all public hospitals in the state ofVictoria, Australia, for the year 2005/2006.
  3. Mitchell MD, Hong JA, Lee BY, et al. Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention. Circ Cardiovasc Qual Outcomes. 2012;5:454-462.$275 (95% CI, -$374 to -$183)a systematic review of published randomized controlled trials