Association of Same-Day Discharge after Elective Percutaneous Coronary Intervention in the United States with Costs and Outcomes

Amit P. Amin, Duane Pinto, John A. House, Sunil V. Rao, John A. Spertus, Mauricio G Cohen, Samir Pancholy, Adam C. Salisbury, Mamas A. Mamas, Nathan Frogge, Jasvindar Singh, John Lasala, Frederick A. Masoudi, Steven M. Bradley, Jason H. Wasfy, Thomas M. Maddox, Hemant Kulkarni

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

Importance: Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. Objective: To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. Design, Setting, and Participants: This observational cross-sectional cohort study included 672470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up. Exposures: Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. Main Outcomes and Measures: Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals' perspective, inflated to 2016. Results: Among 672470 elective PCIs, 221997 patients (33.0%) were women, 30711 (4.6%) were Hispanic, 51961 (7.7%) were African American, and 491823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95% CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates. Conclusions and Relevance: Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.

Original languageEnglish (US)
JournalJAMA Cardiology
DOIs
StateAccepted/In press - Jan 1 2018

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Percutaneous Coronary Intervention
Costs and Cost Analysis
Acute Kidney Injury
Hospital Costs
Myocardial Infarction
Hemorrhage
Incidence
Safety
Cost Savings
Patient Discharge
Hispanic Americans
Blood Transfusion
African Americans
Cohort Studies
Cross-Sectional Studies
Outcome Assessment (Health Care)
Databases
Delivery of Health Care
Mortality

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Association of Same-Day Discharge after Elective Percutaneous Coronary Intervention in the United States with Costs and Outcomes. / Amin, Amit P.; Pinto, Duane; House, John A.; Rao, Sunil V.; Spertus, John A.; Cohen, Mauricio G; Pancholy, Samir; Salisbury, Adam C.; Mamas, Mamas A.; Frogge, Nathan; Singh, Jasvindar; Lasala, John; Masoudi, Frederick A.; Bradley, Steven M.; Wasfy, Jason H.; Maddox, Thomas M.; Kulkarni, Hemant.

In: JAMA Cardiology, 01.01.2018.

Research output: Contribution to journalArticle

Amin, AP, Pinto, D, House, JA, Rao, SV, Spertus, JA, Cohen, MG, Pancholy, S, Salisbury, AC, Mamas, MA, Frogge, N, Singh, J, Lasala, J, Masoudi, FA, Bradley, SM, Wasfy, JH, Maddox, TM & Kulkarni, H 2018, 'Association of Same-Day Discharge after Elective Percutaneous Coronary Intervention in the United States with Costs and Outcomes', JAMA Cardiology. https://doi.org/10.1001/jamacardio.2018.3029
Amin, Amit P. ; Pinto, Duane ; House, John A. ; Rao, Sunil V. ; Spertus, John A. ; Cohen, Mauricio G ; Pancholy, Samir ; Salisbury, Adam C. ; Mamas, Mamas A. ; Frogge, Nathan ; Singh, Jasvindar ; Lasala, John ; Masoudi, Frederick A. ; Bradley, Steven M. ; Wasfy, Jason H. ; Maddox, Thomas M. ; Kulkarni, Hemant. / Association of Same-Day Discharge after Elective Percutaneous Coronary Intervention in the United States with Costs and Outcomes. In: JAMA Cardiology. 2018.
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abstract = "Importance: Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. Objective: To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. Design, Setting, and Participants: This observational cross-sectional cohort study included 672470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up. Exposures: Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. Main Outcomes and Measures: Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals' perspective, inflated to 2016. Results: Among 672470 elective PCIs, 221997 patients (33.0{\%}) were women, 30711 (4.6{\%}) were Hispanic, 51961 (7.7{\%}) were African American, and 491823 (73.1{\%}) were white. The adjusted rate of SDD was 3.5{\%} (95{\%} CI, 3.0{\%}-4.0{\%}), which increased from 0.4{\%} in 2006 to 6.3{\%} in 2015. We observed substantial hospital variation for SDD from 0{\%} to 83{\%} (median incidence rate ratio, 3.82; 95{\%} CI, 3.48-4.23), implying an average (median) 382{\%} likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95{\%} CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates. Conclusions and Relevance: Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.",
author = "Amin, {Amit P.} and Duane Pinto and House, {John A.} and Rao, {Sunil V.} and Spertus, {John A.} and Cohen, {Mauricio G} and Samir Pancholy and Salisbury, {Adam C.} and Mamas, {Mamas A.} and Nathan Frogge and Jasvindar Singh and John Lasala and Masoudi, {Frederick A.} and Bradley, {Steven M.} and Wasfy, {Jason H.} and Maddox, {Thomas M.} and Hemant Kulkarni",
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T1 - Association of Same-Day Discharge after Elective Percutaneous Coronary Intervention in the United States with Costs and Outcomes

AU - Amin, Amit P.

AU - Pinto, Duane

AU - House, John A.

AU - Rao, Sunil V.

AU - Spertus, John A.

AU - Cohen, Mauricio G

AU - Pancholy, Samir

AU - Salisbury, Adam C.

AU - Mamas, Mamas A.

AU - Frogge, Nathan

AU - Singh, Jasvindar

AU - Lasala, John

AU - Masoudi, Frederick A.

AU - Bradley, Steven M.

AU - Wasfy, Jason H.

AU - Maddox, Thomas M.

AU - Kulkarni, Hemant

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Importance: Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. Objective: To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. Design, Setting, and Participants: This observational cross-sectional cohort study included 672470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up. Exposures: Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. Main Outcomes and Measures: Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals' perspective, inflated to 2016. Results: Among 672470 elective PCIs, 221997 patients (33.0%) were women, 30711 (4.6%) were Hispanic, 51961 (7.7%) were African American, and 491823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95% CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates. Conclusions and Relevance: Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.

AB - Importance: Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. Objective: To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. Design, Setting, and Participants: This observational cross-sectional cohort study included 672470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up. Exposures: Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. Main Outcomes and Measures: Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals' perspective, inflated to 2016. Results: Among 672470 elective PCIs, 221997 patients (33.0%) were women, 30711 (4.6%) were Hispanic, 51961 (7.7%) were African American, and 491823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95% CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates. Conclusions and Relevance: Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.

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