Same-Day Discharge After Elective Percutaneous Coronary Intervention for Chronic Total Occlusion in the UK.

OBJECTIVES: This study examines the safety and feasibility of same-day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) to coronary chronic total occlusions (CTOs) and explores independent associations of clinical and procedural characteristics with SDD. BACKGROUND: While the recently published consensus statements recommend SDD following uncomplicated CTO-PCI, there are limited studies to support this approach. METHODS: Data were obtained from the British Cardiovascular Intervention Society (BCIS) registry dataset including 21,330 patients who underwent CTO-PCI electively from 2007 to 2014 in England and Wales. We used multiple logistic regression to evaluate associations with SDD and the BCIS national risk model to examine for safety of SDD. RESULTS: Although overnight stay remained the standard of care following elective CTO-PCI, SDD practice increased from 21.7% to 44.7%. Women were less likely to have SDD than males. SDD was more common in higher CTO volume centers (36.3%) than low CTO volume centers (31.6%), and SDD patient profiles grew riskier over time, with the average age of SDD patients increasing from 61.4 years to 63.2 years. Transradial PCI was most strongly independently associated with SDD (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.80-2.09). Finally, the SDD observed 30-day mortality rates were not different vs those predicted by the BCIS risk model, and SDD was not independently associated with 30-day mortality (OR, 0.54; 95% CI, 0.25-1.15). CONCLUSION: This study illustrates that SDD is safe in selected patients undergoing CTO-PCI.

Rotational atherectomy and same day discharge: Safety and growth from a national perspective.

OBJECTIVES: We explore whether same day discharge (SDD) is a feasible and safe practice following rotational atherectomy (ROTA) treatment during elective percutaneous coronary intervention (PCI), and examine which baseline characteristics are independently associated with SDD. BACKGROUND: SDD following elective ROTA PCI is not recommended as per the recent SCAI consensus. However, reports show it is practiced and no previous study has evaluated its safety and feasibility. METHODS: Our dataset included 4,591 patients undergoing elective ROTA PCI in England & Wales within an 8-years period. Independent associations with SDD were quantified via a multiple logistic regression model and the BCIS 30-day mortality risk model was used to evaluate the safety of SDD. RESULTS: The majority of elective ROTA PCI cases remain at the hospital for overnight (ON) observation, although SDD rates increased substantially from 6.7% in 2007 to 35.5% in 2014. The use of glycoprotein IIb/IIIa antagonists, Q wave AMI, left main PCI and valvular heart disease were independently associated with ON, while patients operated underwent transradial PCI were more likely to be SDD (OR = 1.77, 95% CI [1.45-2.15]). Over the study period, observed mortality rates were not significantly higher than those expected from the BCIS risk model. CONCLUSIONS: Our findings did not show superiority of the ON strategy over SDD for higher risk cases undergoing elective ROTA PCI, in terms of 30-day mortality. This is the first study to examine the safety of SDD after elective ROTA PCI and more should follow.

Adoption of same day discharge following elective left main stem percutaneous coronary intervention.

BACKGROUND: This study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI. METHODS: We analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality. RESULTS: SDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30-1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17-1.41) and those requiring ON stay (OR 0.58 95%CI 0.25-1.34). CONCLUSIONS: We did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.

Comparative quantitative survey of patient experience in Barrett's oesophagus and other gastrointestinal disorders.

Objective: To assess health-related quality of life in patients with non-dysplastic Barrett's oesophagus (NDBO) and endoscopically treated dysplastic Barrett's oesophagus (DBO). Design: This quantitative, self-administered questionnaire study was conducted across three National Health Service hospitals. Data were collected from three other cohorts; gastro-oesophageal reflux disease (GORD), colonic polyp surveillance and healthy individuals. Fisher's exact and Spearman's rank correlation tests were used for analysis. Propensity score matching adjusted for age, sex and comorbidities. Results: 687 participants were eligible for analysis (NDBO n=306, DBO n=49, GORD n=132, colonic polyps n=152 and healthy n=48). 53% of NDBO participants reported similarly high cancer worry, comparable to DBO (50%, p=0.933) and colonic polyp participants (51%, p=0.355). Less cancer worry was reported in GORD participants (43.4%, p=0.01 vs NDBO). NDBO participants reported anxiety in 15.8% and depression in 8.6% of cases, which was similar to the other disease cohorts. Moderate or severe heartburn or acid regurgitation was found in 11% and 10%, respectively, in the NDBO cohort, comparable to DBO participants (heartburn 2% p=0.172, acid regurgitation 4% p=0.31) but lower (better) than GORD participants (heartburn 31% p=<0.001, acid regurgitation 25% p=0.001). NDBO participants with moderate or severe GORD symptoms were associated with higher rates of anxiety (p=<0.001), depression (p=<0.001) and cancer worry (p=<0.001). NDBO patients appropriately perceiving their cancer risk as low had lower rates of cancer worry (p=<0.001). Conclusion: This study provides insight into the problems Barrett's oesophagus patients may face. Future care pathways must be more patient focussed to address misconceptions of cancer risk, oesophageal cancer related worry and GORD symptom control.

Contributors to the Growth of Same Day Discharge After Elective Percutaneous Coronary Intervention.

BACKGROUND: Financial pressures for reducing hospitalization costs have driven to a move toward same day discharge (SDD) following uncomplicated percutaneous coronary intervention. The UK healthcare system has transitioned to predominantly SDD for elective percutaneous coronary intervention. This study aimed to examine patient's clinical, procedural, and institutional characteristics that are associated with the increased adoption of SDD adoption over time in the United Kingdom and determine whether these vary by region. METHODS: The data were derived from the British Cardiovascular Intervention Society including all the elective percutaneous coronary intervention from 2007 to 2014 in the United Kingdom. We structured 8 meaningful groups of variables, and their relative importance was obtained by decomposing the R2 in each study year. RESULTS: The relative importance of Strategic Health Authorities was substantially higher than all other factors every year, with some reduction over time, from 49.2% (95% CI, 45.4%-52.4%) in 2007 to 43.4% (95% CI, 39.9%-46.6%) in 2014. Center volume followed with 8.95% (95% CI, 7.0%-10.9%) to 19.8% (95% CI, 16.7%-22.4%). Between patients' clinical and procedural characteristics, pharmacology and access site had the highest relative importance values, from 14.3% (95% CI, 12.1%-16.4%) to 7.1% (95% CI, 5.5%-8.8%) and from 3.6% (95% CI, 2.3%-5.1%) to 11.8% (95% CI, 9.4%-14.3%), respectively. Relative importance of different groups varied differently across Strategic Health Authorities. CONCLUSIONS: Growth of SDD was mainly associated with regional characteristics, while subcontributors varied substantially between different regions. Standardized guidelines would provide more homogenous adoption of SDD nationally. This analysis might be of wider interest in healthcare systems slower in SDD adoption.

Same-Day Discharge After Elective Percutaneous Coronary Intervention: Insights From the British Cardiovascular Intervention Society.

OBJECTIVES: The aim of this study was to evaluate national temporal trends in same-day discharge (SDD) and compare clinical outcomes with those among patients admitted for overnight stay undergoing elective percutaneous coronary intervention (PCI) for stable angina. BACKGROUND: Overnight observation has been the standard of care following PCI, with no previous national analyses around changes in practice or clinical outcomes from health care systems in which SDD is the predominant practice for elective PCI. METHODS: Data from 169,623 patients undergoing elective PCI between 2007 and 2014 were obtained from the British Cardiovascular Intervention Society registry. Multiple logistic regressions and the British Cardiovascular Intervention Society risk model were used to study the association between SDD and 30-day mortality. RESULTS: The rate of SDD increased from 23.5% in 2007 to 57.2% in 2014, with center SDD median prevalence varying from 17% (interquartile range: 6% to 39%) in 2007 to 66% (interquartile range: 45% to 77%) in 2014. The largest independent association with SDD was observed for radial access (odds ratio: 1.69; 95% confidence interval: 1.65 to 1.74; p < 0.001). An increase in 30-day mortality rate over time for the SDD cases was observed, without exceeding the predicted mortality risk. According to the difference-in-differences analysis, observed 30-day mortality temporal changes did not differ between SDD and overnight stay (odds ratio: 1.15; 95% confidence interval: 0.294 to 4.475; p = 0.884). CONCLUSIONS: SDD has become the predominant model of care among elective PCI cases in the United Kingdom, in increasingly complex patients. SDD appears to be safe, with 30-day mortality rates in line with those calculated using the national risk prediction score used for public reporting. Changes toward SDD practice have important economic implications for health care systems worldwide.