Early discharge compared with ordinary discharge after percutaneous coronary intervention - a systematic review and meta-analysis of safety and cost.

AIM: We aimed to summarize the pooled effect of early discharge compared with ordinary discharge after percutaneous coronary intervention (PCI) on the composite endpoint of re-infarction, revascularization, stroke, death, and incidence of rehospitalization. We also aimed to compare costs for the two strategies. METHODS: The study was a systematic review and a meta-analysis of 12 randomized controlled trials including 2962 patients, followed by trial sequential analysis. An estimation of cost was considered. Follow-up time was 30 days. RESULTS: For early discharge, pooled effect for the composite endpoint was relative risk of efficacy (RRe)=0.65, 95% confidence interval (CI) (0.52-0.81). Rehospitalization had a pooled effect of RRe=1.10, 95% CI (0.88-1.38). Early discharge had an increasing risk of rehospitalization with increasing frequency of hypertension for all populations, except those with stable angina, where a decreasing risk was noted. Advancing age gave increased risk of revascularization. Early discharge had a cost reduction of 655 Euros per patient compared with ordinary discharge. CONCLUSION: The pooled effect supports the safe use of early discharge after PCI in the treatment of a heterogeneous population of patients with coronary artery disease. There was an increased risk of rehospitalization for all subpopulations, except patients with stable angina. Clinical trials with homogeneous populations of acute coronary syndrome are needed to be conclusive on this issue.

In-hospital cost comparison between percutaneous pulmonary valve implantation and surgery.

Objectives: Today, both surgical and percutaneous techniques are available for pulmonary valve implantation in patients with right ventricle outflow tract obstruction or insufficiency. In this controlled, non-randomized study the hospital costs per patient of the two treatment options were identified and compared. Methods: During the period of June 2011 until October 2014 cost data in 20 patients treated with the percutaneous technique and 14 patients treated with open surgery were consecutively included. Two methods for cost analysis were used, a retrospective average cost estimate (overhead costs) and a direct prospective detailed cost acquisition related to each individual patient (patient-specific costs). Results: The equipment cost, particularly the stents and valve itself was by far the main cost-driving factor in the percutaneous pulmonary valve group, representing 96% of the direct costs, whereas in the open surgery group the main costs derived from the postoperative care and particularly the stay in the intensive care department. The device-related cost in this group represented 13.5% of the direct costs. Length-of-stay-related costs in the percutaneous group were mean $3885 (1618) and mean $17 848 (5060) in the open surgery group. The difference in postoperative stay between the groups was statistically significant ( P ≤ 0.001). Conclusions: Given the high postoperative cost in open surgery, the percutaneous procedure could be cost saving even with a device cost of more than five times the cost of the surgical device.

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.

BACKGROUND: Misinterpretation of radiological examinations is an important contributing factor to diagnostic errors. Consultant radiologists in Norwegian hospitals frequently request second reads by colleagues in real time. Our objective was to estimate the frequency of clinically important changes to radiology reports produced by these prospectively obtained double readings. METHODS: We retrospectively compared the preliminary and final reports from 1071 consecutive double-read abdominal CT examinations of surgical patients at five public hospitals in Norway. Experienced gastrointestinal surgeons rated the clinical importance of changes from the preliminary to final report. The severity of the radiological findings in clinically important changes was classified as increased, unchanged or decreased. RESULTS: Changes were classified as clinically important in 146 of 1071 reports (14%). Changes to 3 reports (0.3%) were critical (demanding immediate action), 35 (3%) were major (implying a change in treatment) and 108 (10%) were intermediate (requiring further investigations). The severity of the radiological findings was increased in 118 (81%) of the clinically important changes. Important changes were made less frequently when abdominal radiologists were first readers, more frequently when they were second readers, and more frequently to urgent examinations. CONCLUSION: A 14% rate of clinically important changes made during double reading may justify quality assurance of radiological interpretation. Using expert second readers and a targeted selection of urgent cases and radiologists reading outside their specialty may increase the yield of discrepant cases.

Double reading of current chest CT examinations: Clinical importance of changes to radiology reports.

OBJECTIVES: Misinterpretation of radiological examinations is an important contributing factor to diagnostic errors. Double reading reduces interpretation errors and increases sensitivity. Consultant radiologists in Norwegian hospitals submit 39% of computed tomography (CT) reports for quality assurance by double reading. Our objective was to estimate the proportion of radiology reports that were changed during double reading and to assess the potential clinical impact of these changes. MATERIALS AND METHODS: In this retrospective cross-sectional study we acquired preliminary and final reports from 1023 consecutive double read chest CT examinations conducted at five public hospitals. The preliminary and final reports were compared for changes in content. Three experienced pulmonologists independently rated the clinical importance of these changes. The severity of the radiological findings in clinically important changes was classified as increased, unchanged, or decreased. RESULTS: Changes were classified as clinically important in 91 (9%) of 1023 reports. Of these: 3 were critical (demanding immediate action), 15 were major (implying a change in treatment) and 73 were intermediate (affecting subsequent investigations). More clinically important changes were made to urgent examinations and less to female first readers. Chest radiologist made more clinically important changes than other second readers. The severity of the radiological findings was increased in 73 (80%) of the clinically important changes. CONCLUSION: A 9% rate of clinically important changes made during double reading may justify quality assurance of radiological interpretation. Using expert second readers and targeting a selection of urgent cases prospectively may increase the yield of discrepant cases and reduce harm to patients.

Safe and feasible immediate retransfer of patients to the referring hospital after acute coronary angiography and percutaneous coronary angioplasty for patients with acute coronary syndrome.

BACKGROUND: The challenge with fast track (FT) is to avoid compromising medical safety. We aimed to investigate whether patients with acute coronary syndrome could be safely retransferred to the referral hospital on the same day after coronary angiography and/or percutaneous coronary angioplasty (PCI). METHODS AND RESULTS: A total of 399 consecutive patients were prospectively randomized: 206 to ordinary care (OC) and 193 to the FT group. Of these, 30% of patients were admitted for unstable angina pectoris and 70% for non-ST-segment elevation myocardial infarction. The FT patients were evaluated for possible same-day return after angiography and/or PCI. Crossover, acute, and 30-day major events were recorded. The radial approach was used in 91 and 87% in the OC and FT group, respectively. Of the FT patients, 95% were returned on the same day and nine crossover patients (4.7%) the next day or later. Major events occurred in nine patients (2.2%); five in the OC and four in the FT group. There were a total of five events within 24 hours. No events were observed during transportation and there were no early retransfers. CONCLUSIONS: Immediate written reports and good communication with the referring hospital enabled thoroughly selected patients to be safely returned on the same day as angiography and/or PCI.