Current usage and attitudes among interventional cardiologists regarding the performance of percutaneous coronary intervention (PCI) in the outpatient setting

Trends and Outcomes After Same-Day Discharge After Percutaneous Coronary Interventions

BACKGROUND

Despite the demonstrated safety of the same-day discharge (SDD) after percutaneous coronary intervention (PCI), uptake of this program has been relatively poor in the United States. We evaluated the temporal trends and variations in the utilization of SDD after PCI during the contemporary era. In addition, we evaluated the predictors of SDD (compared with next-day discharge) and the causes of readmission in these 2 patient cohorts.

METHODS AND RESULTS

Data were extracted from State Ambulatory Surgical Database and State Inpatient Database from Florida and New York ranging from 2009 to 2013. All adults undergoing PCI in an outpatient setting were included. Data were merged with the directory available from the American Hospital Association to obtain detailed information on hospital-related characteristics. Unplanned readmissions within 7 and 30 days constituted the coprimary outcomes. There was modest increase in the proportion of SDD after PCI from 2.5% in 2009 to 7.4% in 2013 (P-trend <0.001). SDD was more frequently used among male and younger patients with fewer comorbidities. There were considerable differences in the discharge practices among the different hospital types. Larger hospitals, teaching hospitals, and high PCI volume hospitals had higher utilization of SDD compared with their respective counterparts. SDD and next-day discharge cohorts had similar rates of unplanned readmissions, in-hospital mortality, and acute myocardial infarction during follow-up. Furthermore, uninsured patients had significantly lower odds of SDD along with higher incidence of unplanned readmission within 30 days after PCI compared with insured patients.

CONCLUSIONS

During 2009 to 2013, there has been a modest increase in SDD after PCI. Several demographic and clinical characteristics play critical role in determination of SDD after PCI. There were significant disparities in discharge practices between different sex, racial, and insurance-based strata.

Current use of fractional flow reserve: a nationwide survey

Major medical society guidelines recommend the measurement of fractional flow reserve (FFR) as an aid in choosing percutaneous coronary intervention in patients with stable coronary artery disease. We investigated the measurement of FFR among interventionalists, analyzing operators' attributes and decision-making processes to reveal differences in their applications of FFR and the reasons for those differences. An electronic survey study of 1,089 interventionalists was performed from 2 February through 6 March 2012, yielding 255 responses. Most respondents were >45 years old (58%), worked primarily in a community hospital (59%), and performed 10 to 30 cases per month (52%). More than half (145/253, 57%) used FFR measurement in less than one third of cases, and 39 of 253 (15%) never used it. There were no differences in use of FFR by age, practice location, or angiogram volume (P >0.05 for all). Respondents used FFR measurement more frequently than intravascular ultrasonography (73% vs 60%) to help guide the decision to stent (P <0.01). Operators reported that their primary reasons for not using FFR were lack of availability (47%) and problems with reimbursement (39%). There was no difference in FFR use by operator age, practice setting, or case volume.

Cost effectiveness of a gene expression score and myocardial perfusion imaging for diagnosis of coronary artery disease

BACKGROUND

Over 3 million patients annually present with symptoms suggestive of obstructive coronary artery disease (oCAD) in the United States (US), but a cardiac etiology is found in as few as 10% of cases. Usual care may include advanced cardiac testing with myocardial perfusion imaging (MPI), with attendant radiation risks and increased costs of care. We estimated the cost effectiveness of CAD diagnostic strategies including "no test," a gene expression score (GES) test, MPI, and sequential strategies combining GES and MPI.

METHODS

We developed a Markov-based decision analysis model to simulate outcomes and costs in patients presenting to clinicians with symptoms suggestive of oCAD in the US. We estimated quality-adjusted life years (QALYs), total costs, and incremental cost-effectiveness ratios (ICERs) for each strategy.

RESULTS

In our base case, the 2-threshold GES strategy is the most cost-effective strategy at a threshold of $100,000 per QALY gained, with an ICER of approximately $72,000 per QALY gained relative to no testing. Myocardial perfusion imaging alone and the 1-threshold strategy are weakly dominated. In sensitivity analysis, ICERs fall as the probability of oCAD increases from the base case value of 15%. The ranking of ICERs among strategies is sensitive to test costs, including the time cost for testing. The analysis reveals ways to improve on prespecified GES thresholds.

CONCLUSIONS

Diagnostic testing for oCAD with a novel GES strategy in a 2-threshold model is cost effective by conventional standards. This diagnostic approach is more efficient than usual care of MPI alone or a 1-threshold GES strategy in most scenarios.

Risks of death and graft failure after surgical versus percutaneous coronary revascularization in renal transplant patients

Background

Reliable data regarding absolute and relative risks of death and graft failure after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in renal transplant patients are unavailable.

Methods and Results

Renal transplant patients undergoing inpatient CABG (n=1400) or PCI (n=4097) were identified from United States Renal Data System data. Cumulative incidence of nonfatal graft failure and death was reported for observed events. A Cox model with the Fine–Gray method was used to account for competing risks in assessing relative hazards. Age and race were similarly distributed; patients who underwent CABG were more likely to have acute arrhythmia and congestive heart failure but less likely to have acute myocardial infarction on index admission. In‐hospital death was more frequent after CABG (5.6% versus 3.0%, P<0.001). Cumulative incidence of death, graft failure, and the combined outcome at 3 years were 23.1%, 15.4%, and 38.5% after CABG and 22.9%, 13.3%, and 36.1% after PCI, respectively. In adjusted analyses, CABG was not associated with increased risk of graft failure versus PCI during the first 6 months (hazard ratio 1.06, 95% CI 0.79 to 1.43) or from 6 to 36 months (0.98, 0.78 to 1.22). Risk of death increased after CABG during the first 3 months (1.37, 1.08 to 1.73), but decreased from 6 months on (0.76, 0.63 to 0.93).

Conclusions

CABG does not appear to be associated with a difference in risk of graft failure compared with PCI in renal transplant patients. Compared with PCI, adjusted risk of early death is higher after CABG; however, mortality from 6 months on is lower.

Trends during 1993-2004 in the availability and use of revascularization after acute myocardial infarction in markets affected by certificate of need regulations

This study examines trends in the diffusion of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) during 1993-2004 for patients with acute myocardial infarction in markets with and without Certificate of Need (CON) regulations for open-heart surgery or cardiac catheterization and in markets that repealed CON for either of these procedures. In contrast to prior studies, this study accounts for regional hospital markets that cross state boundaries-often with different CON activities in each state. The overall use of CABG increased modestly throughout the 1990s and subsequently decreased, corresponding to a dramatic increase in PCI. There was a greater rise in the number of CABG programs in markets with significant reduction in CON regulations during 1993-2004 compared with other markets, but CON reduction was not related to growth of PCI programs. Reimbursement, ease of use, clinician endorsement, and technological advances in PCI may outweigh effects of CON.

Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Endorsed by the American College of Cardiology Foundation

Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same-day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention.

Outpatient percutaneous coronary intervention: Ready for prime time?

Outpatient practice after percutaneous coronary intervention (PCI) is gaining momentum due to constantly optimizing results. Furthermore, the availability of limited beds to handle the large volume of coronary interventions also promotes outpatient practice. The present report relates the current experience with same-day discharge and defines persisting challenges in promoting accelerated in-hospital turnover. Since the mid-1990s, there have been several reports on same-day discharge following uncomplicated procedures. Overall, the success of outpatient PCI practice is based on a few technological and pharmacological advances. First, the systematic use of stents and potent antiplatelet agents have revolutionized the acute success rates of PCI by virtually eliminating the risks of acute vessel closure within the first 24 h following a successful procedure. Second, the miniaturization of catheter sizes has also simplified access site management, accelerated ambulation time and limited the risks of puncture site bleeding. In this regard, the transradial approach initially described in Canada and later popularized in Europe has transformed the acute care of patients after PCI. Today, however, the practice of transradial PCI still varies largely from country to country. From the literature review, it appears that after a short period of observation (4 h to 6 h), the majority of eligible patients who have undergone uncomplicated coronary stenting can be discharged on the same day. Whereas implementation of same-day discharge to referring centres is simple, home discharge requires the development of structured outpatient programs with dedicated resources to assist the patient and family with short-term logistics, to provide reassurance, to serve as a 'safety net' and, lastly, to promote medication compliance and cardiovascular risk factor management. Further studies are required to better define the cost-minimization effects of outpatient PCI practice, as well as patient perception of fast-track PCI. It is proposed that outpatient PCI will likely continue to expand over the next decade.

Coronary revascularization in the community. A population-based study, 1990 to 2004

OBJECTIVES

We sought to examine temporal trends in the utilization of coronary revascularization in a geographically defined population.

BACKGROUND

Earlier reports on revascularization utilization focused on inpatient settings and did not distinguish incident from recurrent procedures. Furthermore, little is known on age- and gender-specific trends. Finally, longitudinal data on the utilization and results of coronary angiography as explanatory factors for the changing revascularization practice are lacking.

METHODS

Data integrating diagnostic and therapeutic coronary procedures performed in Olmsted County (Minnesota) between 1990 and 2004 were analyzed. Standardized rates were calculated applying the direct method and temporal trends compared using Poisson regression models.

RESULTS

Revascularization utilization increased by 24% during the study (95% confidence interval [CI] 5% to 46%), but the trends diverged by procedure type, with a sustained increase (69%, 95% CI 43% to 101%) for percutaneous coronary interventions (PCI) contrasting with a stabilization, then decline (-33%, 95% CI -16% to -47%) for coronary artery bypass grafting (CABG). For PCI, although the use increased in all categories, greater increases were noted in the elderly, in women, and for recurrent procedures. No such patterns were detected for CABG. Angiography use remained stable, and the rate of 3-vessel and/or left main disease declined (-22%, 95% CI -8% to -33%).

CONCLUSIONS

Over the 15-year period, revascularization increased in the community with a large increase in PCI partially offset by a decrease in CABG. More PCIs are performed in women and the elderly and for recurrent disease. These changes occurred within the context of a decline in multivessel disease and thus likely reflect the natural history of coronary artery disease.