Candidate for the Lee B. Lusted Student Prize Competition
Purpose: For patients undergoing elective percutaneous coronary intervention (PCI), shortening hospitalization has important cost implications and safety considerations. In studies of same-day discharge (SDD) compared to routine overnight observation in highly selected PCI populations, the overall safety profile is uncertain as some outcome were better with SDD and others were not. We assessed the cost-effectiveness of SDD for all eligible PCI patients.
Method: We developed a decision-analytic Markov model of patients post PCI to compare same-day discharge to routine overnight observation. Patients were followed from their index PCI over their remaining lifetime, including the possibility of repeat coronary procedures. We derived inputs from registries, randomized trials, and meta-analyses. The probabilities for SDD adverse outcomes were death (0.6%), major bleed (MB) (0.9%), myocardial infarction (MI) (2.6%), and target vessel revascularization (1.1%); overnight observation outcomes differed only for MI, at 0.6%. We adjusted mortality rates for previous adverse procedure outcomes. We estimated costs using micro-costing methods (2012 USD) and measured outcomes in QALYs, both considered from a societal perspective and discounted at 3% annually.
Result: Compared to current practice (routine overnight observation), same-day discharge costs $1,639 less but delivers 0.0028 fewer QALYs ($585,000 saved per QALY lost). This finding is sensitive to adverse outcome probabilities. SDD costs less and provides more QALYs for values of safety measures within the 95% confidence intervals – when the probabilities of adverse outcomes for SDD patients are lower (<0.57% for death, <0.60% for MB, or <2.32% for MI) or when the probabilities of adverse outcomes for overnight observation are higher (>0.63% for death, >0.90% for major bleeding events, or >2.89% for MI). In contrast, SDD costs more and is less effective if risks of SDD adverse events are substantially higher (>6.46% for MI) but still within the 95% confidence interval. Probabilistic sensitivity analyses reveal that SDD is frequently cost-effective even at higher willingness-to-pay thresholds (see figure).
Conclusion: While same-day discharge can likely reduce costs in many health systems, its health benefits relative to overnight observation appear close and uncertain. The attractiveness of same-day discharge may depend on the ability of particular systems to monitor and quickly respond to adverse events out of the hospital. Research in this area should prioritize establishing the safety profile of same-day discharge in representative patient populations.
