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Gilchrist IC - AIMRADIAL 2013 - Outpatient in the US
1. Same-Day Discharge in the US
Ready for Prime Time?
Ian C Gilchrist, MD, FACC, FSCAI
Professor of Medicine
Pennsylvania State University
Heart & Vascular Institute
Hershey, PA
2nd Advanced International Masterclass
AIM-RADIAL 2013
5. Hazard of Hospitalization
AIM-RADIAL 2013
Model from all 206,489 pts in Victoria, Australia 2005/6
Predicted Probability of Adverse Event (%)
30
Risk of an overnight hospital stay
Skin Ulcers
25
20
0.4
Infections
15
11.1
10
Adverse
Drug
Reactions
5
3.4
0
1
2
3
4
5
Nights in the Hospital
Hauck K, Zhao X. Med Care. 2011 Dec;49(12):1068-75
6
7
6. Drivers of Same Day Care
AIM-RADIAL 2013
Minimize Cost
Hospital
Hazards
Improved PCI
Reimbursement
Same
Day PCI
9. Same Day v Overnight
30 Day Outcome
AIM-RADIAL 2013
Odds Ratio
Mantel-Haenszel Random effect, 95% CI
Hospitalization
MACE
Complications
RCT
n=5
Subtotal
(95% CI)
Observational
n=8
Subtotal
(95% CI)
Total (95% CI)
0.01
0.1
Same Day
1
Favors
10
100
Overnight
0.01
0.1
Same Day
1
Favors
10
100
Overnight
0.01
0.1
Same Day
1
Favors
10
100
Overnight
Despite analysis of >110,000 patients, unable to resolve a difference
A non-inferiority design with a sample size of > 320,000 patients needed for certainity
JACC: Cardiovascular Interventions 2013; 6(2):99-112.
11. Evolution Cath Lab Procedures
AIM-RADIAL 2013
2010’s
Admit day of
Cath/PCI &
Discharge
2000’s
Admit day of
Cath/PCI
Discharge day after PCI
1990’s
Admit day of cath
PCI next day
1980’s Discharge day after PCI
Admit day before
Dx Procedure
Discharge day after cath
Driven by:
Technical Improvements
Patient Satisfaction
Efficacy
Payer Demands
12. “No Place Like Home”
AIM-RADIAL 2013
Dorothy-Wizard of Oz
After a well placed stent
Thank you
The Wizard of Oz. Metro-Goldwyn-Mayer, 1939
206,489 medical inpatients in all public hospitals in the state ofVictoria, Australia, for the year 2005/2006.
Mitchell MD, Hong JA, Lee BY, et al. Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention. Circ Cardiovasc Qual Outcomes. 2012;5:454-462.$275 (95% CI, -$374 to -$183)a systematic review of published randomized controlled trials