Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

Accelerated care with early discharge after PTCA was safe and cost-effective

ACP J Club. 1998 Nov-Dec; 129:79. doi:10.7326/ACPJC-1998-129-3-079


Source Citation

Grines CL, Marsalese DL, Brodie B, et al., for the PAMI-II Investigators. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. J Am Coll Cardiol. 1998 Apr;31:967-72.


Abstract

Question

Is early discharge (within 3 d) after percutaneous transluminal coronary angioplasty (PTCA) safe and cost-effective for low-risk patients after myocardial infarction (MI)?

Design

Randomized controlled trial with 6-month follow-up (Primary Angioplasty in Myocardial Infarction [PAMI-II] Trial).

Setting

34 clinical centers in 5 countries.

Patients

981 patients with symptoms for < 12 hours who had electrographic or angiographic evidence of MI. Exclusion criteria were cardiogenic shock, clinical indications for intra-aortic balloon pumping, lack of peripheral vascular access, contraindications for aspirin or heparin, unlikely benefit from PTCA, or need for bypass surgery. Patients received aspirin, 325 mg; heparin as a 10 000-unit bolus; intravenous nitroglycerin; β-adrenergic blocking agents (if no contraindications existed); and PTCA. 471 low-risk patients (mean age 55 y, 76% men), defined as ≥ 70% stenosis, left-ventricular ejection fraction > 45%, and successful PTCA of a native coronary artery, were studied. Follow-up was 96%.

Intervention

237 patients were allocated to accelerated care and 234 to traditional care. Accelerated care included admission to a nonintensive care unit, full-dose heparin for 48 hours and half-dose heparin for 12 hours, and discharge on day 3 if no adverse events occurred. Non-invasive testing was not recommended. Traditional care included admission to a coronary care unit, intravenous heparin for 72 hours, and hospital stay ≥ 5 days.

Main cost and outcome measures

A combined end point of death, re-infarction, unstable ischemia, stroke, or congestive heart failure by 6 months. Costs included all inpatient expenses in U.S. dollars (room and board, laboratory and diagnostic testing, and pharmacy).

Main results

The groups did not differ for events that occurred in the hospital. 142 of 178 (80%) patients in the accelerated-care group were discharged on day 3. The groups did not differ for the combined end point at 6 months (15.2% for accelerated care vs 17.5% for traditional care, P > 0.2) or for any individual outcome except the initial hospital stay, which was shorter in the accelerated-care group (4.2 vs 7.1 d, P < 0.001). Initial costs were lower in the accelerated-care group (U.S. $9658 vs $11 604, P = 0.002).

Conclusion

Accelerated care with early discharge after percutaneous transluminal coronary angioplasty was safe and cost-effective for low-risk patients with myocardial infarction.

Sources of funding: Advanced Cardiovascular Systems; Mallinckrodt Medical, Inc.; Datascope Corporation; St. Jude Medical; Siemens Corporation.

For correspondence: Dr. C.L. Grines, Division of Cardiology, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073-6769, USA. FAX 248-551-8806.


Commentary

Hospital length of stay and procedure utilization are the best targets for cost-reduction interventions in patients with acute coronary syndromes. Grines and colleagues selected a very low-risk group of patients with acute MI and showed that immediate successful revascularization with PTCA permitted early hospital discharge and reduced subsequent noninvasive testing without compromising 6-month outcome. It is not known whether a similar strategy in patients excluded from this study (i.e., those who were > 70 y, had multivessel disease, had left ventricular dysfunction, or had early complications) would achieve the same economic benefits without risking adverse events or whether early discharge is possible in uncomplicated patients without cardiac catheterization and PTCA.

This study finished enrollment 3.5 years ago, and economic pressures have since dramatically reduced mean length of stay for patients in the United States to approximately 5 days. In addition, this study was done before endoluminal stents and more potent antiplatelet agents (the glycoprotein IIb/IIIa inhibitors abciximab, eptifibatide, and tirofiban) were available to facilitate PTCA. These adjuncts increase the interventional procedure cost but should decrease costs associated with treating recurrent ischemia, reocclusion, and restenosis and should produce better clinical outcomes in higher-risk patients.

The economic analysis in this paper is limited by the absence of 6-month data; thus, maintenance of the cost benefit of an early discharge strategy remains to be shown. Nevertheless, the ongoing debate about the superiority of pharmacologic compared with catheter-based reperfusion therapy in acute MI may ultimately be decided not by clinical outcomes (e.g., death, MI, or stroke) but by 6-month economic analyses, which should show fewer subsequent hospital days and lower procedure costs for the early interventional strategy.

Eric R. Bates, MD
University of Michigan Medical CenterAnn Arbor, Michigan, USA

Eric R. Bates, MD
University of Michigan Medical Center
Ann Arbor, Michigan, USA