Same-Day Discharge: Requirement or Nice to Have?

For the past several months, we have attempted to inform, educate, and bring greater awareness to the challenges, complexities and solutions to operating a cardiac cath lab in the modern healthcare era. Whether it is the ongoing uncertainty of the Affordable Care Act (ACA), or the changing dynamics of an evolving healthcare system, the cath lab has endured throughout the decades as a place where new life-saving procedures evolve and eventually mature. It is a remarkable place to work if you are fortunate enough to be a part of this dynamic environment within a hospital.  

 

Well, times they are a-changin’, as they say. New procedures still find their way into the cath lab, and it continues to become an increasingly complex environment, but now it is forced to face increasing economic and operational challenges, which, after decades, has caused many labs to struggle to demonstrate profitability. Therefore, it is essential that cath labs look inward and assess their internal operations and care pathways. Cath labs must determine where they can operationalize improvements to lead to new care pathways that ostensibly are far more cost effective and generate additional benefits to the patient, e.g., same-day discharge (SDD).Such change is essential if today’s labs are to meet the dual challenge of population health and patient consumerism. Data continue to support the cost effectiveness, patient preference, and profitability of SDD.¹   

 

Pundits would argue that SDD is nothing more than “marketing”, but with the advent of the Centers for Medicare & Medicaid Services (CMS) Two-Midnight Rule and the Recovery Audit Contractor’s (RAC) increased attention to Medicare claims, there is a purposeful shift toward seeing more procedures performed as outpatient. This has definitely put stress and strain on the cath lab to manage profitability. A recent publication by Amin et al identified significant costs associated with non-same day discharge (NSDD), irrespective of access technique (radial vs femoral); however, costs were improved when utilizing the transradial access technique.²   

 

Numerous single-center studies and meta-analyses have been published over the past several years that speak to the feasibility of performing SDD discharge for the uncomplicated percutaneous coronary intervention (PCI). Recently, Din et al published results from a survey of U.S., Canadian, and U.K. interventional cardiologists assessing length of stay (LOS) variability, appropriateness, and safety for the PCI patient.³ Of note was the utilization of SDD by country, with the U.K. making greatest use of SDD at 57% and the U.S. at only 14%. Din et al emphasized the urgent need for an update of the guidelines, as well as a need for a concerted effort to educate interventional cardiologists regarding appropriate LOS. In 2016, Shroff et al sought to evaluate the current perspectives and evidence related to SDD and the PCI patient.⁴ They observed a need to address specific programmatic features to achieve the successful implementation of a SDD program, as well as the potential for a SDD program to improve patient satisfaction, increase bed availability, and reduce costs. In a recent editorial commenting on a single-center study from Koutouzis et al, Ian Gilchrist, an interventional cardiologist from Hershey Medical Center in Hershey, Pennsylvania, commented, “once the patient has undergone a relatively uneventful PCI, pre-procedural risk models are no longer relevant since the dominate short-term risk of the procedure has passed, and chronic risk factors for long-term outcome dominate the future risk.”⁵ Dr. Gilchrist further comments that the consensus on SDD is consistent with three criteria: 1) an uncomplicated procedure with an excellent stent result; 2) no complications during hemostasis and 4 to 6 hours of observation; and 3) social support immediately available after discharge with access to healthcare.⁵

 

Therefore, when assessing the results from various studies, SDD has been shown to be safe and feasible, but it appears that there is reluctance in the U.S., whether on the part of physicians or hospitals, to embrace any programmatic use of SDD in the cardiac cath lab. With an ever-increasing need within healthcare to drive down costs, this would seem to be a missed opportunity. When surveying hospital executives, surveys (Figure 1) continue to point to reduction in care variation, care standardization, shifting care to ambulatory care settings, improved use of clinical resources, etc., as key areas for increased value, quality, and costs.⁶

To address these challenges, cath labs must consider how they rank in four key areas: transformational, organizational, clinical, and operational. To help labs assess their current state relative to other labs, MedAxiom has developed the Cath Lab MedXcellence survey. This tool allows cath lab leaders and physicians to self-assess their performance and receive a customized score card that benchmarks one’s own responses against those of other respondents. To take the survey, simply go to: 

 

www.medaxiom.com/CathLabSurvey

 

Achieving the necessary programmatic changes requires that labs will need to address challenges that include (but are not limited to) population health and consumerism. It will require cath lab leaders to ensure an environment that embraces the “quadruple aim” in terms of physician and staff satisfaction, analytical capability to assess clinical performance across all settings of care, understanding episodic costs of care and how resources are utilized by specific populations across the care continuum, and a clear understanding of the lab’s clinical performance in relation to the CMS initiatives (Episode Payment Models [EPMs] or Alternative Payment Models [APMs]) and/or commercial payer contracts with value-based reimbursement or incentives.⁷

 

In closing, there are significant opportunities for cath labs to achieve the necessary operational changes to address the challenges facing the dynamic cath lab environment. These operational changes include greater use of SDD, increased attention to case mix, physician alignment, and the use of the appropriate care pathways that will achieve quality outcomes in the most cost-effective manner. CMS will continue to challenge providers to meet new value-based reimbursement requirements, e.g., acute myocardial infarction (AMI) bundles. Consumerism will continue to put pressure on providers to deliver care in a setting that is most conducive to the lowest cost without sacrificing quality. Hospital cath labs need to be cognizant that in some markets, we are already witnessing leakage of high-paying, low-acuity cath lab procedures into the ambulatory setting. Should reimbursement change to support greater use of these freestanding cath labs, hospitals will be further challenged to manage their cath lab profitability. 

 

Terumo and MedAxiom have formed a partnership that is working with cath labs to assess and implement operational improvements with the specific goal of achieving the full clinical and operational benefits associated with, but not limited to, transradial access and SDD. The combined expertise of clinical and cardiovascular operational knowledge makes the Terumo and MedAxiom teams ideally suited to assist your cath lab. If you are interested in an assessment of your program’s staffing, operations, care hand-offs, clinical standardization, quality, and per case cost, contact us, and see how we can help to enhance your program’s operational efficiency and improve profitability.