Outpatient stenting James R Wilentz MD Assistant Professor

Outpatient stenting James R Wilentz, MD Assistant Professor of Medicine Albert Einstein College of Medicine Interventional Cardiologist Beth Israel Medical Center and St Vincent’s Hospital New York, NY Ian C Gilchrist, MD Associate Professor of Medicine Cardiology Division MS Hershey Medical Center Hershey, PA

Outpatient stenting Motivation My patients wanted to go home early. Radial approach to stenting puts patients on their feet quickly, and I couldn’t come up with any good reason to keep them in hospital. -Ian Gilchrist

Outpatient stenting Adjunctive therapies All patients receive: aspirin and Plavix (or something similar) GP IIb/IIIa inhibitor (6 -hour infusion due to time constraints) Heparin in the cath lab (up to an ACT of 200 -300 seconds) -Ian Gilchrist

Outpatient stenting Catheterization procedure Radial artery approach (5 Fr or 6 Fr catheter) Direct stenting, or balloon and stent If procedure is uncomplicated with an optimal result, the patient is offered the chance to go home the same day. -Ian Gilchrist

Outpatient stenting Motivation We were doing early studies with vascular sealing and patients didn’t need to stay. It feels to the patients like a diagnostic catheterization. The post-procedural course is less complicated than for some other outpatient surgeries. -James Wilentz

Outpatient stenting Catheterization procedure Femoral approach with vascular sealing devices (DUETT™ and Vaso. Seal®) We were concerned about using the radial artery because there was a 3 -5% rate of occlusion which could potentially compromise a bypass conduit for the future. 6 Fr and 8 Fr devices Ambulation at 4. 25 hours and discharge at 5 hours (6 Fr) 45 outpatients and only 1 complication (pseudoaneurysm) -James Wilentz JR, et. al. J Invasive Cardiol 1999 Dec; 11(12): 709 -717.

Outpatient stenting Using GP IIb/IIIa inhibitor GP IIb/IIIa for only 6 hours should be looked at in a serious way, because all reports demand long infusion for efficacy. We excluded GP IIb/IIIa from our group, and that might open us to some criticism. The strongest data for GP IIb/IIIa is from the CAPTURE study (unstable angina with positive troponin) and those patients ought not to be considered for outpatient stenting. -James Wilentz

Outpatient stenting On GP IIb/IIIa EPIC started the idea that “longer is better” for GP IIb/IIIa infusion. The idea is being reconsidered following recent trials (oral IIb/IIIa and GUSTO IV-ACS). Unpublished retrospective analysis of ESPRIT data suggests the same benefit in low-risk patients who got integrilin for <6 hours, 6 -12 h, or the full 18 -24 h. We don’t really know the optimum infusion time. -Ian Gilchist

Outpatient stenting Cost savings Cost of outpatient stenting per patient, including vascular sealing $213/patient Cost savings per patient by avoiding average overnight stay (26 hours) in our cardiac stepdown unit $478/patient Cost savings per patient if using average length of hospital stay (2. 2 days) reported nationally $1155/patient Wilentz JR, et. al. J Invasive Cardiol 1999 Dec; 11(12): 709 -717.

Outpatient stenting Nationwide savings “And when you look throughout the United States 666, 000 percutaneous interventions, 65% stenting with a conservative estimate of 20% eligible for an outpatient therapy, that would be savings nationwide of between 40 and 100 million dollars. Which although it may not be a huge dent in the national budget, it’s significant. ” -James Wilentz

Outpatient stenting Throughput Our incentive was not only cost considerations. Our cath-lab holding area also doubles as our chest pain center. If we can get a patient out in 6 -8 hours, we have another bed available. -Ian Gilchrist Throughput is eased by this method. If you know patients are outpatient candidates, you can schedule patients more easily. -James Wilentz

Outpatient stenting Family logistics The families don’t understand that they block the system by not picking up their family member on time. With outpatient treatment, the family often doesn’t leave and therefore aren’t delayed getting back. -Ian Gilchrist

Outpatient stenting Safety has improved over the years. Rates of acute closure: -NHLBI angioplasty registry (1983) 7. 5% -NHLBI angioplasty registry (1985 -6) 6. 8% -Richard Myler study in JACC (1992) 4. 9% -Ticlopidine/stent registries (1996) 0. 8% -STARS trial (1998) 0. 5% -James Wilentz

Outpatient stenting Safety Most recently at our institution, 12/1600 (0. 75%) stenting patients have had acute closures (includes CCU patients). Patients chosen for outpatient treatment MI >24 hours ago stable or unstable angina no active ST segment deviations no angiographic thrombus in the lesions In this group one would expect the in-hospital occlusion rate to be vanishingly low. -James Wilentz

Outpatient stenting Hazards Recent data pooled from 3 trials not using GPIIb/IIIa found a stent thrombosis rate in these patients of 2 in a 1000 over a 30 -day period. Cutlip DE, et al. Circulation 2001 Apr 17; 103(15): 1967 -1971. There are hazards of being in a hospital. Patients don’t get a good night’s sleep, and are less able to understand their discharge instructions or otherwise function the next day. -Ian Gilchrist

Outpatient stenting Staff mindset The staff in the cath-lab and discharge unit need a whole different mindset. There has to be a protocol for education of the patient. Patients must receive discharge instructions re possible bleeding. -James Wilentz

Outpatient stenting Patient education A full-time nurse practitioner in our holding bay Pre-written instructions for the patient A 24 -hour number for patient questions The nurses need to take the initiative in preparing patients for discharge in the outpatient setting. -Ian Gilchrist

Outpatient stenting Post-procedure protocol We aim for a 2. 5 hour time to ambulation with observation of patients just prior to ambulation. Discharge is half an hour after they have ambulation, if there are no complications. A study is needed of either short infusion GP IIb/IIIa or perhaps a high dose Plavix bolus or pre-treatment to see if it is safe from acute complications. -James Wilentz

Outpatient stenting Will it catch on? “If you look at, historically, other procedures that have gone from ‘must be done in the hospital’, to ‘could be done maybe as an outpatient’, to ‘now done invariably as an outpatient’, that this is something that is going to be a primarily outpatient procedure for the patient who is an elective stent patient. ” -James Wilentz

Outpatient stenting Patient enthusiasm Patients usually feel good at the end of the day, more so than for some other outpatient procedures. Locally, we have had patients leaving other hospitals because they want outpatient stenting at Hershey. If the finances can be straightened out, it can be more cost effective, and if the payor recognizes the benefit they may start to demand it. -Ian Gilchrist

Outpatient stenting Why use the radial approach? A convenient, one-day approach It is a cost saving measure. The radial approach eliminates major groin complications. You can make the argument that it is safer than keeping a patient in-hospital overnight. -Ian Gilchrist

Outpatient stenting Why use the femoral approach? The patients love it. They feel like they were a healthy person who went in for a procedure and came home. The femoral approach is compatible with more implements. Surgeons like to use the radial artery and prefer if it hasn’t been previously compromised. -James Wilentz

Outpatient stenting Reimbursement “When I talk to my European colleagues, they say that they can’t possibly do it because they have absolutely no incentive to decrease length of stay from their payer point of view. […] I just hope that HCFA can find its way to understand that we’re giving the same service and therefore ought to be recompensed similarly. ” -James Wilentz

Outpatient stenting