Outpatient stenting

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

• My patients wanted to go home early.
•  
• Radial approach to stenting puts patients on
  their feet quickly, and I couldnt come up with
  any good reason to keep them in hospital.
• -Ian Gilchrist

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Adjunctive therapies
Outpatient stenting

• 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

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Catheterization procedure
Outpatient stenting

• 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

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Motivation
Outpatient stenting

• We were doing early studies with vascular sealing
  and patients didnt 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

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Outpatient stenting
Catheterization procedure

• Femoral approach with vascular sealing devices
  (DUETT and VasoSeal)
• 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

Wilentz JR, et.al. J Invasive Cardiol 1999 Dec
11(12)709-717.
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Using GP IIb/IIIa inhibitor
Outpatient stenting

• 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

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On GP IIb/IIIa
Outpatient stenting

• 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 lt6 hours, 6-12 h, or the
  full 18-24 h.
• We dont really know the optimum infusion time.
• -Ian Gilchist

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Cost savings
Outpatient stenting

• 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
  step-down 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.

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Nationwide savings
Outpatient stenting

• 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, its significant.
•  
• -James Wilentz

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Throughput
Outpatient stenting

• 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

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Family logistics
Outpatient stenting

• The families dont understand that they block the
  system by not picking up their family member on
  time.
• With outpatient treatment, the family often
  doesnt leave and therefore arent delayed
  getting back.
• -Ian Gilchrist

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Safety
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

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Safety
Outpatient stenting

• Most recently at our institution, 12/1600 (0.75)
  stenting patients have had acute closures
  (includes CCU patients).
• Patients chosen for outpatient treatment
• MI gt24 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

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Hazards
Outpatient stenting

• 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 dont get a good nights sleep, and are
  less able to understand their discharge
  instructions or otherwise function the next day.
• -Ian Gilchrist

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Staff mindset
Outpatient stenting

• 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

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Patient education
Outpatient stenting

• 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

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Post-procedure protocol
Outpatient stenting

• 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

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Will it catch on?
Outpatient stenting

• 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

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Patient enthusiasm
Outpatient stenting

• 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

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Why use the radial approach?
Outpatient stenting

• 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

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Why use the femoral approach?
Outpatient stenting

• 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 hasnt been previously
  compromised.
• -James Wilentz

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Reimbursement
Outpatient stenting

• When I talk to my European colleagues, they say
  that they cant 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 were giving the same service and therefore
  ought to be recompensed similarly.
•  
• -James Wilentz

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Outpatient stenting