A Randomized Controlled Trial of Hospital Discharge Three Days after Myocardial Infarction in the Era of Reperfusion

Abstract

To evaluate the feasibility and cost savings of hospital discharge three days after acute myocardial infarction, we screened 507 consecutive patients prospectively for clinical complications and exercise-test performance. Of 179 patients whose condition was classified as uncomplicated (no angina, heart failure, or arrhythmia 72 hours after admission), 126 underwent early exercise testing and 90 had no provocable myocardial ischemia. Eighty of these patients were randomly assigned to early (day 3) or conventional (days 7 to 10) hospital discharge. Seventy-six of them had received coronary reperfusion therapy (thrombolysis, angioplasty, or both). At six months of follow-up, there were no deaths or new ventricular aneurysms, and the early-discharge and conventional-discharge groups had similar numbers of hospital readmissions (6 and 10), reinfarctions (none and 5), and patients with angina (3 and 8). In the early-discharge group, 25 of 29 previously employed patients returned to work 40.7 +/- 21.9 days (mean +/- SD) after admission, as compared with 25 of 27 patients in the conventional-discharge group, who returned to work after a mean of 56.9 +/- 30.3 days (P = 0.054). The mean cumulative hospital and professional charges were $12,546 +/- 3,034 in the early-discharge group, as compared with $17,868 +/- 3,688 in the conventional-discharge group (P less than 0.0001). In carefully selected patients with uncomplicated myocardial infarction, hospital discharge after three days is feasible and leads to a substantial reduction in hospital charges. Before this strategy can be widely recommended, however, its safety must be confirmed in larger prospective clinical trials.

Economic Consequences of Early Inpatient Discharge to Community-Based Rehabilitation for Stroke in an Inner-London Teaching Hospital

“…[23][24][25][26] However, only 1 similar economic study concerning an integrated policy of early discharge and home-based rehabilitation for stroke was identified. 27 That report, based on a Swedish population, gave results of a pilot study covering only 15 patients.…”

Feasibility of early hospital discharge directly from coronary care unit after primary angioplasty for uncomplicated acute myocardial infarction

“…It is difficult to determine at which time risk decreases to an acceptably low level for safe discharge, as small proportion of patients will experience adverse events. However, for selected patients, based on results from our and other similar studies, successful reperfusion techniques and aggressive medical treatment decrease the risk of complications to a level that enables safe early discharge after three days [9,12,13].…”

“…Several clinical studies identified these patients based on simple clinical criteria. Low-risk patients were characterized by the absence of reinfarction, ischemia, shock, heart failure, ventricular fibrillation or ventricular tachycardia, during the first 72 hours of index admission [7][8][9][10]. In these early studies, patients treated with thrombolysis were mainly enrolled.…”

Cost Effectiveness of Early Discharge after Uncomplicated Acute Myocardial Infarction

“…[1][2][3] In the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, patients who had an uncomplicated course through day 4 after thrombolysis had a very low rate of death within 30 days. 4 A randomized trial of early discharge would be needed to demonstrate conclusively the clinical and economic soundness of this change in the standard of care, but the extremely challenging logistics of such a trial make it unlikely that one will ever be conducted.…”

“…Most centers probably cannot achieve this goal without substantially reengineering their current practices of care. Data from small clinical studies support the safety and prognostic usefulness of stress testing as early as three to four days after uncomplicated myocardial infarction, 1,[16][17][18][19] but a concerted effort among clinicians and providers of support services would be needed for testing to be performed and results to be made available by the end of the third day of hospitalization. Our model assumed a long-term societal perspective in which all short-term inefficiencies involved in implementing a program of early discharge would be resolved.…”