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Comment & Response
March 13, 2019

Same-Day Discharge After Percutaneous Coronary Intervention—An Elusive Bargain

Author Affiliations
  • 1Department of Internal Medicine, University of Maryland School of Medicine, Baltimore
  • 2Decision Support, University of Maryland Medical Center, Baltimore
  • 3University of Maryland School of Medicine, Baltimore
JAMA Cardiol. 2019;4(5):495-496. doi:10.1001/jamacardio.2019.0306

To the Editor The pressure to improve the value of hospital services is pervasive at our institution, as it operates within a capitated budget under the Global Budget Revenue system, implemented statewide for Maryland hospitals in 2014.1 Based on initial success with this model, additional states are positioned to adopt a global budget strategy to contain health care expenditures.2 Amin et al3 provide a robust analysis of hospital cost savings achieved by implementing same-day discharge (SDD) after percutaneous coronary intervention (PCI), driven by savings in supply and room and board costs. Importantly, 49% of hospitals included in the analysis by Amin et al3 were academic hospitals, where SDD was accomplished at rates higher than the overall cohort. Increasingly, academic medical centers function as specialized hubs within multihospital systems, and it is unclear how such centers fared with regards to cost savings in this study.4 As the flagship hospital of a larger medical system, where routine PCIs are performed at 5 other sites within our system, a significant proportion of our PCI volume consists of high-risk referrals as well as surgical revascularization turndowns from our own system hospitals. As would be expected, institution of a global budget paradigm has further concentrated complex PCI cases at our institution. Consequently, patients truly eligible for SDD are rare in our practice setting. Furthermore, SDD does not lead to an ability to close beds or relieve or reallocate ancillary staff at our institution. As 1 of 2 quaternary care centers in a capitated budget state, a discharged patient’s bed is almost always immediately backfilled; thus, a decrease in supply and bed expenses corresponding to SDD is not accomplished. Our challenges and experience may mirror those at other academic centers that are part of larger hospital systems.

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