Rates of Early Discharge Remain Low for Patients with Uncomplicated Acute Myocardial Infarction

The practice of early hospital discharge for patients with acute myocardial infarction who are at low-risk for additional adverse events varies significantly between the United States, Canada, Australia, New Zealand, Belgium, France, Germany, Spain, and Poland, according to an analysis of 3 major fibrinolytic trials completed between 1990 and 1998.

The trials were performed by the Virtual Coordinating Center for Global Collaborative Cardiovascular Research (VIGOUR) group.

“Although lengths of stay decreased significantly during the study across all countries, median lengths of stay in Germany, France, Belgium, Spain, and Poland remained at least 3-4 days longer than those in the USA, Canada, Australia, or New Zealand,” writes Padma Kaul, MD, University of Alberta, Edmonton, Canada, and colleagues.

The overall analysis consisted of 54,174 patients who sought medical care within 6 hours of symptom onset and had no history of stroke or had recently undergone major surgery, and were followed to determine mortality at 30-days and 1-year. The researchers used previously established criteria to identify those patients with uncomplicated acute myocardial infarction who were eligible for early discharge and determined how many of these patients were actually discharged within 4 days of admission.

Patients eligible for early discharge ranged from 61% in the earliest completed study to 50% in the most recently completed study. While the proportion of eligible patients actually discharged by day 4 increased in the United States, Canada, Australia, and New Zealand over the study period, the highest proportion of eligible patients actually discharged was 40%, in the United States and New Zealand with Canada and Australia showing rates of discharge between 9% and 10%.

In Belgium, France, Germany, Spain, and Poland the rates of patients eligible for early discharge ranged from 57% to 72%, but the rate of actual early discharge was consistently below 2% in these countries.

Overall, 30-day mortality rates in patients eligible for early discharge were 2% or less in all countries except New Zealand which showed rates of 3% in 2 of the studies. One-year mortality rates were similarly low – less than 5%, in patients eligible for early discharge.

Very few of the patients eligible for early discharge, overall, were actually discharged within 4 days, “despite the availability of simple and effective clinical indices to identify low-risk patients,” the authors note. “The potential for more efficient discharge of low risk patients exists in all countries examined,” they conclude, “but was especially evident in the European countries included in the study.”

Lancet 2004;363:511-17.