In a publically-funded health system, and especially in times of budgetary deficits, it is essential to make the most of available resources.1 Clinical management encourages cost containment by avoiding unnecessary hospitalizations without decreasing the quality of the medical care provided. One approach to achieve this objective is to perform lower-risk, elective, diagnostic and therapeutic invasive procedures on an ambulatory basis by creating minor surgery units within day hospitals.

Day hospitalization refers to a hospital stay lasting some hours for various purposes: diagnostic testing, clinical and other examinations, and treatments that cannot be performed in the outpatient clinic, but do not justify hospital admittance.2 It is a medical care unit where certain interventions are performed and postprocedure medical or nursing attention is provided under the supervision or indication of a specialized physician.3

In the field of cardiovascular disease, several diagnostic and therapeutic activities can be carried out during a short stay limited to the day of the procedure, and these would be amenable to the medical care available in a day hospital. Certain factors, such as radial artery access in catheterization, have been key elements in this regard, as they reduce the incidence of complications and the need for puncture site care in both diagnostic and interventional procedures.4,5 The safety of ambulatory treatment has also been verified in device implantation and arrhythmia ablation procedures.6,7

Heart failure (HF) is one of the most prevalent cardiovascular syndromes, leading to heave resource utilization.8,9 HF units have proven effective in the treatment of these patients and have reduced the number of emergency room visits and rehospitalizations.10,11 Day hospitals are an excellent support tool for these units, as they facilitate close follow-up after hospital discharge and offer patients fast access to care in situations of clinical worsening. This benefit would apply not only to HF patients; it could be extended to others with a prompt hospital discharge or patients seen in the emergency department (eg, pericardial syndromes, atrial fibrillation, following heart surgery), who might need preferential access to reassessment, diagnostic tests, or therapeutic interventions that cannot be covered in the outpatient setting.

The cardiology day hospital (CDH) is conceived as an area designed to provide complex or sophisticated medical care with little delay and avoiding hospitalization in patients with cardiovascular conditions that can be treated in an ambulatory setting.12

Although numerous hospital cardiology departments have converted a large part of their invasive procedures to ambulatory ones because of CDH availability, there are no studies evaluating the clinical and cost-effectiveness of these areas within the specific field of cardiology. The aim of this study was to perform a descriptive analysis of the activity carried out, evaluate the quality of the care provided, and determine the cost-effectiveness of a CDH in the first year of operation.

A retrospective, descriptive, observational study was performed of all activity recorded in the CDH during its first year of operation (June 2014 to May 2015). We collected information on the reason for the visit, clinical and demographic data, and the origin and destination of the patients following the CDH visit (hospital discharge or admission).

During its first year of operation, the CDH was open for 246 weekdays. A mean of 10 ± 3 patients were attended per day, and a mean of 1.5 visits were made per patient (range, 1-20). In total, 1646 patients were attended (mean age, 69 ± 15 years), and 60% were men. Among the total of visits, 67% were first visits and 33% were successive visits.

The most common reason for the appointment was a clinical examination, performed in 850 patients (35%); the most prevalent diagnosis was HF (65%). In addition, some type of medical treatment was administered to 182 patients (7%), mainly intravenous diuretics, (Table 2). HF patients attended in the CDH came from the emergency department (20%), hospital discharge (16%), and scheduled visits referred from the outpatient clinic or other departments (13%).

In total, 2550 procedures were scheduled. The cancellation rate (excluding rescheduled procedures for which the patient did not attend the CDH) was 4%, and the suspension rate was 1.7%. The most prevalent reasons for cancellation were hospital admission for another cause (58%) and failure to attend the appointment (19%). The type of procedure with the highest suspension rate (16%) was electrical cardioversion (Table 2).

The incidence of complications could be analyzed in 716 patients discharged from the CDH following an invasive procedure. Fifteen patients presented to the emergency room within the first 48hours after discharge. There were 4 cases of HF, 3 contrast-related adverse reactions, 1 posttransfusion reaction, 1 pacemaker lead displacement, and 1 hematoma at the puncture site for catheterization. Only 1 of the HF patients required hospitalization.

During the last month of the first year of operation, 113 satisfaction surveys were carried out. Among the total, 94% of patients surveyed considered that the care provided by the nursing staff was good or very good, and 92% rated the care by the medical staff as good or very good. Ninety percent considered that the clinical information provided on the procedure and at the time of discharge was adequate. Only 5 patients (4%) had difficulties in finding or gaining access to the CDH, and 12 (11%) were not attended within the first 15minutes after the scheduled time for admission. The overall rating of the CDH was good or very good in the opinion of 107 users (95%), and 90 (80%) stated they would definitely recommend it to other patients (Figure 1).

Figure.

Results of the satisfaction survey. The total of responses for each item are shown. A. Overall evaluation of the care. B. Recommendation to other patients.

DK/NO, don’t know/no opinion.

(0.08MB).

The cost of hospital stays and the average estimated savings are shown in Table 3, together with a comparison of the mean cost of each type of scheduled procedure before and after implementation of the day hospital.

After the CDH became operational, there was an estimated saving of €219 199.55 in hospitalization expenditure, which remained stable or even increased in successive years (Table 4). Within the total amount saved, €103 804.29 (47%) was attributable to hospitalizations avoided the day before the procedure.

As the expenditure for remodeling the area and purchasing the equipment needed was €12 000 and the cost of the permanent staff (2 nurses and 2 auxiliary nursing care technicians) was €135 746, the total balance was a saving of €71 453.5 in hospitalization expenditure. Hence, the start-up cost of the CDH was recouped in the first year of operation.

This is the first study to analyze the activity and cost-effectiveness of a CDH. In our center, it was found to be a useful health care tool that significantly decreased the need for hospitalization related to scheduled procedures without detriment to the care provided, and produced a considerable saving in expenditure for hospital stays.

The document on standards and recommendations for care units in cardiology depatrtments12 has established that a CDH should be designed to allow patients to recover following an invasive procedure before they are discharged or referred back to their center of origin. Furthermore, an HF unit should have day hospital stations for administering medication. In the present case, the CDH was conceived as a multifunctional unit that carries out widely heterogeneous activity; therefore, it was decided that the staff should consist of specifically dedicated nursing personnel.

In the morning, the CHD mainly attends patients referred for procedures, and in the afternoon, patients requiring clinical examinations. As a large part of the activity involves care for HF patients, the fact that the staff is a stable team facilitates their involvement in the HF unit and their participation in activities such as patient instruction. The CDH has become an essential health care resource for administration of intravenous medication (diuretics, iron replacement therapy, antibiotics, and inotropic agents such as levosimendan) with proven safety of use in the ambulatory setting.15,16 The quality of the care provided is actually improved, and not only because patients do not have to be hospitalized, which can imply a disruption of family life. The CDH provides closer monitoring of this type of patient, prompt detection of complications, and fast treatment initiation before hospital or emergency room admission is needed.

There are no standards for the quality indicators evaluated here. However, the results obtained are useful for future comparisons and setting goals for improvement. With regard to the cancellation and suspension rates, it could be effective to call the patient 24 or 48hours before their scheduled visit as a reminder. This would also identify patients who cannot attend their appointment, and enable scheduling of another person in their place.17 Electrical cardioversion was the procedure associated with the highest suspension rate; 11 procedures (16%) were not carried out, indicating the need to design a plan for improvement. The reasons were the presence of sinus rhythm (n = 6), poor anticoagulation (n = 3), atrial appendage thrombus (n = 1), and the consideration that electrical cardioversion was not indicated (n = 1). It may be necessary to optimize the coordination with primary care to improve this indicator. This could include confirmation of adherence to anticoagulant therapy, measuring the international normalized ratio, or even a previous electrocardiography examination to avoid unnecessary visits by patients already in sinus rhythm.

Most of the invasive procedures scheduled do not require special preparation; therefore, patients can arrive the same day as the procedure. Centers equipped with hemodynamic and arrhythmia areas attend patients from other hospitals in the region and offer coverage for both scheduled and emergency processes. Thus, an area is needed where patients can wait and where care can be provided during the procedure and before patients can be transferred to their center of origin.18 If these areas are not available, hospital admission is often required, even though the procedure may be a low-risk one without complications. This can lead to problems of overcrowding, which makes it difficult to schedule other procedures or even admit emergency patients. The CDH not only decreases hospital stays in scheduled procedures, it also enables increased scheduling of ambulatory procedures.

Considerable cost savings were achieved by eliminating the preprocedure hospital stays in all types of scheduled procedures, even the more complex ones for which hospitalization cannot be avoided. The remaining savings were, to a great extent, the result of complete conversion of some invasive procedures to ambulatory procedures, for which postprocedure hospital monitoring could be prolonged without hospital admittance. Even though the performance of the CDH was lower during the first year of operation compared with successive years, the entire cost of implementing the day hospital was recouped in this period.

The CDH is a quick-to-respond, dynamic health care tool that promotes a change in the organization of cardiologic hospital care. CHD implementation in our center has enabled conversion of two-thirds of the scheduled invasive procedures to ambulatory ones. This has considerably reduced procedure-related hospital stays, with consequent cost savings, without incurring a reduction in the quality of care. Furthermore, patients who need preferential attention that cannot be covered in the outpatient clinic can be attended with this model, and it provides support for the HF unit for administering intravenous treatment.

This study was carried out in the scientific setting of the Cardiovascular Research Network and CIBERCV (Biomedical Research Network Center for Cardiovascular Diseases; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares) of the Carlos III Health Institute of the Spanish Ministry of Economy, Industry, and Competitiveness. M. Gallego-Delgado received grants through the Carlos III Health Institute within the Action Plan for the promotion of clinical and translational research (contract for a professional who has passed specialized medical training).

None declared.