A study published last August that compared one of healthcare's hottest topics-coronary angioplasty-with medication in the treatment of heart attacks dropped a potential bombshell on community and rural hospitals that cannot provide interventional cardiac services.
Heart attack patients who were transferred in less than two hours from hospitals that could not perform the invasive procedure to hospitals that could fared significantly better than heart attack patients who were simply given clot-busting drugs in local emergency rooms. Transfer to a so-called invasive treatment center reduced the risk of a second heart attack by about 40%, according to the Danish study, which appeared in the New England Journal of Medicine.
The study appears to carry major implications for local ambulance services transporting suspected heart attack patients and community hospitals that do not have licenses to perform primary angioplasty, also known as emergency angioplasty-an artery-clearing procedure involving a catheter to get into a clogged artery, a balloon to open it and a stent to keep it open. This study and an earlier one that also supported the superiority of emergency angioplasty over drugs was named the third top health story of 2003 by the Harvard Health Letter.
Common wisdom is that cardiac services can be one of the biggest cash cows for a hospital. Consequently, regulating coronary-care services is generally one of the most politically charged issues a state health department faces. Add to this combustible mix a wealth of clinical studies that provide convincing evidence that the busiest hospitals are also the safest for cardiac patients-practice makes perfect-and you have a full-blown hospital market share war on your hands.
It would thus appear that the proven superiority of angioplasty over drugs in treating heart attacks would serve to cement whatever monopoly a regional tertiary heart center already has, but many community hospitals are not going to let that happen without a fight. Indeed, on the very same day the New England Journal study was published, 487-bed Trinitas Hospital in Elizabeth, N.J., announced its newly acquired capabilities to perform emergency angioplasty, tying the study's findings into the marketing of the new service.
"The study does tell perfectly what we are trying to do by reducing the door-to-balloon time for people living in the Elizabeth area," says Doug Harris, a Trinitas spokesman.
Trinitas is one of six New Jersey hospitals that are newly licensed to perform emergency angioplasty, although another five hospitals have had certificates of need approved but are not yet licensed. Those 11 hospitals are in addition to the 16 New Jersey hospitals that have full-service open-heart-surgery centers.
Even more facilities will be offering those services in the near future as the state has taken steps to expand access to primary angioplasty. New rules were approved in December 2003 that make it easier for hospitals to qualify to perform the service "while still maintaining high-quality care," Donna Leusner, a spokeswoman for the New Jersey Department of Health and Senior Services, says in a written statement. Already nearly one-third of the state's 82 hospitals have been approved to do primary angioplasty and more are expected to seek approval under the new rules, which take effect early this year, she says.
Connecticut similarly is considering revamping its policy to allow emergency angioplasty, having completed a draft last October that assesses the need, utilization and capacity of cardiac services in the state. In the draft, regulators at the Connecticut Office of Health Care Access noted that primary angioplasties for the treatment of heart attack represent about 14% to 20% of all angioplasties, with elective angioplasties accounting for 80% to 86% of all angioplasties performed. "The importance of determining the best treatment strategy in the community hospital setting without interventional cardiac therapies is crucial, for they receive two-thirds of all (heart attack) patients," according to the draft. In Connecticut, seven of 31 hospitals offer interventional cardiac therapies.
The draft concludes that based on national standards, Connecticut residents have "appropriate access" to experienced, high-volume cardiac centers with "a reasonable travel time." About 80% of the population travels one hour or less to reach a full-service hospital. Still, there are geographic pockets in the small state where some people must travel an hour or more, an important consideration only in the context of emergency angioplasty in the treatment of heart attack, according to the draft.
The draft also recommends that Connecticut institute a comprehensive statewide approach to health planning for cardiac services, pointing to the research associating primary angioplasty with better outcomes for heart attack patients. The state should consider whether to increase access for emergency angioplasty, it says. At present no hospitals in the state provide primary angioplasty without an open-heart surgery backup, but four hospitals do have proposals in front of state regulators to perform them, says John Blair, chief of staff for the Office of Health Care Access. Another two hospitals have filed proposals to provide comprehensive cardiac services. The draft awaits final approval from the newly appointed commissioner for the Office of Health Care Access, Cristine Vogel, who happens to come from one of those two hospitals-268-bed Waterbury (Conn.) Hospital.
The heart of the matter
How much business is really at stake if community hospitals nationwide, based on the studies, are suddenly shut out from treating heart attack patients? The American Heart Association estimates that in 2003, 1.1 million Americans suffered a heart attack, and about 515,000 of them died-nearly half before they even reached a hospital. That sounds like a lot, but everything is relative. In New Jersey, for example, there were 1.1 million inpatient admissions in 2002, of which 32,748 were attributed to a heart attack, according to Marilyn Riley, a spokeswoman for the state's Department of Health and Senior Services. The 21,809 heart attack patients that were admitted through hospital emergency departments in New Jersey that same year represented barely 2% of all admissions.
Kyle Kramer, executive director of cardiovascular services at 808-bed Yale-New Haven (Conn.) Hospital, says heart attacks are on the decline thanks to new medications such as cholesterol-lowering drugs and better management of coronary patients. The volumes for primary angioplasty in the catheterization laboratory at Yale-New Haven have declined even as overall volumes for angioplasty are increasing by as much as 10% per year, he says.
Noting the proven link between high volume and high-quality outcomes, Kramer says the issue shouldn't be whether patients have access to more hospitals that can perform emergency angioplasties but what is the best way to open those clogged arteries.
"What hospitals have to think about is whether or not they are prepared to make the level of infrastructure investment to support primary angioplasty services because it is low volume, high intensity and high visibility," Kramer says. "If you are going to do it, you have no choice but to do it right." Kramer says that at Yale-New Haven, which has one of the largest full-service heart surgery programs in the state, the average time needed to perform a primary angioplasty has been reduced to less than 70 minutes from door to balloon, "but it's taken us three years to move that far, and it's extremely difficult to do."
Getting a hospital up to speed just to perform emergency angioplasty is a considerable investment of time, staff and money. An ill-conceived venture could drain resources for more needed services such as neonatal care, says Peter Plantes, vice president of clinical and business services at hospital cooperative VHA. Plantes says capital costs alone could exceed $1 million, and that doesn't include the operating costs of cardiac nurses, technicians and availability of interventional cardiologists on a round-the-clock basis. Hospitals considering chasing this particular brass ring should first assess the prevalence of heart attacks in their particular communities, he says.
"If it impacts the ability to provide care to women and children, you get into a difficult situation: which is more important for the community," Plantes says. "It has to be looked at from the needs of the entire community in terms of healthcare needs, prevalence and proportion."
Plantes adds that from both a business and quality aspect, a hospital could find itself experiencing diminishing returns on its investment if it can't generate the volumes necessary to maintain quality outcomes. If a hospital can't support a rock-solid program, "it would be more important for an institution to research rapid transportation systems to a (medical) center where it is supported or the continuation of (treating patients with) clot-busting medications," Plantes says. "A worse case scenario is a hospital puts in a capital investment for a cardiac catheterization unit and then doesn't have activity and loses its staff. Then they are sitting there with a white elephant of an investment."
That advice isn't as gloomy as it may sound. Plantes suggests that most hospitals that cannot provide emergency angioplasty are already transferring patients to cardiac centers anyway along with many that do offer the procedure.
"I don't think the change is going to be that great based on the study. What it will do will cause many smaller community hospitals to consider whether to initiate an interventional cardiac program," Plantes says. The study may tip the scales in favor of the interventional service only for those hospitals that were already on the fence about providing it, he adds.
Pocatello, Idaho's 235-bed Portneuf Medical Center has decided to make the investment in full-service cardiac services after three years of planning. The hospital, which already has one diagnostic catheterization lab, will be performing angioplasties by May and open-heart surgery no later than October, says Cal Northam, its vice president of strategy and business development. Portneuf's situation is unique in that until a merger created it in 2002, the area had two community hospitals that were "competing for market share and so capital wasn't being used to develop tertiary care services," Northam says.
As it stands now, the nearest competitors are a 21/2-hour drive away in Salt Lake City, he says. Heart attack patients generally are stabilized and then transported by helicopter to a heart center in Salt Lake City. Hospital planners calculated that the hospital is losing 331 open-heart surgeries and as many as 500 angioplasties to Salt Lake annually.
Accordingly, the hospital has invested more than $5 million in bricks, mortar and equipment to develop the program. Even though bypass surgeries are trending downward nationally, Northam says planners anticipate that 75 bypass surgeries will be performed in the first year building up to a high of 200 procedures. The program is expected to bring in as much as $10 million in new revenue annually, Northam says.
"We strategically made the decision after the merger to take our rightful place as the tertiary hospital of the region," Northam says.