Cardiovascular Business - September/October 2008 - (Page 22) elective PCI Procedures at Facilities Without Surgical Backup 600– 500– 521 505 513 386 234 255 235 180 41 47 53 91 111 57 113 n 400– 300– 200– 100– 0– 2001 2002 2003 27 2004 the average quarterly increase in rates of elective PCi (20 percent) were significantly higher at facilities without onsite surgical backup (shown above), compared to the average quarterly rate (8 percent) for facilities with onsite surgical backup. the increase occurred despite national guidelines that state elective PCi should not be done in centers without onsite cardiac surgery. source: american Journal of Cardiology 2007;99(3):329-332 established, such as: ■ Careful patient selection ■ Detailed training of all clinicians and allied health staff in highvolume institutions ■ Formal interventionalist training at U.S. accredited programs, and ■ An elaborate transport system in case of emergencies. Long also says that a key component of the Mayo protocol was that the physicians and allied staff at ISJ maintained procedural volume compliance. “They were coming to SMH in Rochester to perform procedures, as well as those they performed at ISJ.” Interestingly, Long and colleagues found that those treated at ISJ incurred significantly increased direct medical costs compared to SMH: $13,771 versus $10,746, respectively, in estimated total costs. ISJ-treated patients also incurred about $6,000 more in billed charges than SMH, but had similar length-ofstay postprocedure (1.53 days). Long attributes the increase in costs to a more liberal use of expensive drugs, such as glycoprotein IIb/III inhibitors, as well as more liberal stent use. “This might indicate practice patterns aimed at trying to reduce ischemic complications to minimize the risk of need for cardiac surgery, which contributed greatly to the cost differentials between the two sites,” she says. Despite the increased costs to patients at ISJ, Long says they are providing a necessary service for their rural population. trials in question Still, many criticize these single-center studies, not because they doubt the successful outcomes of protocol-laden environments, but because they are not randomized controlled trials, the gold standard. No such trials have been completed as of yet. However, an analysis of the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) supports the assertion that primary and elective PCI procedures in hospitals with or without on-site surgery can have similar outcomes. (Circulation 2005;112[Suppl II]:II-737). However, ACC-NCDR data are collected only from those facilities that choose to submit them. A contradicting retrospective review of Medicare patients revealed a 2.8 percent higher mortality rate in primary/ rescue PCI patients treated at sites without surgical backup. The increase was primarily confined to hospitals performing 50 or less PCIs per year (JAMA 2004;292:1961-1968). The authors concluded that policies aimed at increasing access to primary/rescue PCI “through promoting PCI in hospitals without cardiac surgery may inadvertently lead to an overall increase in mortality related to PCI.” Even though it is based on administrative data, the Medicare study is more revealing because data from all patients are submitted, as opposed to single-center studies that might tend to omit negative outcomes, according to some experts. The trend is clear, says Dehmer. More and more rural and community hospitals realize that they need to start a cath lab program to remain competitive and attractive to patients. But as they do, they leach volume from surrounding institutions, particularly in urban and suburban areas, potentially interfering with physician competency in higher-volume facilities. A cynic might say that the proliferation of cath labs is not an altruistic pursuit, especially when research has revealed that the vast majority of Americans already live within 30 minutes of a cath lab. “The decision to begin or operate a PCI program without onsite surgical backup should be based on the health needs of a local area, not on desires for personal or institutional gain, prestige, market share, or other similar motives,” Dehmer says. Despite the controversy over the specific types of clinical trials, evidence exists to suggest that PCIs can be performed successfully in institutions without cardiac surgical backup. Experts caution, however, to be wary of letting these data from single-center studies be the sole driver for the increasing growth of cath labs, particularly in urban and suburban areas where the actual geographic need may not be as great as in rural areas. 22 Cardiovascular Business September/october 2008
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.