New PCI Programs Cost Billions, Do Not Improve Timely Access
New PCI Programs Cost Billions, Do Not Improve Timely Access
BOSTON, MA — From 2004 to 2008, the number of US hospitals that set up new PCI programs grew by 16.5%, but the percentage of the population with timely access to PCI grew only by 1.8%, according to a new study.
The researchers estimate that there were 251 hospitals with new PCI programs, which cost the healthcare system about $2 billion to $4 billion, depending on whether the hospitals also added a facility to perform CABG surgery. New, large hospitals that had other expensive medical equipment and competition from a nearby hospital with a cardiac catheterization lab were more likely to set up a PCI program.
"What you want to see is if you are adding a great number of hospitals [performing PCI], you're reducing the time to treatment," lead author Dr Thomas W Concannon (RAND Corporation, Boston, MA), told heartwire. "We didn't see that in most places; we only saw that in one state (Missouri)." Access to PCI also improved in Mississippi, but that state had a small number of facilities offering PCI at baseline.
In an email to heartwire, Dr Harlan Krumholz (Yale University, New Haven, CT) praised the authors for "showing that the new PCI programs were more likely to be built in markets with a good payer mix and existing programs, rather than places that may have had the greatest need." He agrees that stakeholders need to work together to find ways to "be sure we are building capacity that is most likely to provide [at least a] marginal benefit to our patients and the public."
The study is published July 9, 2013 in Circulation: Cardiovascular Quality and Outcomes.
More Cath Labs, More Duplication?
Although about 80% of the US population lives within a 60-minute drive to a cardiac catheterization laboratory, fewer than half of patients who have an acute ST-segment elevation MI (STEMI) receive timely PCI, the authors write.
To investigate factors propelling the growth in cardiac catheterization laboratories in the US and to see whether new services duplicate existing ones, they analyzed programs that were introduced from 2004 to 2008.
In general, new programs were offered in neighborhoods already served by others, and the median time needed to drive to a facility with PCI remained essentially unchanged.
Hospitals were less likely to adopt a new PCI program if they had more outpatients, served more foreign-born or elderly residents, or were in a state that required automatic reviews of proposed new catheterization laboratories. Hospitals in the 27 states with strong certificate-of-need (CON) programs were 40% less likely to establish a new PCI program.
Three-Pronged Strategy
To improve patient care, the authors recommend three types of strategies. First, payers such as Medicare or Blue Cross could reduce payments for PCI, Concannon noted. Second, more states could adopt regulatory programs such as CON. Third, hospitals and emergency-medical systems could develop voluntary STEMI regional plans, such as North Carolina's Regional Approach to Cardiovascular Emergencies (RACE) protocol, the largest in the US.
Although the rate of growth in hospitals offering new cardiac catheterization programs slowed in 2007 and 2008 to about 50 hospitals a year, this is "still too many," according to Concannon. "We ought to be looking at ways to collaborate, to improve the rate of access to these procedures, rather than acting on our commercial interests."
Provocative Questions Merit Attention
"It is a very well-done study that raises very provocative questions that merit our attention," Krumholz summarized. What needs to be determined is the best way to disseminate technology and ensure that capacity is added in ways likely to benefit patients and the public, he said.
Duplicate services could potentially improve quality of care but are most likely wasteful. In addition to cost, when a new PCI service is expected to provide a large revenue stream, "the concern is that [institutions] will actually increase volume by doing more discretionary procedures that provide patients with little marginal benefit," he noted.
Perhaps "we need to determine . . . [how to] enhance cooperation [between institutions] within regions, so that there are not 'winners' and 'losers' . . . but [rather] a shared sense of purpose and a business model that rewards everyone when the capacity in the region fits the need."
Concannon was supported by the Agency for Healthcare Research and Quality and by the Tufts Medical Center Research Fund. Other study authors were supported by the Tufts Medical Center Research Fund and the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or National Institutes of Health. Krumholz has no financial disclosures.
BOSTON, MA — From 2004 to 2008, the number of US hospitals that set up new PCI programs grew by 16.5%, but the percentage of the population with timely access to PCI grew only by 1.8%, according to a new study.
The researchers estimate that there were 251 hospitals with new PCI programs, which cost the healthcare system about $2 billion to $4 billion, depending on whether the hospitals also added a facility to perform CABG surgery. New, large hospitals that had other expensive medical equipment and competition from a nearby hospital with a cardiac catheterization lab were more likely to set up a PCI program.
"What you want to see is if you are adding a great number of hospitals [performing PCI], you're reducing the time to treatment," lead author Dr Thomas W Concannon (RAND Corporation, Boston, MA), told heartwire. "We didn't see that in most places; we only saw that in one state (Missouri)." Access to PCI also improved in Mississippi, but that state had a small number of facilities offering PCI at baseline.
In an email to heartwire, Dr Harlan Krumholz (Yale University, New Haven, CT) praised the authors for "showing that the new PCI programs were more likely to be built in markets with a good payer mix and existing programs, rather than places that may have had the greatest need." He agrees that stakeholders need to work together to find ways to "be sure we are building capacity that is most likely to provide [at least a] marginal benefit to our patients and the public."
The study is published July 9, 2013 in Circulation: Cardiovascular Quality and Outcomes.
More Cath Labs, More Duplication?
Although about 80% of the US population lives within a 60-minute drive to a cardiac catheterization laboratory, fewer than half of patients who have an acute ST-segment elevation MI (STEMI) receive timely PCI, the authors write.
To investigate factors propelling the growth in cardiac catheterization laboratories in the US and to see whether new services duplicate existing ones, they analyzed programs that were introduced from 2004 to 2008.
In general, new programs were offered in neighborhoods already served by others, and the median time needed to drive to a facility with PCI remained essentially unchanged.
Hospitals were less likely to adopt a new PCI program if they had more outpatients, served more foreign-born or elderly residents, or were in a state that required automatic reviews of proposed new catheterization laboratories. Hospitals in the 27 states with strong certificate-of-need (CON) programs were 40% less likely to establish a new PCI program.
Three-Pronged Strategy
To improve patient care, the authors recommend three types of strategies. First, payers such as Medicare or Blue Cross could reduce payments for PCI, Concannon noted. Second, more states could adopt regulatory programs such as CON. Third, hospitals and emergency-medical systems could develop voluntary STEMI regional plans, such as North Carolina's Regional Approach to Cardiovascular Emergencies (RACE) protocol, the largest in the US.
Although the rate of growth in hospitals offering new cardiac catheterization programs slowed in 2007 and 2008 to about 50 hospitals a year, this is "still too many," according to Concannon. "We ought to be looking at ways to collaborate, to improve the rate of access to these procedures, rather than acting on our commercial interests."
Provocative Questions Merit Attention
"It is a very well-done study that raises very provocative questions that merit our attention," Krumholz summarized. What needs to be determined is the best way to disseminate technology and ensure that capacity is added in ways likely to benefit patients and the public, he said.
Duplicate services could potentially improve quality of care but are most likely wasteful. In addition to cost, when a new PCI service is expected to provide a large revenue stream, "the concern is that [institutions] will actually increase volume by doing more discretionary procedures that provide patients with little marginal benefit," he noted.
Perhaps "we need to determine . . . [how to] enhance cooperation [between institutions] within regions, so that there are not 'winners' and 'losers' . . . but [rather] a shared sense of purpose and a business model that rewards everyone when the capacity in the region fits the need."
Concannon was supported by the Agency for Healthcare Research and Quality and by the Tufts Medical Center Research Fund. Other study authors were supported by the Tufts Medical Center Research Fund and the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or National Institutes of Health. Krumholz has no financial disclosures.