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Driven by financial incentives, many US hospitals have introduced new invasive cardiac care services, including percutaneous coronary intervention (PCI), despite the availability of such procedures at nearby hospitals, according to a study published online July 19, 2013, ahead of print in Circulation. Yet the proportion of the population who live outside the range of timely urgent care has remained largely unchanged.

A team led by Jill R. Horwitz, PhD, JD, of the University of California, Los Angeles School of Law (Los Angeles, CA), looked at all US hospitals that billed the Centers for Medicare and Medicaid Services for at least 5 invasive cardiac procedures annually for acute MI patients between 1996 and 2008.

Over the study period, 8% of hospitals added diagnostic angiography, 7% PCI, and 6% CABG. Although many hospitals progressed from offering only diagnostic angiography to providing intervention (the rate of diagnostic angiography-only hospitals declined by half), adopting diagnostic angiography was not always a prelude to instituting PCI or CABG. Among urban hospitals, about 1 in 5 acute-care centers offered only diagnostic care. 

Competing in the Same Market

Larger hospitals were more likely than smaller ones to add new capabilities. However, hospitals were also more likely to adopt a new service if another hospital within 40 miles already offered it, even after controlling for hospital size, population size, other market characteristics, and the proportion of people who already lived within 40 miles of a service. The same held true for hospitals with similar numbers of potential patients, regardless of whether or not those patients already had geographic access to the service.

This adoption pattern was strongest for PCI, with a hospital nearly twice as likely to introduce the technology in a market of 10 equal-size hospitals when 1 other center added PCI (OR 1.794; 95% CI 1.29-2.50). On the other hand, hospitals were less likely to adopt PCI if nearby hospitals already had CABG capability (OR 0.726; 95% CI 0.575-0.916).

The pattern was similar for diagnostic angiography (OR 1.102; 95% CI 1.02-1.19), although hospitals were less likely to provide angiography if a neighboring hospital already offered PCI. Hospitals were more likely to provide CABG if nearby hospitals offered PCI (OR 1.44) or recently added PCI (OR 2.30), but less likely to do so if the hospitals offered diagnostic angiography (OR 0.81) or CABG (OR 0.93).

More Services Does Not Equal More Access

Overall, the dissemination of invasive procedures to more hospitals led to clustering of these services, adding little to geographic access to cardiac care. In 1997, 94% of the population lived within 40 miles of a hospital that provided diagnostic angiography and 88% within that distance of hospitals offering PCI and CABG. Despite widespread adoption of these procedures over 11 years, the proportion of the population with access to diagnostic angiography only increased by 1%, 5% for PCI, and 4% for CABG.

Over the study period, the duplication of invasive services increased. In 1996, about 80% of people who lived within 40 miles of an invasive cardiac service (the maximum distance considered reasonable for acute MI patients to travel to obtain timely revascularization) added within the previous year already had access to that service; by 2008, that number had risen to 95%.

Nonetheless, in an accompanying editorial, Karen E. Joynt, MD, MPH, of the Harvard School of Public Health (Boston, MA), says “the straightforward message of this paper is that . . . we still have inadequate access to care across wide areas of the country,” and the consequences of this disparity are visible in the “widening gulf in clinical outcomes between urban and rural patients with acute MI.”

 Overuse, Underuse Both Harmful

Dr. Joynt also points to the “flip side” of the concentration of invasive resources: overuse. While inappropriately high rates of PCI have often been blamed on unnecessary stress testing or lack of trust in medical therapy, the current finding suggests another possible explanation: “supply-induced demand,” she asserts. 

But “while PCI is rampantly overused in some areas of the country, there are entire communities that are being left without access to invasive cardiac services at all. Ironically, both overuse and underuse are likely associated with worse clinical outcomes.

“We need to right-size the use of invasive cardiac services in the US,” Dr. Joynt continues. “Currently, our policy and reimbursement climate are failing to remedy the problem.” 

In a telephone interview with TCTMD, Thomas W. Concannon, PhD, of the Rand Corporation (Boston, MA), observed that using different data and different methods, both his group (Concannon TW, et al. Circ Cardiovasc Qual Outcomes. 2013;06:400-408) and the current researchers “came up with essentially the same story: that hospitals introduce interventional capability to compete with each other.”

How to Slow the Trend

Dr. Concannon identified a variety of potential policy interventions that may slow or halt the current service duplication trend:

• Voluntary regionalization strategies in which hospitals and EMS services work together to increase timely access to revascularization for STEMI patients: Although these have been successful in selected locations, some markets are not yet ready for them, Dr. Concannon commented
• Market-based incentives to discourage introduction of redundant services, such as accountable care organizations or reimbursement reforms
• Direct regulation involving certificates of need (CON): In fact, Dr. Concannon’s study showed that hospitals in states with robust CON programs were 40% less likely to introduce a new PCI program; The current trend toward relaxation of CON requirements needs to be reversed, he added

Dr. Concannon said hospital leaders should use these new data to reevaluate plans to institute new interventional programs. Future research should assess the effects of excessive PCI concentration in certain areas on outcomes over time, he added.

In an e-mail communication with TCTMD, Ted A. Bass, MD, of University of Florida Health (Jacksonville, FL), the current president of the Society for Cardiovascular Angiography and Interventions, underlined what is at stake in how invasive care is allocated.

“The key take-away from this study is that people who make business decisions about distribution of hospital resources—in this case, new cardiac cath labs—need to work with physicians and other health-care providers to assess where and how available resources should be disbursed to make a difference for patients,” he noted. “Decisions about where to establish new cardiac cath labs should be carefully considered in the context of where patients who are currently underserved are living.”

2. Joynt KE. Right-sizing invasive cardiac services in the United States [editorial]. Circulation. 2013;Epub ahead of print.

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