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March 6, 2007

Do specialty heart hospitals drive up heart care use?
U-M-led study suggests the answer is yes

Bypass surgery & angioplasty rise in areas where freestanding heart hospitals open, compared with areas where general hospitals deliver heart care

ANN ARBOR, MI – Across the country, states are embroiled in a debate over “specialty hospitals” – physician-owned hospitals that focus on a single disease process such as heart care or orthopedics. The debate has intensified ever since a federal government moratorium on opening new specialty hospitals expired last year.

Brahmajee Nallamothu, M.D., MPHNow, a new study reveals more about the effect that new “heart” hospitals might have on heart care use in their local area. The data differ from previous findings which suggested an uncertain relationship between heart hospitals and heart care use.

Specifically, the study, which was performed in Medicare beneficiaries 65 years or older, shows that the opening of a new specialty cardiac hospital is associated with a regional rise in heart procedures to open clogged arteries — such as bypass surgery and angioplasties. The rise was twice as great as the rise that occurred in regions where an existing general hospital added heart services, or where no new heart care facilities opened.

And while the study wasn’t designed to look at whether each heart procedure was medically warranted, the authors note that the launch of a specialty hospital appears to particularly drive up the use of angioplasty in patients without heart attacks: a group where the procedure’s long-term clinical benefit may be less clear.

The findings, published in the March 7 issue of the Journal of the American Medical Association, come from a team from the University of Michigan Cardiovascular Center, the VA Ann Arbor Healthcare System and the Michigan Surgical Collaborative for Outcomes Research and Evaluation, and their colleagues from Harvard University and Yale University. The study was funded by the Agency for Healthcare Research and Quality.

“This is the first study to show that specialty cardiac hospitals increased the use of these procedures in the hospital markets where they opened, compared with regions where existing hospitals added heart care services or regions where there was no change in heart care services,” says lead author Brahmajee Nallamothu, M.D., MPH, an assistant professor of cardiovascular medicine at the U-M Medical School and interventional cardiologist at the U-M Cardiovascular Center. He is also a member of the Health Services Research & Development Center at the Ann Arbor VA.

The authors emphasize that the specialty heart hospitals in the study are different from heart centers that operate as part of larger hospitals, such as the U-M CVC. In fact, the state of Michigan does not have any standalone specialty heart hospitals because of a strict “certificate of need” statute that gives the state government control over the opening of new hospitals or major clinical expansions.

Many other states, especially in the South and West of the United States, don’t have such statutes. In such states, specialty heart hospitals owned and operated by physicians cropped up throughout the late 1990s and early 2000s.

But in 2003, the federal government took action that halted the opening of new ones, due to concerns over the potential for doctors who co-own specialty hospitals to be influenced by financial rather than medical reasons when referring patients for hospital care. Concern has also arisen about specialty hospitals’ potential to “skim” the most lucrative patients from a region, leaving other hospitals with sicker and uninsured patients. Meanwhile, advocates for specialty hospitals say they increase quality and efficiency of care by focusing clinical expertise for these disease processes.

Last year the moratorium was lifted, and in August 2006 the Centers for Medicare & Medicaid Services (CMS) presented a strategic plan to address the long-term development of specialty hospitals. This plan recommended adjustments to Medicare payments to limit financial incentives as well as rule changes to require physicians to disclose their financial interests to patients. New specialty hospitals continue to be planned around the country, often spurring debate in local areas.

The new study used Medicare data from 1995 to 2003, and focused on heart hospitals that offered bypass surgery or percutaneous coronary intervention (PCI, which includes angioplasty, stenting and related procedures). The researchers analyzed patterns of use for these procedures within 306 hospital referral regions or HRRs, which represent unique hospital markets for specialized care. After identifying 13 HRRs where one or more specialty cardiac hospital opened during the study period, the team calculated population-based rates for each year across the United States.

In every region, the use of PCI rose steadily over the time period, and the use of bypass surgery was level in the 1990s and declined in the early 2000s – reflecting a well-known national trend toward minimally invasive techniques instead of surgery to reopen clogged heart arteries. In that same time period, many general hospitals began to offer PCI for the first time.

But the use for these procedures rose faster in the HRRs where a specialty cardiac hospital opened. Four years after the specialty cardiac hospitals opened, the population-adjusted rates of heart procedures in their surrounding HRRs had grown by more than twice as much as the rates in HRRs where no specialty hospital had opened. There was no major difference in those rates when the researchers compared HRRs where a new heart program had begun at a general hospital, and HRRs where no new heart services launched.

When the researchers separated the bypass surgery numbers from the angioplasty and other PCI numbers, they found the same effect. And when they considered post-heart attack emergency PCI rates with PCI rates for patients who had not had a heart attack, the difference was much greater. In regions where specialty heart hospitals opened, the rate of these “non-emergent” PCI procedures rose 42 percent in four years, compared with a 23 percent rise in areas where a general hospital offered new heart services, and a 24.8 percent rise in areas where no new services began.

“We’re not saying that specialty cardiac hospitals are bad, nor that they provide services inappropriately,” says John Birkmeyer, M.D., a U-M professor of general surgery who has studied many surgical utilization issues. “Nonetheless, our findings suggest that patients treated there are more likely to be treated with invasive interventions than at general hospitals. Payers in markets served by specialty hospitals can also expect higher overall costs associated with more procedures.”

In addition to Nallamothu and Birkmeyer, the study’s authors are Kim Eagle, M.D., one of the directors of the U-M Cardiovascular Center; Mary A.M. Rogers, Ph.D., research director of the U-M Patient Safety Enhancement Program; Michael Chernew, Ph.D., of Harvard University, formerly of the U-M School of Public Health; and Harlan Krumholz, M.D., S.M., of Yale University. Reference: JAMA, March 7, 2007. Vol. 297, No. 9, pp. 962-968.

Written by Kara Gavin

 

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