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Regionalizing CABG May Save Lives

In the U.S., approaches to regionalization of open heart surgery range from the strict certificate-of-need (e.g., New York) to the deregulated, market-oriented (e.g., California). In Canada the government controls facilities. This joint study by Canadian and Californian researchers examined regionalization's effects on geographic access to CABG in New York, California, and two Canadian provinces.

The authors reviewed discharge records of all adult patients who underwent CABG between 1987 and 1989 at a nonfederal hospital in the study jurisdiction, and calculated the straight-line distance from the patient's residence to each CABG facility in his or her jurisdiction. In New York and Canada CABG was concentrated in a relatively small number of high-volume hospitals; only 4% in New York and 2% in Canada were performed in hospitals with a volume of less than 200 CABG cases per year. In California, on the other hand, 33% of reviewed CABG procedures were in lower-volume hospitals. Mortality was highest in California hospitals performing fewer than 100 CABGs per year. The percentage of the population residing within 25 miles of at least one CABG hospital was 91% in California, 82% in New York, and below 60% in Canada. The elimination of all low-volume California hospitals would increase distance to a CABG hospital only slightly for a small number of California residents.

Comment: The authors argue that lack of regionalization in areas of uncontrolled health care delivery, such as California, leads to higher rates of coronary revascularization, excess surgical capacity, and high postoperative mortality rates in low-volume hospitals. They find that modest regionalization like New York's could decrease the number of CABG facilities per capita in California by 50% without significantly increasing patients' travel. This suggests patient access to CABG would not be jeopardized and perioperative mortality could be significantly decreased by greater regionalization of cardiac surgical centers.

— GW Dec

Published in Journal Watch Cardiology January 1, 1996

Citation(s):

Grumbach K et al. Regionalization of cardiac surgery in the United States and Canada. JAMA 1995 Oct 25 274 1282-1288.

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