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Do Specialty Cardiac Hospitals Drive Regional Increases in Revascularization Rates?

An analysis of Medicare data from 1995 through 2003 suggests that possibility.

Hospitals that specialize in treating particular, complex medical conditions are touted as providing high-quality, cost-efficient care, but critics argue that they might adversely affect case distribution within a healthcare market. Now, researchers have focused specifically on how specialty cardiac hospitals affect the overall use of revascularization procedures. They analyzed data from 1995 through 2003 on Medicare beneficiaries in three types of hospital referral regions: 13 where new specialty cardiac hospitals opened during that period, 142 where new cardiac programs opened at general hospitals, and 151 where no new cardiac programs started.

In 1995, rates of both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) were statistically similar among the three types of regions (range, 22.5%–26.8%; adjusted for age, sex, and race). From 1995 to 2003, the rate of total revascularizations grew significantly more in regions with newly opened specialty cardiac hospitals than in the other two types of regions (by about 4 more revascularizations per 10,000 population).

Within 4 years after specialty hospitals opened, the relative increase in revascularization procedures within those regions was 19%, compared with roughly 7% in each of the other two types of regions. This significant difference was reflected in both the relative decline in CABG over time (–4% in regions with new specialty cardiac hospitals vs. about –19% in the other regions) and in the relative increase in PCI (+35% vs. +23%); the latter was due entirely to PCI in patients without acute MI (+42% vs. +24%).

Comment: This study raises the troubling possibility that opening specialty cardiac hospitals increases regional coronary revascularization rates among Medicare patients. Physicians own many specialty hospitals, so financial incentives could be driving this growth, which would have important implications for reimbursement policy. The editorialists cite another potential contributor: growth in procedure rates at nonspecialty hospitals within the specialty-hospital regions, due to new competition. They also note that the current study did not report on the clinical appropriateness of procedures. A previous observational study, which focused on outcomes, showed that Medicare patients who underwent coronary revascularization procedures at specialty hospitals had no outcome advantage over those treated at general hospitals, after adjustment for patient characteristics and hospital procedure volumes (Journal Watch Cardiology May 13 2005).

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology March 6, 2007

Citation(s):

Nallamothu BK et al. Opening of specialty cardiac hospitals and use of coronary revascularization in Medicare beneficiaries. JAMA 2007 Mar 7; 297:962-8.

• Original article (Subscription may be required)
• Medline abstract (Free)

Cram P and Rosenthal GE. Physician-owned specialty hospitals and coronary revascularization utilization: Too much of a good thing? JAMA 2007 Mar 7; 297:998-9.

• Original article (Subscription may be required)
• Medline abstract (Free)