Editorial
Universal Access to a Percutaneous Coronary
Intervention Hospital
Is It Feasible or Desirable?
Saket Girotra, MD, SM; Peter Cram, MD, MBA
is frequently delayed because ⬍10% of these patients achieve
the recommended door-to-balloon (D2B) time of ⬍90 minutes.8 This is in sharp contrast to patients presenting directly
to PCI-capable hospitals, where the astounding success of the
D2B Alliance Program has led to a remarkable reduction in
reperfusion delays and achievement of a median D2B time of
64 minutes.9 Given this disparity in reperfusion times for
direct-arrival and transferred patients with STEMI, it is
important to assess whether new PCI programs have brought
more patients closer to a PCI-capable hospital.
To address this matter, in this issue of Circulation: Cardiovascular Quality and Outcomes, Concannon et al10 provide interesting new data describing the growth of PCI
capability in US hospitals between 2001 and 2006 and how
this expansion has affected geographic access to PCI hospitals for the general population. By using data from the
American Hospital Association survey, they found that the
proportion of US hospitals providing PCI increased from
25.5% in 2001 (1176 of 4609) to 36.2% in 2006 (1695 of
4673), a 44% relative increase in the proportion of hospitals
with PCI.11 Despite the addition of ⬎500 new PCI programs,
geographic access for patients improved little during the
period of study. In particular, the percentage of the US
population residing within 60 minutes of a PCI-capable
hospital increased by a mere 0.9% (79.0% in 2001; 79.9% in
2006). Moreover, the average driving time and total elapsed
time from 9 –1-1 call to hospital arrival decreased by 48 and
30 seconds, respectively, suggesting that most new PCI
programs have opened in areas with preexisting PCI hospitals. Although the improvement in geographic access from
new PCI programs appears to have been small, the costs of
these new programs are likely substantial. The fixed costs of
setting up a new cardiac catheterization laboratory (construction and equipment) have been estimated at $3.1 million,
without including the cost of physicians, nurses, and technologist staffing.12 Thus, the capital costs of the new PCI
laboratories that have opened in this 5-year period are likely
to have exceeded $1.5 billion.
Although these analyses advance our understanding of how
geographic access for patients has changed with growth in
PCI services, important limitations need to be kept in mind.
First, the method used to identify PCI hospitals by Concannon et al10 in the current study differs from the method used
by Nallamothu et al11 that serves as the comparator. It is
unclear precisely how differences in methods between the 2
studies may have biased results. Second, the authors did not
attempt to map new PCI programs to population density.
From the data that are presented, it seems likely that many
D
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uring the past decade, advances in device technology
(eg, drug-eluting stents), development of safer anticoagulants (eg, bivalirudin), and refinement in procedural techniques have led to a dramatic improvement in the effectiveness and safety of percutaneous coronary intervention (PCI),
despite increasing clinical and anatomic complexity of treated
patients.1 As safety and effectiveness have been documented,
the indications for PCI have expanded. In patients with
ST-segment elevation myocardial infarction (STEMI), the
superiority of primary PCI (when readily available) over
thrombolytics is well established.2 More recently, PCI has
also become a viable alternative to coronary artery bypass
grafting in select patients with coronary artery disease.3
Article see p 14
As appreciation of the effectiveness of PCI has grown,
there has been rapid diffusion of PCI capability into US
hospitals. Dissemination of PCI has been further augmented
by generous hospital and physician reimbursement, reductions in federal regulatory policies, and accumulating evidence that PCI can be performed safely at hospitals without
on-site cardiac surgical backup.4,5 As a result, hospitals with
PCI availability in the United States increased from 929 in
1993 to 1316 in 2004.6
Despite the growth in capacity, PCI is not available at all
hospitals at all times. In fact, most patients with STEMI
initially present to hospitals without PCI capability, where
treatment options may include on-site thrombolytics or transfer to the nearest PCI-capable hospital for primary PCI. Based
on demonstration of the superiority of primary PCI over
thrombolytics,2 transfer to a PCI-capable hospital has been
widely promoted as a treatment strategy for these patients.7
However, reperfusion in patients transferred for primary PCI
The views expressed in this article are those of the authors and do not
necessarily represent the views of the Department of Veterans Affairs.
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Divisions of Cardiovascular Diseases (S.G.) and General
Internal Medicine (P.C.), Department of Internal Medicine, University of
Iowa Hospitals and Clinics, and the Center for Comprehensive Access
and Delivery Research and Evaluation, Iowa City Veterans Affairs
Medical Center (P.C.), Iowa City, IA.
Correspondence to Saket Girotra, MD, SM, Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa
Hospitals and Clinics, 200 Hawkins Dr, Suite E 318-5, Iowa City, IA
52242. E-mail [email protected]
(Circ Cardiovasc Qual Outcomes. 2012;5:9-11.)
© 2012 American Heart Association, Inc.
Circ Cardiovasc Qual Outcomes is available at
http://circoutcomes.ahajournals.org
DOI: 10.1161/CIRCOUTCOMES.111.964270
9
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Circ Cardiovasc Qual Outcomes
January 2012
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new PCI programs were redundant (ie, built in areas that
already had PCI available), but it is also possible that some
new programs expanded access in important ways, especially
in areas where there may have been significant “unmet” need
for PCI services. Finally, although the authors found significant state-level variation in geographic access to PCI hospital, variation in geographic access by urban and rural location
and how this access changed over time were largely
unexplored.
Despite the previously described limitations, these analyses
are thought provoking, mainly because of the questions they
raise. The apparent disconnect between growth in PCI hospitals and improvement in geographic access is striking.
Although not clearly quantified, these data suggest that most
new PCI programs opened in areas with preexisting PCI
hospitals nearby. The potential impact of the growth in PCI
hospitals on healthcare outcomes and costs is critically
important. Although some may argue that establishing new
PCI programs in close proximity to existing PCI programs
will encourage competition, thereby increasing quality and
lowering costs, empirical evidence suggests otherwise. Studies have shown that total healthcare costs are higher for
patients treated in hospitals that operate in competitive
markets because of perceived threat for “customers,” which
may result in non–price-based competition (eg, investments
to improve amenities of care).12 Furthermore, given that
national PCI volume has remained relatively unchanged
during this period,13 patient outcomes may worsen if increased local competition results in redistribution of a fixed
volume of cases between more hospitals. There is also
concern that market competition increases use rates of procedures, especially for discretionary or even inappropriate
indications to fulfill unmet capacity to provide a service.14,15
Because of these concerns, growth of new revascularization programs, including PCI, was regulated by federal
certificate-of-need programs in the past. After the federal law
was repealed in 1984, nearly half of the US states continued
certificate-of-need regulation for cardiac revascularization,
including PCI. States that discontinued this legislation had
greater expansion in the number of new PCI programs, higher
inappropriate use of cardiac catheterization, and a higher
overall PCI use rate compared with states with certificate-ofneed regulations.4,6,14 However, the impact of these regulations in improving patient outcomes or achieving equitable
access remains unsettled. With the ongoing proliferation of
new PCI programs, a better understanding of the markets (and
hospitals) in which these programs have been established,
their impact on clinical appropriateness, use, cost of care,
patient outcomes, and population health is clearly warranted.
This will inform future policy aimed at aligning growth in
PCI capacity with improved access to quality care. To their
credit, the authors validated the American Hospital Association data as a reliable source of information about a hospital’s
PCI capability, which would be useful in conducting future
research in this area.
The findings from this study also carry implications for
STEMI regionalization. Despite the growth in PCI capacity,
⬇42 million Americans lived outside a 60-minute prehospital
time window to a PCI-capable hospital, a number that has
remained largely unchanged over the past 5 years. Although
several hospital systems have developed innovative transport
strategies (eg, emergency air medical services) to make PCI
available to some of these patients, these efforts have not
been successful in achieving timely revascularization in these
patients8 as the result of significant delays at local hospitals.16
Does this argue for a PCI laboratory in every hospital?
Although this may achieve universal access to PCI and
obviate the need for interhospital transfer, this strategy is
impractical and expensive.17 To overcome this, some centers
have been successful in improving interhospital transfer times
through targeted interventions (strengthening of emergency
medical response and systematic treatment protocols)18; this
requires substantial investment that may not be realistic for
all hospitals and communities. With new evidence suggesting
that modern thrombolytic therapy has substantially attenuated
the mortality benefit from primary PCI,19 it may be time to
re-examine initial thrombolysis as a reperfusion strategy for
eligible patients, followed by transfer to a PCI hospital. As
we deliberate strategies to deliver optimal care to patients
with STEMI, especially those who present to non-PCI hospitals, we may be well served to also learn from technological
innovations in the area of stroke regionalization. Several
hospital systems have effectively used telemedicine to support hospitals without a neurologist on site in initial evaluation, management, and decision making in stroke patients
with improved patient outcomes.20 There may be potential for
a similar strategy in improving care for patients with acute
coronary syndrome, including STEMI, who present to hospitals without PCI capability.
Last, access to quality care is a complex construct, and
geographic proximity represents only 1 of its dimensions.21
Other dimensions of access that are particularly relevant
include socioeconomic factors (eg, health insurance), cultural
factors (eg, perceived stigma), and perceived need for care
(eg, treatment-seeking behavior). The current study analyzes
only geographic access and does not directly measure
whether new PCI programs provided greater access to patient
subgroups who have historically been less likely to receive
revascularization with PCI (eg, women, elderly individuals,
African Americans, and patients without health insurance).22
If the new programs markedly improved access among these
patient subgroups, this would be of major importance, despite
the limited improvement in geographic access that the new
programs added. This is an importance area for future
research.
In conclusion, the study by Concannon et al10 documented
a marked increase in the number and proportion of US
hospitals offering PCI between 2001 and 2006; however, this
was accompanied by little improvement in geographic access
to PCI. Future studies need to better understand the impact of
the new programs on patient outcomes, healthcare use, and
costs to better inform policy.
Disclosures
Dr Girotra is a Fellow in Interventional Cardiology at the University
of Iowa Hospitals and Clinics. Dr Cram was supported by a K23
career development award (RR01997201) from the National Center
for Research Resources at the National Institutes of Health and the
Robert Wood Johnson Physician Faculty Scholars Program. This
Girotra and Cram
work is funded by R01 HL085347 from the National Heart, Lung,
and Blood Institute at the National Institutes of Health. Dr Cram is
supported by the Department of Veterans Affairs and is an investigator at Center for Comprehensive Access and Delivery Research
and Evaluation (CADRE) at the Iowa City Veteran Affairs. The
funding sources had no role in the analyses or drafting of the
manuscript. Dr Cram has received payment for advising Vanguard
Health, an operator of for-profit hospitals, on quality
improvement efforts.
References
Downloaded from http://circoutcomes.ahajournals.org/ by guest on June 15, 2017
1. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B,
Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange
RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK,
Ting HH. 2011 ACCF/AHA/SCAI guideline for percutaneous
coronary intervention: a report of the American College of Cardiology
Foundation/American Heart Association task force on practice
guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574 – e651.
2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous
thrombolytic therapy for acute myocardial infarction: a quantitative
review of 23 randomised trials. Lancet. 2003;361:13–20.
3. Bravata DM, Gienger AL, McDonald KM, Sundaram V, Perez MV,
Varghese R, Kapoor JR, Ardehali R, Owens DK, Hlatky MA. Systematic
review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med.
2007;147:703–716.
4. Popescu I, Vaughan-Sarrazin MS, Rosenthal GE. Certificate of need
regulations and use of coronary revascularization after acute myocardial
infarction. JAMA. 2006;295:2141–2147.
5. Ting HH, Raveendran G, Lennon RJ, Long KH, Singh M, Wood DL,
Gersh BJ, Rihal CS, Holmes DR Jr. A total of 1,007 percutaneous
coronary interventions without onsite cardiac surgery: acute and
long-term outcomes. J Am Coll Cardiol. 2006;47:1713–1721.
6. Vaughan Sarrazin MS, Bayman L, Cram P. Trends during 1993–2004 in
the availability and use of revascularization after acute myocardial
infarction in markets affected by certificate of need regulations. Med Care
Res Rev. 2010;67:213–231.
7. Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of
systems of care for ST-elevation myocardial infarction patients. Circulation.
2007;116:217–230.
8. Wang TY, Peterson ED, Ou FS, Nallamothu BK, Rumsfeld JS, Roe MT.
Door-to-balloon times for patients with ST-segment elevation myocardial
infarction requiring interhospital transfer for primary percutaneous
coronary intervention: a report from the National Cardiovascular Data
Registry. Am Heart J. 2011;161:76e1– 83e1.
9. Krumholz HM, Herrin J, Miller LE, Drye EE, Ling SM, Han LF, Rapp
MT, Bradley EH, Nallamothu BK, Nsa W, Bratzler DW, Curtis JP.
Improvements in door-to-balloon time in the United States, 2005 to 2010.
Circulation. 2011;124:1038 –1045.
10. Concannon TW NJ, Goetz J, Griffith JL. A percutaneous coronary intervention lab in every hospital? Circ Cardiovasc Qual Outcomes. 2012;5:
14 –20.
Universal Access to a PCI Hospital
11
11. Nallamothu BK, Bates ER, Wang Y, Bradley EH, Krumholz HM. Driving
times and distances to hospitals with percutaneous coronary intervention
in the United States: implications for prehospital triage of patients with
ST-elevation myocardial infarction. Circulation. 2006;113:1189 –1195.
12. Lieu TA, Lundstrom RJ, Ray GT, Fireman BH, Gurley RJ, Parmley WW.
Initial cost of primary angioplasty for acute myocardial infarction. J Am
Coll Cardiol. 1996;28:882– 889.
13. Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary
revascularization trends in the United States, 2001–2008. JAMA. 2011;
305:1769 –1776.
14. Ross JS, Ho V, Wang Y, Cha SS, Epstein AJ, Masoudi FA, Nallamothu
BK, Krumholz HM. Certificate of need regulation and cardiac catheterization appropriateness after acute myocardial infarction. Circulation.
2007;115:1012–1019.
15. Nallamothu BK, Rogers MA, Chernew ME, Krumholz HM, Eagle KA,
Birkmeyer JD. Opening of specialty cardiac hospitals and use of coronary
revascularization in Medicare beneficiaries. JAMA. 2007;297:962–968.
16. Herrin J, Miller LE, Turkmani DF, Nsa W, Drye EE, Bernheim SM, Ling
SM, Rapp MT, Han LF, Bratzler DW, Bradley EH, Nallamothu BK, Ting
HH, Krumholz HM. National performance on door-in to door-out time
among patients transferred for primary percutaneous coronary intervention. Arch Intern Med. 2011;171:1879 –1886.
17. Concannon TW, Kent DM, Normand SL, Newhouse JP, Griffith JL,
Cohen J, Beshansky JR, Wong JB, Aversano T, Selker HP. Comparative
effectiveness of ST-segment-elevation myocardial infarction regionalization strategies. Circ Cardiovasc Qual Outcomes. 2010;3:506 –513.
18. Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR,
Lips DL, Madison JD, Menssen KM, Mooney MR, Newell MC, Pedersen
WR, Poulose AK, Traverse JH, Unger BT, Wang YL, Larson DM. A
regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007;116:
721–728.
19. Claeys MJ, de Meester A, Convens C, Dubois P, Boland J, De Raedt H,
Vranckx P, Coussement P, Gevaert S, Sinnaeve P, Evrard P, Beauloye C,
Renard M, Vrints C. Contemporary mortality differences between
primary percutaneous coronary intervention and thrombolysis in
ST-segment elevation myocardial infarction. Arch Intern Med. 2011;171:
544 –549.
20. Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas T,
Chumbler NR, Handschu R, Jauch EC, Knight WA, Levine SR, Mayberg
M, Meyer BC, Meyers PM, Skalabrin E, Wechsler LR; on behalf of the
American Heart Association Stroke C, the Interdisciplinary Council on
Peripheral Vascular D. A review of the evidence for the use of telemedicine within stroke systems of care. Stroke. 2009;40:2616 –2634.
21. Fortney JC, Burgess JF Jr, Bosworth HB, Booth BM, Kaboli PJ. A
re-conceptualization of access for 21st century healthcare. J Gen Intern
Med. 2011;26(suppl 2):639 – 647.
22. Popescu I, Vaughan-Sarrazin MS, Rosenthal GE. Differences in mortality
and use of revascularization in black and white patients with acute MI
admitted to hospitals with and without revascularization services. JAMA.
2007;297:2489 –2495.
KEY WORDS: Editorials
intervention
䡲
healthcare access
䡲
percutaneous coronary
Universal Access to a Percutaneous Coronary Intervention Hospital: Is It Feasible or
Desirable?
Saket Girotra and Peter Cram
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Circ Cardiovasc Qual Outcomes. 2012;5:9-11
doi: 10.1161/CIRCOUTCOMES.111.964270
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