AHJ: PCI patients may be better off at specialty hospitals
“In the United States, there continues to be debate about whether certain types of hospitals deliver improved patient outcomes,” Peter Cram, MD, MBA, of the University of Iowa Carver College of Medicine in Iowa City, and colleagues wrote. “Despite more than two decades of analyses, it remains uncertain whether certain models of hospital care deliver improved outcomes.”
To evaluate whether hospital characteristics impacted PCI outcomes, Cram et al used the CathPCI Registry to identify 1,113,554 patients who underwent PCI at 471 nonprofit hospitals, 131 major teaching hospitals, 79 for-profit hospitals and 13 physician-owned specialty hospitals.
The researchers included outcomes of in-hospital mortality, stroke, bleeding events, vascular injury and a composite of one or more complications. The researchers found patients treated in academic medical centers to be younger and more likely to be black, while patients undergoing PCI at electrophysiology hospitals were likely to be admitted through the emergency department. Patients undergoing care at specialty hospitals were more likely to have had a previous revascularization.
The researchers reported that 4.2 percent of patients experienced one or more in-hospital adverse outcomes post-PCI. The percentage of patients experiencing one or more adverse events was lower in speciality hospitals compared with nonproft hospitals, major teaching hospitals and for-profit hospitals. These numbers were 2.4 percent, 4.1 percent, 4.6 percent and 4.3 percent, respectively.
However, the researchers said that specialty hospitals treated less acute patients, including a lower patient cohort with STEMI. However, among the STEMI subgroup of patients, patients treated at specialty hospitals fared better compared with those treated at other types of hospitals. The percentage of patients who experienced one of more adverse outcomes was 7 percent at specialty hospitals, 9.6 percent at nonprofit hospitals, 11.1 percent at major teaching hospitals and 9.8 percent at for-profit hospitals.
“Specialty hospitals had substantially improved risk-adjusted mortality in unadjusted analyses, and this benefit was consistent among all patients in aggregate and all subgroups,” the authors wrote.
While the researchers did report that patients treated at physician-owned specialty hospitals had better outcomes, they said that these improved outcomes could be due to a difference in the complexity of patients treated within the various hospital groups.
“Our findings extend the current evidence surrounding the potential benefits of specialty hospitals in the area of cardiovascular disease,” the authors said.
But the authors added that “it is important to acknowledge significant and lingering concerns over physician-owned specialty hospitals and the conundrum that they represent”—the fact that they tend to avoid more complex patients who cost more and may be less profitable.
"These findings have led to an acrimonious debate at the federal and state level over the wisdom of allowing physicians to invest in hospitals, with many critics calling for an outright ban on physician ownership,” they added. “Although banning physician ownership of hospitals is an intuitively appealing solution, such a solution would likely eliminate the chance to obtain knowledge from a group of hospitals that appear to deliver very good outcomes.”
Within the current study, adding PCI volume to the mix had little effect on the mortality advantage seen in specialty hospitals, the authors noted.
“It is possible that the improved outcomes seen in specialty hospitals relates to the much maligned physician ownership or the standardization of care that comes with specialization around a single condition or disease,” the authors wrote.
“These results add to evidence that physician-owned specialty hospitals may have developed expertise in narrow procedural areas that could be adapted to the larger population of general hospitals,” Cram et al summed.