Expansion of PCI does not improve access

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New emergent PCI programs introduced in hospitals across the U.S. potentially cost billions to operate, yet do not improve access to these urgent services for most of the STEMI patients who need them, according to a study.

A team of researchers from The RAND Corporation, Tufts Medical Center and Tufts University School of Medicine analyzed the specific hospitals and locations where new programs were set up between 2004 and 2008, focusing on characteristics of the neighborhoods and the transport time between the 911 call and arrival at the facility. They also looked at the costs of running each new program.

The study, published online July 9 in Circulation: Cardiovascular Quality and Outcomes, found that 251 new programs emerged nationwide over the four-year period and the number of hospitals able to offer services grew by 16.5 percent. The estimated costs of operating the new programs were between $2 billion and $4 billion.

Despite the vast growth and expenditures, comparatively few STEMI patients were able to get to a PCI-equipped facility in a short period of time—the number of patients able to receive timely PCI increased by only 1.8 percent.

“Over a 10-year period, the number of patients who get access to this procedure in an emergency has not moved. It’s stayed below 50 percent of patients with heart attack,” Thomas Concannon, PhD, the lead author and policy researcher at RAND told Cardiovascular Business.

That percentage should be much higher, he said. Based on the locations of new and existing PCI programs and how many patients live within an hour of an equipped facility, there is the potential to reach close to about 80 percent.

He did note, however, that the trends were more promising in Mississippi and Missouri. Access improved significantly after the addition of new programs in Mississippi, and transport times to catheterization facilities—defined as the time between the call to 911 and arrival at the hospital—were considerably reduced.

Across the rest of the nation, however, Concannon believes the number of new programs was driven by a factor other than better patient care.

“Competition was the incentive behind the growth in services rather than improvement in access or a reduction of times to treatment,” he said.

Based on the data, researchers also identified proximity to populations with higher rates of private insurance and weak or no state regulations for cardiac catheterization laboratories as influencing factors.

In an accompanying editorial, Isuru Ranasinghe, MD, of the Yale University School of Medicine, added there also isn’t as great a demand for PCI as there once was. “Incident acute myocardial infarction, and particularly STEMI, rates have declined over the last 15 years,” he wrote. 

He added that the expansion of other procedures, such as transcatheter aortic valve replacement and CT angiography, has also been duplicative and exorbitantly costly. As with PCI, he explained that it is not yet clear whether the expenditures on these treatments have led to better overall patient outcomes. 

“There are a few strategies that can restrain some of this unnecessary growth,” Concannon said. 

One approach is for hospitals and emergency medical service providers to come together and plan how to improve access and prevent duplication. The state of North Carolina has such a statewide system in place, resulting in a 95 percent utilization rate.

A second strategy is for a state or a large insurer to reduce the amount of reimbursement for PCI or devise an incentive payment plan. Yet another option is to require state reviews and regulations of PCI programs.

Concannon said growth has slowed over the past few years, but his team has not yet gathered any data after 2008. 

“We’d like to know if the rate of adoption is continuing to slow over time and how quickly we need to get in front of this.”