Ice-cream stand syndrome: Hospitals set up cardiac services near rivals

While the number of hospitals providing invasive coronary services has increased, access to these procedures has not improved because hospitals offer new services in locations where similar cardiac programs already exist.

In a retrospective cohort study published July 19 in Circulation, Jill R. Horwitz, PhD, JD, of the University of California Los Angeles School of Law and her colleagues analyzed data from Medicare fee-for-service hospitals between 1996 and 2008. The hospitals included in the study billed Medicare for at least five procedures a year—diagnostic angiography, PCI or CABG—for patients who had a documented MI.

“The main finding is that hospitals are much more likely to adopt new invasive cardiac services if the hospitals nearby already have those services,” Horwitz  told Cardiovascular Business.

Their analysis determined that over the 12-year period, new services varied—8 percent of hospitals offered new diagnostic angiography, 7 percent offered PCI and 6 percent provided new CABG services.

The results were largest with PCI. A 10 percentage-point increase in the rate of local hospitals providing PCI increased the odds of a hospital offering new PCI services by 79.4 percent. The same percentage point increase raised a hospital’s odds of adding diagnostic angiography by 10 percent, but had no effect on the addition of CABG.

The increase in services, however, did not lead to an increase in geographic access to them. They determined how many people lived within 40 miles of facilities with newly added invasive cardiac services and compared their results to the number of people living within that distance before the new services emerged. The 40-mile distance was based on the recommended maximum 60-minute travel time.

“We were trying to figure out whether the expansion of services led to more people being within 40 miles of hospitals offering the new services, but we found there wasn’t much of an increase in geographic access.

The proportion of people who had geographic access to diagnostic angiography increased by only 1 percent point. The increase was five percentage points for PCI and four for CABG.

“The motivation behind the growth in invasive cardiac services seems to be more competition rather than expanding geographic access to services,” Horwitz said.

Cardiovascular Business reported on a similar study published July 9 that found that despite widespread expansion of new emergent PCI programs nationwide, the bulk of the new services are duplicative and did not improve access. In their research, Thomas Concannon et al. also found competition to be a major incentive.

It is unclear what health outcomes result from the way services are distributed.

“Although our study does not address the health risks associated with current patterns of cardiac care diffusion, the mismatches we identified between technology supply and population suggest possible implications for both cost-effectiveness and quality,” they wrote.

In addition to underuse of these cardiac procedures due to access issues, Karen Joynt, MD, MPH, of Brigham and Women’s Hospital in Boston, argued that there is also the problem of overuse.

“The authors’ findings suggest that the financial incentives to adopt new services in places in which they already exist are clearly powerful enough to encourage hospitals to do so, leading to waste,” she wrote.