Published in the November 2008 issue of Today’s Hospitalist
As a hospitalist, you may not feel plugged into the debate that’s raging in the cardiology community over the growth of percutaneous coronary intervention (PCI) in community hospitals. But physicians who have seen PCI come either to their hospital directly or to another facility in their community say that hospitalists stand to be affected by the change.
Interventional cardiologists are sharply divided about whether it’s a good idea for small hospitals to embrace PCI, particularly in facilities without on-site surgical back-up. But faced with a growing body of evidence indicating that PCI is safe in smaller hospitals “and lured by a convincing business case “more community hospitals are opening cath labs, or considering doing so.
For the most part, hospitalists have watched this debate from the sidelines. That’s because most candidates for primary PCI “patients with ST elevation myocardial infarction (STEMI) “go from the ED to a facility with a cath lab, or they’re seen by a cardiologist for alternative therapy like thrombolysis.
As smaller hospitals bring PCI in-house, however, hospitalists may find their involvement in treating STEMI and other cardiac patients changing. That may hold true whether they work in a hospital that starts its own cath lab, or in a facility that transfers those patients across town.
Impact on hospital medicine
A good example of how changes in interventional cardiology are intersecting with hospital medicine can be found at Exeter Hospital in Exeter, N.H. Exeter, which has been in the forefront of the movement to bring PCI to smaller hospitals, began doing emergent and elective PCI in 1999.
Russell Kaphan, MD, a hospitalist at Exeter, says that working at a hospital with PCI capabilities can be a mixed blessing for hospitalists, although he rates the experience as positive.
On one hand, he gets to be involved with complex cardiology patients who stay at his community hospital. That means that community hospitalists now see “a whole class of people we wouldn’t have taken care of at all in the old situation,” says Dr. Kaphan. “Those patients with STEMI would have been shipped directly from the ED to another hospital.”
He also likes working at a community hospital with the ability to perform emergency and elective PCI on a 24/7 basis because of the standard of care. “Patients here are more likely to get to the cath lab and get the balloon open in the requisite length of time,” he says. That’s typically not the case for patients either in a community hospital without a cath lab or patients at a big tertiary facility that isn’t as small or nimble as a community hospital.
Plus, the PCI program can be used as a selling point to show hospitalist recruits how progressive the hospital is. And, Dr. Kaphan adds, “the halo effect” of the PCI program makes it easier to mobilize hospital resources for financial incentives that have brought heart failure care at Exeter “up to virtually 100% compliance with core measures.”
Improving patient care
Dr. Kaphan acknowledges that there can be downsides to working at a small hospital that provides PCI, but he says most are minor.
For example, hospitalists and cardiologists need to work out details of issues like admission procedures and discharge communication. While these issues crop up in every comanagement program, they can be exacerbated when a new hospitalist group starts up at an established PCI center.
Dr. Kaphan says that hospitalists find they’re sometimes “dropped into” the care of cardiac patients who have already had an emergency intervention. “The patients can be admitted to our service after the cardiologists have already been working on them for a couple of hours,” he points out. “Occasionally, there can be questions of whether our docs are providing nothing but an H&P service when we are called and told to admit a patient.”
Despite such issues, “there is strong evidence that making PCI available in community hospitals improves patient care,” says Thomas P. Wharton Jr., MD, the cardiologist who heads Exeter Hospital’s cardiac catheterization program. “Angioplasty is underused when patients are admitted to a hospital without PCI, and patients treated conservatively instead of with primary PCI have higher mortality rates. The need to transfer a patient elsewhere for angioplasty is a major barrier.”
While there are concerns about community hospitals offering PCI without on-site surgical back-up (see “The question of surgical back-up” on page 34), angioplasty technology has improved since the mid-1990s. With the advent of newer-generation stents and better anticoagulation and antiplatelet therapies, complications during angioplasty have fallen.
Restenois rates have also dropped, in part because of improvements in PCI itself, including drug-eluting stents, but also because of advances in medical management. Christopher Davis, MD, an interventional cardiologist who practices in three community hospitals in Florida, credits hospitalists for being part of that improvement.
“We’re not doing as many cases,” he says, “partly because medical management has gotten better. Now there are a lot more protocols and quality measures to make sure everybody leaves the hospital on aspirin, ACE inhibitors, statins and beta-blockers “and hospitalists are instrumental in getting those things started.”
Despite evidence that PCI is getting safer, hospitalists in some community facilities take a slightly different approach.
For instance, CHRISTUS-St. Michael Hospital in Texarkana, Texas, offers both PCI and on-site surgical back-up. James Urbina, MD, program director of the Cogent Healthcare hospitalist group there, points out that ideally, STEMI patients should go to primary PCI in less than 90 minutes to reduce morbidity and mortality.
But because the cath lab at CHRISTUS doesn’t operate 24/7, the hospitalists “not the cardiologists “frequently get the after-hours call to admit a patient with severe chest pain and to accept patients from rural hospitals with acute MI.
“Yes, we can fire up the cath lab at night,” Dr. Urbina explains, “but we have to call several people, and it may not happen quickly.” The problem, Dr. Urbina feels, is that most non-tertiary care hospitals simply don’t have enough volume to run the cath lab day and night.
For the hospitalists at CHRISTUS-St. Michael, managing challenging cardiac patients means they have to function as “true internists, not paperwork monkeys.” He and his colleagues play a big role in treating cardiac patients, from administering pressors to performing some basic invasive procedures.
Beyond taking all chest pains that are probably noncardiac, “we manage patients on our own for simple heart failure and simple cardiac dysrhythmias, and we consult cardiology if we need an invasive procedure,” Dr. Urbina says. Hospitalists may admit patients with uncomplicated MIs if they are stable and chest-pain free. Those patients may then be seen by cardiology in the morning and go on to the cath lab. “We do our own stress tests, and if these stress tests prove to be positive, we consult cardiology for a cardiac cath.”
As a result, he explains, hospitalists help free up the cardiologists in the area to do “a significant number of procedures in the hospital.”
As more community hospitals get in the business of operating cath labs, the effort to reduce door-to-balloon times is accelerating. That trend could end up affecting the patient loads of even hospitalists who aren’t working at a hospital with PCI.
Geisinger Medical Center in Danville, Pa., is a good example. When the hospital’s cardiac cath lab looked at its door-to-balloon times for patients transferred from non-PCI hospitals in 2004, the median was 188 minutes. By streamlining the transfer process, the hospital had by 2007 reduced that time to 89 minutes, says Jim Blankenship, MD, a cardiologist and director of Geisinger’s “Level 1 Heart Attack Program of Central and Northeastern PA.”
Those efforts weren’t aimed only at Geisinger staff and faculty, but at hospitals in neighboring communities. EDs in the area can now call one phone number when a STEMI patient presents and Geisinger will automatically send a helicopter and fire up its cath lab. Local hospitals can bypass all intermediate steps, like administering thrombolytics and calling a local cardiologist.
Efforts to speed door-to-balloon times for STEMI patients also affect the types of cardiac patients who eventually are admitted to hospitalist services.
For instance, many non-STEMI patients and individuals with unstable angina also get transferred instead of admitted. That’s according to Michael Donegan, MD, ED director at the 130-bed Evangelical Community Hospital in Lewisburg, Pa., which sends its interventional cardiology patients to Geisinger and to another facility.
“The natural progression is to send the spectrum of ACS patients,” Dr. Donegan explains. “We do see a change in the disposition of cardiac patients at Evangelical. There certainly is a group of patients that previously were treated here who are now being transferred.”
At Exeter Hospital, Dr. Wharton says that his experience backs up that observation. Hospitals that don’t offer angioplasty lose business as ambulances take all chest pain patients “not just those with STEMIs “to hospitals with primary PCI. In addition, primary care doctors and patients tend to choose hospitals that offer PCI for their diagnostic angiography.
“At Exeter, when we made the move in 1999 to shift PCI only in heart attacks to elective PCI as well, our diagnostic volume went up by 50% overnight,” he explains. “All the people who were going elsewhere for their initial diagnostic cath were now staying here.”
A question of autonomy
Not everyone believes that the growth of PCI in community hospitals has such a strong impact on hospitalist practice.
“Nobody is going to pay $15,000 for a helicopter ride” if it’s not an emergency, says Chris Fellin, MD, who heads the five-year-old hospitalist program at Evangelical in central Pennsylvania. He points out that at least 15% to 25%of the admissions to his hospitalist service are for chest pain, mainly rule-outs, but his patient panel also includes many very elderly seniors who either elect conservative medical management for both STEMI or ACS or do not qualify for catheterization due to poor renal function or generalized debility.
“The literature from studies done at academic medical centers suggests that almost everyone with ACS should be a cath candidate,” Dr. Fellin says, “but that’s not the way the real world works.”
As in many community hospitals, there recently have been discussions at Evangelical about whether it should look into doing PCI. Although he believes the research that shows its safety, Dr. Fellin says he is “on the fence” about whether adding interventional services would be worthwhile.
Issues include the costly set-up, the fact that it will affect relations with cardiology groups and neighboring tertiary care hospitals, and the awareness that it would probably change the hospitalists’ current ability to “function pretty autonomously in how we manage about 75% to 80%of things.”
“Drip-and-ship” working fine
Then there are plenty of hospitals “and hospitalists “that say their current policy of “drip-and-ship” works just fine.
John Krisa, MD, director of the hospital medicine program at the 160-bed Albany Memorial Hospital in Albany, N.Y., which is a Hospitalists Management Group (HMG) practice, says that the community seems to like the fact that his 24/7 group admits nearly all cardiac patients, handling all the rule-outs and A-fibs that the cardiologists would rather not care for themselves. “People think the wait times at the bigger hospitals are too long and will sometimes avoid them,” Dr. Krisa says.
He points out that there are plenty of patients who don’t need to go to the cath lab within 90 minutes, and that many of these people would rather receive medical management in the comfort of his smaller hospital and then be transferred to a larger facility for PCI.
Dr. Krisa says working without PCI also has advantages for the hospitalists at Albany. His service is filled with acutely ill cardiac patients, all of whom are under hospitalists’ care.
And while his hospital has looked at the revenue it could bring in by opening a cath lab, Dr. Krisa says the proposal hasn’t gone anywhere yet.
“With health care dynamics being what they are today,” he explains, “I don’t think it makes sense to build something from scratch. If I were a patient, wouldn’t I want to go to the hospital across town that has done this thousands of times for many, many years? There would have to be a pretty compelling reason for patients to go elsewhere.”
Deborah Gesensway is a freelance health care writer based in Sierra Madre, Calif.
The question of surgical back-up
Should community hospitals get in the business of percutaneous coronary intervention (PCI) if they don’t have on-site surgical back-up?
While several large studies are trying to answer that question, the simple answer right now is that there’s not enough information to say either way. But that’s not stopping a growing number of small hospitals from opening up a lab. No one knows exactly how many hospitals without on-site surgical back-up are performing PCI, but some experts put the number at about 250.
A much publicized abstract of a yet-to-be-published study presented at a March meeting of the Society for Cardiovascular Angiography and Interventions (SCAI) analyzed a registry of about 300,000 patients treated at centers with on-site back-up cardiac surgery and 61 hospitals without. The conclusion, according to a SCAI press release: Both types of hospitals had “similar rates of procedural success, overall complications, emergency surgery and mortality with emergency surgery.”
Current guidelines from the American College of Cardiology, the SCAI and the American Heart Association say it is acceptable for hospitals without on-site back-up to do primary angioplasty for heart attack patients, as long as they meet a list of requirements. Those include having experienced cardiologists and technicians on staff working on a 24/7 call schedule.
Elective cases currently fall outside the guidelines. Many argue that cath labs need to do elective procedures not only to be economically viable, but to provide the kind of volume necessary to maintain skills.
“Those are the ones I feel nervous about. Angioplasties should not be done as a boutique, just doing elective cases” to earn extra money, says Michael A. Kutcher, MD, director of interventional cardiology at Wake Forest University School of Medicine in Winston- Salem, N.C., and lead author of the study previewed earlier this year.
Then there are the politics of divvying up a lucrative clinical pie. In some states, like New Jersey, pending lawsuits filed by several large referral hospitals have blocked or delayed smaller community hospitals from starting up planned elective angioplasty programs. Regulations in some states also prohibit PCI at centers without on-site back-up.
“It’s a very politically charged issue,” Dr. Kutcher points out. “Large centers don’t want to see their volumes go down, but small centers want to keep viable. They don’t want to be dying on the vine as a center that has to ship out every heart attack patient it gets.”