Study questions safety of heart procedures at hospitals without cardiac surgery programs

10/27/04

HANOVER, NH Rekindling a debate on the safety of performing an increasingly popular non-surgical heart procedure in hospitals that do not have onsite cardiac surgery programs, a study led by Dartmouth Medical School (DMS) concluded that patients who undergo the procedure in hospitals without cardiac surgeons have a higher rate of mortality than those in hospitals with a cardiac surgery program.

The study, which appears in the October 27 issue of JAMA, investigates the outcomes of over 600,000 Medicare enrollees who underwent a cardiac procedure called a percutaneous coronary intervention (PCI) at a US acute care facility between 1999 and 2001. It concluded that patients who underwent PCI at a hospital without a cardiac surgeon onsite had a 29% overall increased risk of mortality compared to those who had the procedure in a hospital with surgical backup.

PCI is a non-surgical procedure that unblocks narrowed coronary arteries, often using a balloon to open a constricted artery and a wire stent to keep the artery clear. Although it is a non-surgical procedure, complications that require emergency cardiac surgery, may arise.

In the United States, hospitals with catheterization laboratories but without cardiac surgery on location are rapidly developing PCI programs in hopes of improving patient care and remaining competitive. "Our findings suggest that the current 'wave' to move PCIs into hospitals that don't have coronary artery bypass surgery programs should be questioned," said lead author Dr. David Wennberg, adjunct associate professor of community and family medicine and of medicine at DMS.

Headed by Dr. David Malenka, associate professor of medicine and a cardiologist at Dartmouth-Hitchcock Medical Center, the study used data from a total of 178 hospitals that performed PCIs without onsite cardiac surgery and 943 hospitals that performed PCIs with onsite cardiac surgery. "Patients undergoing PCIs in hospitals without cardiac surgery were more likely to die," authors wrote.

PCIs in hospitals without cardiac surgery backup are often performed for reasons other than immediate treatment of a myocardial infarction and are associated with a higher risk of adverse outcomes, the study found. "Most of the current clinical and policy debate about where PCIs should be performed surrounds treatment of acute myocardial infarction (AMI) so we were surprised that the majority of cases performed in centers without coronary artery bypass surgical programs were performed for indications other than acute treatment of an acute myocardial infarction," said Wennberg, a member of the Center for the Evaluative Clinical Sciences (CECS) at DMS. "The findings that these non-AMI populations are at higher risk of death - 36% higher - when they have their procedures in hospitals without onsite surgery programs is concerning."

In an editorial accompanying the study in JAMA, Dr. W. Douglas Weaver wrote that, "Clearly, if these findings are true and representative, it is necessary to reconsider and perhaps curtail expanding the availability of PCI."

Other authors of the study are Dr. Lee Lucas, Dr. Merle Kellett and Andrea Siewers from Maine Medical Center.

Source: Eurekalert & others

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