Opening of specialty cardiac hospitals associated with increase in rate of cardiac procedures
(7 March 2007: VIDYYA MEDICAL NEWS SERVICE) -- The opening of a specialty cardiac hospital is associated with an increase in the rate of coronary revascularization in a region, compared to new cardiac programs opened at general hospitals, according to a study in the March 7 issue of JAMA.
Specialty hospitals, which provide care limited to specific medical conditions or procedures, are opening at a rapid pace across the United States, according to background information in the article. Proponents argue that specialty hospitals provide higher quality health care and greater cost-efficiency by concentrating physician skills and hospital resources needed for managing complex diseases. Critics claim that specialty hospitals focus primarily on low-risk patients and provide less uncompensated care, which places competing general hospitals at significant financial risk.
"However, specialty hospitals raise an additional concern beyond their potential to simply redistribute cases within a health care market. Specialty hospitals are typically smaller than general hospitals and have high rates of physician ownership. Physician owners may have stronger financial incentives for providing services that fuel greater utilization," the authors write.
Brahmajee K. Nallamothu, M.D., M.P.H., of the VA Health Services Research and Development Center of Excellence, Ann Arbor, Mich., and colleagues conducted a study to determine whether the opening of specialty cardiac hospitals was associated with greater utilization of coronary revascularization services. The researchers calculated annual population-based rates for total revascularization (coronary artery bypass graft [CABG] plus percutaneous coronary intervention [PCI]), CABG, and PCI of Medicare beneficiaries from 1995 through 2003. Hospital referral regions (HRRs) were used to categorize health care markets into those where (1) cardiac hospitals opened (n = 13), (2) new cardiac programs opened at general hospitals (n = 142), and (3) no new programs opened (n = 151).
The researchers found that overall, rates of change for total revascularization were higher in HRRs after cardiac hospitals opened when compared with HRRs where new cardiac programs opened at general hospitals and HRRs with no new programs. "Four years after their opening, the relative increase in adjusted rates was more than 2-fold higher in HRRs where cardiac hospitals opened (19.2 percent) when compared with HRRs where new cardiac programs opened at general hospitals (6.5 percent) and HRRs with no new programs (7.4 percent)."
"Although we are unable to comment directly on the appropriateness of these procedures, these findings raise the concern that the opening of cardiac hospitals may lead to greater procedural utilization beyond the simple addition of capacity to a market. This is particularly worrisome since cardiac hospitals may not substantially improve clinical outcomes when compared with general hospitals with similar procedural volumes," the researchers write.
"… our findings may have important policy implications. The Centers for Medicare & Medicaid Services recently issued their final report to Congress implementing a strategic plan for specialty hospitals. Their plan primarily involves revisions to the inpatient prospective payment systems to 'level the playing field' between specialty and general hospitals and limit financial incentives for investing in certain services simply due to profitability. It also proposes new 'gainsharing' and value-based payment approaches to better align physician and hospital incentives toward improving care at general hospitals. Reforms directly related to physician ownership include enhanced transparency of financial relationships. More stringent measures, such as limiting investments by physician owners, were not included. The extent to which additional measures are needed will require further data on appropriateness of care at specialty hospitals as well as the impact of greater utilization of these procedures on patient outcomes."
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