A majority of heart specialists say it's safe to clear blocked coronary arteries with angioplasty at hospitals that lack backup heart surgery, according to an exclusive survey by theheart.org and U.S. News & World Report—so long, that is, as the hospitals meet key criteria for proficiency. Their responses echo a study released last month at an American Heart Association meeting concluding that patients who had elective angioplasty at hospitals without a heart surgeon on tap fared as well as patients treated at hospitals with heart surgery suites.
The AHA study, led by Johns Hopkins cardiologist Thomas Aversano, found that death rates for nonemergency angioplasty procedures were just under 1 percent both at hospitals with and without backup heart surgery. The findings prompted U.S. News and theheart.org, a leading online source of cardiology news and views, to explore how heart specialists nationwide view the issue.
The news organizations together surveyed more than 17,000 cardiologists who are recognized as Top Doctors by U.S. News and Castle Connolly Medical Ltd. or who subscribe to theheart.org. About 5,200 cardiologists are board-certified as interventional cardiologists, who perform angioplasties and other heart procedures through thin tubes threaded through a blood vessel, according to the Society for Cardiovascular Angiography and Interventions. A total of 350 cardiologists responded to the 10-question survey; two-thirds responded that angioplasty can be done safely and effectively without surgical backup. (For a breakdown of the questions and responses, see Behind the U.S. News Doctors Survey on Angioplasty.)
Of those who rejected the idea of permitting hospitals without cardiac surgery to do nonemergency angioplasties, most cited more than one reason—66 percent because of safety concerns, more than 60 percent because angioplasty programs that spring up at dozens of smaller hospitals will prompt doctors to send patients for procedures "to keep their institutional volume up."
The suspicion that the real issue was money was clear. Of all the cardiologists who responded to the survey, only a third said they believe the goal is to expand access to areas where angioplasty isn't available. Nearly half said it's about the bottom line.
"I believe that much of this is fueled by greed, not need," says University of Michigan cardiologist Kim Eagle, especially with fewer patients seeking angioplasty because cholesterol-lowering drugs and other preventive therapies have reduced the need. "By making angioplasty available at every hospital in the nation, we will not only drive up costs, we will reduce quality due to exposing patients to unnecessary, risky procedures."
Virtually all of the cardiologists who responded to the survey said it would be a mistake to take angioplasty's safety for granted. For instance, 96 percent said each hospital's angioplasty performance should be tracked and the results publicly reported. The cardiologists were also nearly unanimous in their view that hospitals with poor results should be required to improve, or lose their state certification to perform angioplasty.
"I think that's exactly right," says Aversano. "It validates what New Jersey and New York have been doing for years—monitoring and reporting outcomes for angioplasty and bypass surgery. It helps to rein in the cowboys."
His study involved more than 18,000 elective angioplasty patients who were assigned at random to centers with and without on-site heart surgery. Three-fourths of the patients were treated at centers without heart surgery to make sure each center treated enough patients to provide high quality care. All of the hospitals performed at least 200 angioplasties a year. (Current American Heart Association-American College of Cardiology guidelines recommend that hospitals performing angioplasties do more than 400 cases a year.) With few exceptions, the patients were typical of those who generally get angioplasty.