A new study published in Health Affairs (subscription required) has raised some questions regarding the rapid growth and distribution of cardiac surgery programs from 1993 to 2004 in the face of declining volumes, shedding light on little improvements in patient access - often the justification for creating such programs. As reported in today's Daily Briefing, an increase in cardiac surgery programs has duplicated services and increased competition in many areas while doing little to expand access to cardiac surgery services in poorly served regions.
Since 1997, the number of coronary artery bypass grafts (CABGs) performed in the United States has decreased. Nonetheless, from 1993 to 2004, the number of cardiac surgery programs continued to rise. In fiscal year 2004 they were the third most profitable surgical programs, accounting for 25% to 40% of a hospital's net revenue.
For the study, Lucas et al. from Maine Medical Center analyzed Medicare claims data, identified hospitals' billing for CABGs between 1992 and 2004, and estimated the travel time to the nearest cardiac surgery program for all eligible Medicare beneficiaries. To determine whether services were duplicated, the researchers examined whether a new program opened in a community already served by a cardiac program. In addition, the researchers considered whether states required certificates of need (CON). According to the results, 301 new cardiac surgery programs opened between January 1993 and September 2004. General hospitals launched 276 programs, while 25 were in specialty hospitals. Most new programs opened in the East or Midwest and in states that had dropped CON requirements.
Overall, 42% of new programs were opened in competitive markets. For example, more than 80% of programs opened within 30 miles of an existing program, and more than 55% launched within 10 miles. The average travel time to the nearest program decreased from 17 minutes in 1993 to 14 minutes in 2004; however, the researchers concluded that the change was negligible for the almost 75% of Medicare beneficiaries who live in cities. Instead, the report suggests that new programs have "led to a fight for shares of a shrinking market."
Although the number of CABG procedures did not increase in communities with new programs, the rates of associated procedures, such as stents and angioplasties, increased significantly. Meanwhile, as more programs opened within a specific area, more surgeries were performed in hospitals that performed the surgeries less often, potentially increasing a patient's risk of adverse events.
Despite causing duplication of services in many areas, the researchers acknowledged that the increase in cardiac surgery programs benefited some rural communities. They also noted that more cardiac programs may have opened in some areas so hospitals could perform primary percutaneous interventions on myocardial infarction patients.
The authors use the findings to discuss the applicability - and potential need for - CON regulations to align the availability of cardiac surgery programs with consumer demand.
To understand how CV programs can "right-size" their service offerings across their regions, register for the 2011-2012 Cardiovascular Roundtable National Meeting Series. This research will explore regional and network care delivery to ensure assets are deployed appropriately and effectively in a highly competitive environment.