Evidence of Systematic Duplication by New Percutaneous Coronary Intervention Programs

Published In: Circulation: Cardiovascular Quality and Outcomes, v. 6, no. 4, July 2013, p. 400-408

Posted on RAND.org on January 01, 2013

by Thomas W. Concannon, Jason Nelson, David M. Kent, John L. Griffith

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Research Questions

  1. What was the number of, access to, and hospital investments in new PCI programs from 2004 to 2008?
  2. What hospital-, neighborhood-, and state-level factors were associated with adoption of percutaneous coronary intervention (PCI)?

BACKGROUND: Evidence suggests that recent and projected future investments in percutaneous coronary intervention (PCI) programs at US hospitals fail to increase access to timely reperfusion for patients with ST-segment elevation myocardial infarction. METHODS and RESULTS: We set out to estimate the annual number and costs of new PCI programs in US hospitals from 2004 to 2008 and identify the characteristics of hospitals, neighborhoods, and states where new PCI programs have been introduced. We estimated a discrete-time hazard model to measure the influence of these characteristics on the decision of a hospital to introduce a new PCI program. In 2008, 1739 US hospitals were capable of performing PCI, a relative increase of 16.5% (251 hospitals) over 2004. The percentage of the US population with projected access to timely PCI grew by 1.8%. New PCI programs were more likely to be introduced in areas that already had a PCI program with more competition for market share, near populations with higher rates of private insurance, in states that had weak or no regulation of new cardiac catheterization laboratories, and in wealthier and larger hospitals. CONCLUSIONS: Our data show that new PCI programs were systematically duplicative of existing programs and did not help patients gain access to timely PCI. The total cost of recent US investments in new PCI programs is large and of questionable value for patients.

Key Findings

  • New PCI programs cost $2-4 billion and did not help patients gain access to timely care.
  • Hospitals were more likely to adopt PCI in competitive markets where PCI was already offered.
  • Hospitals facing stronger CON were 40 percent less likely to adopt PCI each year.

Recommendations

  • PCI regionalization programs
  • Payment reform for PCI
  • Tighter regulation of PCI, including Certificate of Need (CON)
  • Routine assessment of medical technology change in hospitals

Author Statement

The typical new PCI program did not improve patient care in the United States. Hospitals are investing in PCI to compete with each other and not to improve the health of the population. The most likely outcome of these investments has been an increase in the cost of procedures and the total costs of heart attack care. There is also some chance that the quality of PCI has been put at risk in some places as a result of lower procedure volumes.

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