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Heart study raises policy questions

Should hospitals without heart surgery programs be allowed to offer invasive though nonsurgical heart procedures like angioplasties and stent implantations? A recent study headed by DMS cardiologist David Malenka, M.D., offers new insight into this controversial question. By comparing Medicare data from over 600,000 patients who underwent any of several nonsurgical procedures classed as percutaneous coronary interventions (PCIs), Malenka and colleagues revealed disparities between hospitals with and without surgical backup.

The study was based on 943 hospitals with a heart surgery program and 178 without one. Overall, patients who had PCIs in hospitals without such programs were 29% more likely to die within 30 days than those treated in hospitals with on-site heart surgery. Patients who had PCIs on a nonemergency basis fared even worse; they were 36% more likely to die in hospitals without than those with surgical backup. But no difference in


Dartmouth cardiologist David Malenka led a study that has policy implications.

mortality was seen between the two kinds of hospitals when PCIs were performed on an emergency basis—which the researchers defined as procedures done the same day patients were admitted for a heart attack.

The puzzling nature of this latter finding was noted in an editorial accompanying the paper, which was published in the Journal of the American Medical Association. "It seems unlikely that the interventional cardiologist would be a poor

operator for one kind of procedure and a superior operator for the other," said the editorial.

Implications: Nevertheless, the findings have important implications. "If PCI programs are allowed to develop in centers without on-site cardiac surgery, patients being treated by [emergency] PCI will likely benefit," concluded the paper's authors. But, they cautioned, policies aimed at increasing access to emergency PCIs by making them available at hospitals without cardiac surgery "may inadvertently lead to an overall increase in mortality related to PCI," since 78% of PCIs performed at such hospitals are done on a nonemergency basis.

While Malenka headed the study, the lead author of the paper reporting the results was David Wennberg, M.D.C.M., an adjunct associate professor at Dartmouth Medical School.

—Jennifer Durgin

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