Specialty Cardiac Hospitals Research Articles

Acute Myocardial Infarction and Coronary Artery Bypass Grafting Outcomes in Specialty and General Hospitals: Analysis of State Inpatient Data

Compare characteristics and outcomes of patients hospitalized in specialty cardiac and general hospitals for acute myocardial infarction (AMI) and coronary artery bypass grafting (CABG). 2000-2005 all-payor administrative data from Arizona, California, Texas, and Wisconsin. We identified patients admitted to specialty and competing general hospitals with AMI or CABG and compared patient demographics, comorbidity, and risk-standardized mortality in specialty and general hospitals. Specialty hospitals admitted a lower proportion of women and blacks and treated patients with less comorbid illness than general hospitals. Unadjusted in-hospital AMI mortality for Medicare enrollees in specialty and general hospitals was 6.1 and 10.1 percent (p<.0001) and for non-Medicare enrollees was 2.8 and 4.0 percent (p<.04). Unadjusted in-hospital CABG mortality for Medicare enrollees in specialty and general hospitals was 3.2 and 4.7 percent (p<.01) and for non-Medicare enrollees was 1.1 and 1.8 percent (p=.02). After adjusting for patient characteristics and hospital volume, risk-standardized in-hospital mortality for all AMI patients was 2.7 percent for specialty hospitals and 4.1 percent for general hospitals (p<.001) and for CABG was 1.5 percent for specialty hospitals and 2.0 percent for general hospitals (p=.07). In-hospital mortality in specialty hospitals was lower than in general hospitals for AMI but similar for CABG. Our results suggest that specialty hospitals may offer significantly better outcomes for AMI but not CABG.

Coronary revascularization at specialty cardiac hospitals and peer general hospitals in black Medicare beneficiaries.

Critics have raised concerns that specialty cardiac hospitals exacerbate racial disparities in cardiovascular care, but empirical data are limited. We used administrative data from the Medicare Provider and Analysis Review Part A and Provider-of-Service files from 2002 to 2005. Multivariable logistic regression models were constructed to examine the likelihood of black Medicare patients being admitted to a cardiac hospital for coronary revascularization when compared with white patients within the same healthcare referral region after accounting for geographic proximity to the nearest hospitals, procedural acuity, and comorbidities. We identified 35 309 patients who underwent coronary artery bypass grafting in 18 healthcare referral regions and 94,525 patients who underwent percutaneous coronary intervention in 20 healthcare referral regions where cardiac hospitals performed these procedures. Patients at cardiac hospitals were more likely to be men and white and have less comorbidity than those at general hospitals. The likelihood of black patients undergoing coronary revascularization at a cardiac hospital was significantly lower for coronary artery bypass grafting (adjusted odds ratio, 0.67; P=0.01) and percutaneous coronary intervention (adjusted odds ratio, 0.63; P<0.0001). However, this relationship was substantially attenuated among black patients living in close proximity (ie, within 10 miles) to cardiac hospitals (adjusted odds ratio for coronary artery bypass grafting, 0.95; P=0.75; adjusted odds ratio for percutaneous coronary intervention, 0.78; P=0.01). Black patients were significantly less likely to be admitted at cardiac hospitals for coronary revascularization. Precise reasons for these findings are unclear but suggest complex associations between race and geography in decisions about where to receive care.

Do specialty cardiac hospitals have greater adherence to acute myocardial infarction and heart failure process measures? An empirical assessment using Medicare quality measures: Quality of care in cardiac specialty hospitals

Supporters of specialty hospitals claim these facilities provide better patient care; however, empirical data on quality of care in specialty hospitals are limited. We used data reported to the Centers for Medicare and Medicaid Services (CMS) during 2005 to 2006 to compare the quality of care of specialty cardiac hospitals, competing general hospitals and a group of top-ranked cardiac hospitals as identified by the US News & World Report's list of "America's best cardiac hospitals" for acute myocardial infarction (AMI) and heart failure (HF). The main outcome was hospital compliance with CMS performance measures, expressed as the percentage of eligible patients with AMI or HF who received guidelines-based treatment. The mean compliance for all 179 hospitals was 95% for AMI measures, 91% for HF measures, and 94% for all cardiac care (AMI plus HF measures). Specialty hospitals' compliance with AMI and HF guidelines (95.2% and 91.3%) was similar to that of competing general hospitals (94.7% and 90.5%), whereas top-ranked cardiac hospitals compliance with both AMI and CHF measures (96.8% and 94.1%) was higher (P < .001). In supplemental analyses, we found that 40% of specialty hospitals were ranked in the top quartile of all 179 hospitals, as compared with 22.9% of top-ranked cardiac hospitals. Conversely, 25% specialty hospitals were in the lowest quartile, as compared to 7% of top-ranked cardiac hospitals. Quality of care in specialty cardiac hospitals is similar to quality in competing general hospitals and top-ranked cardiac care hospitals, as measured by compliance with AMI and HF performance indicators. Quality of care appears to be slightly better for top-ranked cardiac hospitals as compared to general hospitals, but the overall performance of all hospitals is high.

Insurance Status of Patients Admitted to Specialty Cardiac and Competing General Hospitals

There has been widespread concern that procedurally oriented specialty hospitals select well-insured patients for admission, while avoiding the underinsured, but data are limited. To determine if specialty cardiac hospitals admit a higher proportion of well-insured patients than general hospitals and/or preferentially transfer patients with less generous insurance to other acute care hospitals. A retrospective study of patients admitted to specialty cardiac and general hospitals with acute myocardial infarction (AMI; N = 41,863), congestive heart failure (CHF; N = 51,696), percutaneous coronary intervention (PCI; N = 73,966), and coronary artery bypass grafting (CABG; N = 33,327) using 2000-2004 all-payor data from Arizona, California, and Texas. Proportion of all admissions in specialty and general hospitals with more generous insurance (Medicare or private insurance), interhospital transfer patterns of patients with less generous insurance by specialty and general hospitals. Specialty hospitals admitted a higher proportion of patients with more generous insurance for both the medical cohort (AMI and CHF) (92.4% vs. 89.0%; P < 0.0001) and revascularization cohort (PCI and CABG) (94.3% vs. 90.6%; P < 0.0001). After adjustment for patient demographics, comorbidity, and the distance that each patient lived from the nearest specialty and general hospital, odds of admission to specialty hospitals were significantly higher for patients with more generous insurance compared to patients with less generous insurance for the medical cohort [odds ratio (OR), 1.16; 95% confidence interval (CI), 1.07-1.27; P < 0.001] and revascularization cohort (OR, 1.17; 95% CI, 1.08-1.27; P < 0.001). In Cox proportional hazards models, there was no evidence that specialty hospitals were more or less likely to transfer patients with more or less generous insurance to another hospital. The analysis was limited to 3 states and we were unable to track the care of patients after transfer. Patients with more generous insurance are significantly more likely to gain admission to specialty hospitals. Alternatively, we found no evidence that specialty hospitals preferentially transfer patients with less generous insurance who are admitted. Overall, these findings suggest that specialty hospitals may contribute to segregation of the healthcare system along socioeconomic lines.

Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in Medicare Beneficiaries

Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in Medicare Beneficiaries

Specialty Cardiac Hospitals

Specialty hospitals, owned and operated by physicians with an expertise in a particular medical condition, offer the opportunity to design a utopian care environment for optimal delivery of care. In fact, the concept of specialty heart hospitals dates back to the mid-19th century in England, with the opening in 1857 of London’s National Hospital for Diseases of the Heart and Paralysis. The institution of specialty hospitals in the United States underwent acceleration by the mid-1990’s.1 Many confluent factors explain the development of specialty cardiac hospitals in the United States, including significant advances in cardiovascular technology, dramatic increases in the cost (and profitability) of cardiovascular care, and, most important, the perceived financial constraints on both hospitals and practicing physicians from health plans and payers, which results in a perception of reduced practice autonomy by physicians and hospitals.2,3 Presently, >100 specialty hospitals exist in the United States, with many focusing on cardiac care. Although specialty hospitals have the potential to improve care by focusing considerable clinical expertise and resources for the care of a limited spectrum of disease, empirical evidence that demonstrates improved outcomes is minimal or potentially biased because of challenges of adequate risk adjustment for the somewhat debated presence of lower-risk patients treated by specialty hospitals compared with their general hospital counterparts.4–6 Article p 2280 In the absence of substantial data justifying better outcomes, or detailed economic analyses of value, significant issues surrounding specialty cardiac hospitals include7: (1) Do specialized facilities lower costs, increase quality, or both? (2) Do specialty facilities have a negative financial impact on the surrounding community’s “general” hospitals? and (3) Do specialty cardiac hospitals increase or decrease access to care? Critics of specialty hospitals have claimed that specialty hospitals may solicit or “cherry pick” more profitable cases, concentrating on patients with …

Acute Myocardial Infarction and Congestive Heart Failure Outcomes at Specialty Cardiac Hospitals

Outcomes of patients with acute myocardial infarction (AMI) and congestive heart failure (CHF) at specialty cardiac hospitals are uncertain. From 2003 Medicare data, we used hierarchical regression to calculate 30-day standardized mortality ratios and risk-standardized mortality rates for AMI and CHF at 16 cardiac and 121 peer general hospitals in 15 healthcare markets. We then compared cardiac and general hospitals by determining (1) the proportion of facilities with statistically higher, no different, or lower than expected mortality based on 95% interval estimates of standardized mortality ratios and (2) differences in risk-standardized mortality rates between the types of facilities after stratification within healthcare markets. We identified 1912 patients with AMI and 1275 patients with CHF at cardiac hospitals and 13,158 patients with AMI and 18,295 patients with CHF at general hospitals. Patients at cardiac hospitals were younger, were more likely to be male, and had a much lower prevalence of noncardiovascular diseases. After adjustment for patient differences, standardized mortality ratios were significantly better than expected for 4 (25%) and 5 (31%) cardiac hospitals for AMI and CHF, respectively, compared with 5 (4%) and 6 (5%) general hospitals. Risk-standardized mortality rates were modestly lower at cardiac hospitals (15.0% versus 16.2% for AMI, P<0.001, and 10.7% versus 11.3% for CHF, P<0.01). Patients with AMI and CHF at cardiac hospitals differ considerably from those at peer general hospitals. Although outcomes were modestly better at cardiac hospitals, substantial variation was noted across individual facilities.

Specialty Cardiac Hospitals and Coronary Revascularization Rates

Specialty Cardiac Hospitals and Coronary Revascularization Rates

Specialty Cardiac Hospitals and Coronary Revascularization Rates—Reply

Specialty Cardiac Hospitals and Coronary Revascularization Rates—Reply

Opening of Specialty Cardiac Hospitals and Use of Coronary Revascularization in Medicare Beneficiaries

Although proponents argue that specialty cardiac hospitals provide high-quality cost-efficient care, strong financial incentives for physicians at these facilities could result in greater procedure utilization. To determine whether the opening of cardiac hospitals was associated with increasing population-based rates of coronary revascularization. In a study of Medicare beneficiaries from 1995 through 2003, we calculated annual population-based rates for total revascularization (coronary artery bypass graft [CABG] plus percutaneous coronary intervention [PCI]), CABG, and PCI. 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). Rates of change in total revascularization, CABG, and PCI using multivariable linear regression models with generalized estimating equations. 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 (P<.001 for both comparisons). 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% [95% confidence interval {CI}, 6.1%-32.2%], P<.001) when compared with HRRs where new cardiac programs opened at general hospitals (6.5% [95% CI, 3.2%-9.9%], P<.001) and HRRs with no new programs (7.4% [95% CI, 3.2%-11.5%], P<.001). These findings were consistent when rates for CABG and PCI were considered separately. For PCI, this growth appeared largely driven by increased utilization among patients without acute myocardial infarction (42.1% [95% CI, 21.4%-62.9%], P<.001). The opening of a cardiac hospital within an HRR is associated with increasing population-based rates of coronary revascularization in Medicare beneficiaries.

Physician-Owned Specialty Hospitals and Coronary Revascularization Utilization

THE EMERGENCE OF SPECIALTY HOSPITALS THAT FOcus on lucrative procedural aspects of medicine has generated a heated debate among policy makers that largely involves 4 issues: patient selection (ie, “cherry-picking” of healthier and wealthier patients by specialty hospitals); quality of care in specialty and general hospitals; impact of specialty hospitals on the financial health of general hospitals; and influence of specialty hospitals on utilization and health care costs. The debate intensified in 2003 with the passage of a temporary congressional moratorium (allowed to expire in 2005) on new specialty hospital construction. However, empirical data addressing the 4 issues remain limited. Consistent evidence suggests that specialty hospitals admit patients with lower acuity and fewer comorbidities than general hospitals. Studies assessing quality have found that riskadjusted rates of adverse outcomes in specialty hospitals are similar or somewhat lower (perhaps 10%-20%) compared with general hospitals. While anecdotal reports about the negative influence of specialty hospitals on the financial health of general hospitals abound, limited data suggest that, thus far, the impact has been small. In this issue of JAMA, Nallamothu and colleagues provide intriguing new data suggesting that increases in the use of coronary revascularization were 2.5 to 3 times higher in health care markets that experienced entry of a new physician-owned specialty hospital compared with markets without specialty hospitals, including those markets in which new revascularization programs were established at general hospitals. The differences reflected a much lower decline in use of coronary artery bypass graft surgery and a larger increase in use of percutaneous coronary intervention (PCI). The increase in PCI was particularly striking among patients without acute myocardial infarction, a group for whom PCI may provide less benefit, but that accounted for more than two thirds of all PCI procedures. One potential explanation for these findings is that utilization in markets with specialty cardiac hospitals reflects that astute investors chose to open specialty hospitals in markets that were already experiencing rapid growth in demand for revascularization. However, additional analyses conducted by the authors provided little support for this possibility. Alternatively, the growth in utilization in markets with new specialty hospitals may be directly attributable to procedures performed in the new specialty hospitals. Indeed, at the end of the observation period, in the study by Nallamothu et al, specialty hospitals had approximately twice the volume as new cardiac programs in general hospitals and accounted for more than a third of all revascularization procedures performed in their markets. The current study would seem to support the hypothesis that specialty hospitals directly drive utilization of coronary revascularization. However, immediately drawing such a conclusion requires careful consideration and caution, particularly given the lack of direct information in the current study about the clinical appropriateness of procedures. Although new specialty hospitals may directly increase utilization by performing procedures for patients who might receive only marginal benefit from having interventions, it is also possible that specialty hospitals indirectly increase utilization by drawing patients away from existing general hospitals through competition. In turn, existing revascularization programs may respond to losses in patient volume with their own efforts to generate new business, further fueling utilization. Even though it is not possible to dissect the fundamental drivers of utilization from the study by Nallamothu et al, or the influence of increased utilization on patient outcomes, the results need to be considered in light of 3 important issues currently confronting the US health care system. First, and perhaps most important, increasing evidence suggests a general lack of association between more aggressive management practices and greater health care expenditures and better patient outcomes at a population level. At the individualpatient level, the recently published Occluded Artery Trial (OAT) found that PCI performed more than 3 days following an acute myocardial infarction provided no benefits relative to medical therapy. Yet payment policies promoted by Medicare and other third-party payers have created large fi-

Do Specialty Cardiac Hospitals Drive Regional Increases in Revascularization Rates

Hospitals that specialize in treating particular, complex medical conditions are touted as providing high-quality, cost-efficient care, but critics

A Left Atrial Appendage Thrombus Mimicking Atrial Myxoma

A 58-year-old female with a medical history of ≈2 years of chronic atrial fibrillation (on warfarin treatment), previous right mastectomy for invasive ductal carcinoma, and hypertension presented with a hypertensive emergency and mental status changes. Her symptoms resolved with appropriate antihypertensive treatment. The international normalized ratio on presentation was 2.9. During an additional work-up for transient neurological symptoms, transesophageal echocardiography was performed, revealing a 2×2-cm, well-circumscribed, spherical, mobile echodensity within the ostium of the left atrial appendage (LAA), …

Cardiac Revascularization in Specialty and General Hospitals

Background The emergence of specialty hospitals focusing on narrow procedural areas has generated controversy, although little is known about their quality. Methods We conducted a retrospective cohort study of 42,737 Medicare beneficiaries who underwent percutaneous coronary intervention (PCI) and 26,274 who underwent coronary-artery bypass grafting (CABG) during 2000 and 2001 in specialty cardiac hospitals (15 for PCI and 15 for CABG) and general hospitals (82 for PCI and 75 for CABG) in the same markets. Administrative data were used to compare patients' characteristics, hospital procedural volumes, and patient outcomes. Results Patients undergoing PCI or CABG in specialty hospitals were less likely to have coexisting conditions than those being treated at general hospitals and were less likely to have had an acute myocardial infarction (P<0.001). The better health of the patients at specialty hospitals than of those at general hospitals was reflected by the lower mean predicted risk of death (2.1 perce...

Cardiac Revascularization in Specialty and General Hospitals

The emergence of specialty hospitals focusing on narrow procedural areas has generated controversy, although little is known about their quality. We conducted a retrospective cohort study of 42,737 Medicare beneficiaries who underwent percutaneous coronary intervention (PCI) and 26,274 who underwent coronary-artery bypass grafting (CABG) during 2000 and 2001 in specialty cardiac hospitals (15 for PCI and 15 for CABG) and general hospitals (82 for PCI and 75 for CABG) in the same markets. Administrative data were used to compare patients' characteristics, hospital procedural volumes, and patient outcomes. Patients undergoing PCI or CABG in specialty hospitals were less likely to have coexisting conditions than those being treated at general hospitals and were less likely to have had an acute myocardial infarction (P<0.001). The better health of the patients at specialty hospitals than of those at general hospitals was reflected by the lower mean predicted risk of death (2.1 percent vs. 3.1 percent for PCI and 5.0 percent vs. 5.8 percent for CABG; P<0.001 for each comparison). Mean volumes of PCI and CABG procedures in 2000 and 2001 were higher in specialty hospitals than in general hospitals (799 vs. 375 PCI procedures, P<0.001; and 571 vs. 236 CABG procedures, P<0.001). The unadjusted rate of death during the index hospitalization or within 30 days after admission was lower in specialty hospitals than in general hospitals (2.1 percent vs. 3.2 percent for PCI and 4.7 percent vs. 6.0 percent for CABG; P<0.001 for both comparisons). In multivariate analyses adjusted for patients' characteristics, the odds ratio for death after PCI in specialty hospitals and general hospitals was similar (0.89; 95 percent confidence interval, 0.69 to 1.15; P=0.39), but the odds ratio for death after CABG was lower in specialty hospitals than in general hospitals (0.84; 95 percent confidence interval, 0.72 to 0.99; P=0.05). In stratified analyses comparing specialty and general hospitals with similar volumes, differences in mortality were not significant. The lower unadjusted mortality rate after cardiac revascularization in specialty cardiac hospitals is accounted for by their healthier patients and higher procedural volumes.