Medical Device Daily Washington Editor

The Agency for Healthcare Research and Quality (Washington) last week released data from the calendar year 2005 for its Hospital Cost and Utilization Project (HCUP), and the data indicate that not only is hospital care not getting any cheaper, but that overall costs are growing despite an increasing use of angioplasty and decreasing use of coronary artery bypass grafts (CABGs) for treatment of congestive heart disease.

The report also suggests that community hospitals are busier places than in times gone by. The HCUP numbers indicate that between 1997 and 2005, the number of community hospitals dropped by 124, from 5,060 to 4,963, but the volume of hospital stays rose by 4.5 million over that same period, from 34.7 million to 39.2 million, an increase of roughly 13%. The duration of stays fell during that same period, from 4.9 to 4.6 days, but not enough to offset the increase in stays.

One of the more striking figures in the HCUP release was that “the average cost per hospital inpatient stay in 2005 was $7,900, up an average of 5.7% annually since 1997.” For the purposes of the report, community hospitals are described as non-federal, short-term acute care hospitals excluding psychiatric and substance abuse facilities.

Vincent Bufalino, MD, an associate professor of medicine at the Stritch School of Medicine at Loyola University (Chicago), told Medical Device Daily that report data showing heart attack (infarction) as the fifth most common diagnosis for men but ranking only number 20 for women is not surprising. “Men get heart disease earlier than women, and get more clear-cut cases of infarction.”

The HCUP report says that bypass procedures are down by a third since 1997 and angioplasties have doubled since 1993.

Bufalino said that single-vessel bypasses are becoming rare.

“The number of single-vessel bypasses is down to trivial,” he said, adding that patients who are back for a second procedure are often not good candidates for a second thoracic procedure.

“If you have a recurrence 12 years later, it’s usually in one spot, and we can now get at single isolated problems.”

However, such patients are also often less able to withstand a full opening of the chest wall. Such a procedure is often complicated because scar tissue “gets almost rock-like,” Bufalino said, adding that “surgeons talk about chipping down” through scar tissue just to get to the heart.

“There’s an increased migration toward two-vessel angioplasty from a couple of years ago,” which he said is “very much driven by” patients’ natural aversion to more invasive procedures.

There was once a substantial difference in awareness of heart disease by sex, but Bufalino said that data indicated that women are now more aware of heart disease, with 60% to 70% of women having a clear understanding of their risk, a jump of about a factor of 10 from several decades ago.

“I think men are aware and women are aware for their men.”

However, he indicated that reluctance to see the doctor is not just for men anymore. “Wives are sending their husbands but are often reluctant to go to a doctor” themselves.

Bufalino also said he felt that publicity concerning breast cancer has somewhat overshadowed heart disease for women despite the fact that heart disease kills more women.

The HCUP numbers indicate that although the average duration of hospital stays fell by 4%, the incidence of pressure sores is up 76% between 1993 and 2005. Bufalino said that age has a lot to do with this phenomenon.

“The length of stays is down, and the morbidity is less and there are fewer complications,” he said, but “the real issue for us is that folks are older.”

“I have three dozen patients in their 90s,” which is obviously a change from yesteryear. “It was pretty rare to have a patient in their 90s back in the old days.” These patients tend to be bedridden for longer stretches and are less resistant to bed sores.

Despite the popularity of criticizing the state of medical care in the U.S., Bufalino said that the numbers for heart disease are quite encouraging.

“I think we should be celebrating the success” of improvements to heart care in the past three decades, he said. “The way we practiced in 1977, if you came to the hospital with a heart attack, about 30% died in the hospital,” a number he said is down to 3%. In 1977, a patient who checked in with a heart attack could count on spending two weeks in the hospital and was probably out of work for six months.

“If you come to the hospital today, within 90 minutes, you’re in the cath lab opening the arteries,” he said, and that most patients are out of the hospital in three or four days and back to work in two weeks.

With the exception of the development of vaccines, “it is probably the single most successful area of medicine,” Bufalino said.

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