Across the country, states are embroiled in a debate over specialty hospitals, physician-owned hospitals that focus on a single disease process such as heart care or orthopedics. The debate has intensified since a federal government moratorium on opening new specialty hospitals expired last year. The moratorium was part of the Medicare Prescription Drug Improvement and Modernization Act of 2003, which expired in 2005, but Congress extended it to August 2006 as part of 2005’s Deficit Reduction Act.

The issue heated up even more after the Jan. 23 death of a patient at West Texas Hospital (Abilene). Steve Spivey, a 44-year-old truck driver from Gorman, Texas, went into respiratory arrest after elective spinal surgery, and West Texas, lacking an emergency department, called 911. Spivey subsequently died at a hospital in the same town, Abilene Regional Medical Center. The incident provoked a fresh round of outrage on Capitol Hill, in part because West Texas has garnered substantial reimbursement from the Centers for Medicare & Medicaid Services, despite the moratorium.

Now, a new study strongly indicates a corollary to the “build it and they will come” rule. It analyzes Medicare beneficiaries, age 65 or older, and indicates that the opening of a new specialty cardiac hospital is associated with a rise in heart procedures to open clogged arteries such as bypass surgery and angioplasties. The rise was twice as great as the rise that occurred in regions where an existing general hospital chose the alternative of adding heart services, or where no new heart care facilities opened. This contrasts with previous studies that found no direct relationship between heart hospitals and heart care use, according to its authors.

The findings, published in the March 7 issue of the Journal of the American Medical Association, come from a team from the University of Michigan (U-M) Cardiovascular Center, the VA Ann Arbor Healthcare System and the Michigan Surgical Collaborative for Outcomes Research and Evaluation (all Ann Arbor, Michigan), and their colleagues from Harvard University (Cambridge, Massachusetts) and Yale University (New Haven, Connecticut). The Agency for Healthcare Research and Quality (Rockville, Maryland) paid for the study.

“This is the first study to show that specialty cardiac hospitals increased the use of these procedures in the hospital markets where they opened, compared with regions where existing hospitals added heart care services or regions where there was no change in heart care services,” said lead author Brahmajee Nallamothu, MD, assistant professor of cardiovascular medicine at the U-M Medical School and interventional cardiologist at the U-M Cardiovascular Center. He is also a member of the Health Services Research & Development Center at the Ann Arbor VA.

The authors emphasize that the specialty heart hospitals in the study are different from heart centers that operate as part of larger hospitals. In many states in the U.S., especially in the South and West, specialty heart hospitals owned and operated by physicians cropped up throughout the late 1990s and the early part of this decade.

But in 2003, the moratorium halted the opening of new ones, due to concerns over the potential for doctors who co-own specialty hospitals to be influenced by financial rather than medical reasons when referring patients for hospital care. Concern has also arisen about specialty hospitals’ potential to “skim” the most lucrative patients from a region, leaving other hospitals with sicker and uninsured patients.

Meanwhile, advocates for specialty hospitals say they increase quality and efficiency of care by focusing clinical expertise for these disease processes.

The new study used Medicare data from 1995 to 2003, and focused on heart hospitals that offered bypass surgery or percutaneous coronary intervention (PCI), which includes angioplasty, stenting and related procedures. The researchers looked at patterns of use within 306 hospital referral regions (HRRs), representing unique hospital markets for specialized care. After identifying 13 HRRs where one or more specialty cardiac hospitals opened during the study period, the team calculated population-based rates for each year across the U.S.

In every region, the use of PCI rose steadily over the time period, and the use of bypass surgery was level in the 1990s and declined in the early 2000s reflecting a well-known national trend toward minimally invasive techniques instead of surgery to reopen clogged heart arteries. In that same time period, many general hospitals began to offer PCI for the first time.

But the use for these procedures rose even faster in the HRRs where a specialty cardiac hospital opened. Four years after the specialty cardiac hospitals opened, the population-adjusted rates of heart procedures in their surrounding HRRs had grown by more than twice as much as the rates in HRRs where no specialty hospital had opened. There was no major difference in those rates when the researchers compared HRRs where a new heart program had begun at a general hospital, and HRRs where no new heart services launched.

When the researchers separated the bypass surgery numbers from the angioplasty and other PCI numbers, they found the same effect. And when they considered post-heart attack emergency PCI rates with PCI rates for patients who had not had a heart attack, the difference was much greater. In regions where specialty heart hospitals opened, the rate of these non-emergent PCI procedures rose 42% in four years, compared with a 23% rise in areas where a general hospital offered new heart services, and a 24.8% rise in areas where no new services began.

“We’re not saying that specialty cardiac hospitals are bad, nor that they provide services inappropriately,” said John Birkmeyer, MD, a U-M professor of general surgery who has studied many surgical utilization issues. “Nonetheless, our findings suggest that patients treated there are more likely to be treated with invasive interventions than at general hospitals. Payers in markets served by specialty hospitals can also expect higher overall costs associated with more procedures.”

Still more cardio issues raised in relation to length of hormone therapy

A new U.S. study suggests that the risk of heart disease for postmenopausal women taking hormone therapy could go up the longer she leaves the therapy e it after starting menopause. However, the researchers and other experts point out that this was not statistically significant and that all women considering hormone therapy should discuss the risks and benefits with their doctors in the light of their individual health status. The study is published in the Journal of the American Medical Association.

The researchers performed a secondary analysis on the data from trials in the Women’s Health Initiative (WHI), a 15-year program to establish the most common causes of death, disability and poor quality of life in postmenopausal women: cardiovascular disease, cancer, and osteoporosis. For the study, researchers used WHI data from randomized controlled trials of hormone therapy on postmenopausal women aged 50 to 79 years recruited from 40 U.S. clinical centers between September 1993 and October 1998. The trials were designed to look at the effects of postmenopausal hormone therapy, diet changes, and calcium and vitamin D supplements on cardiovascular disease, fractures, and breast and colorectal cancer.

There were two trials: an estrogen-alone study of women without a uterus and an estrogen-plus-progestin study of women with a uterus. In the second trial, women with a uterus were given progestin with estrogen because this is what is normally done in practice to prevent endometrial cancer. The objective of the secondary analysis was to “explore whether the effects of hormone therapy on risk of cardiovascular disease vary by age or years since menopause began.”

The researchers used statistical tests to examine how the relationship between hormone therapy and the risk of coronary heart disease and stroke varied with age and the time delay between onset of menopause and start of hormone therapy.

When compared with a placebo, estrogen plus progestin was linked to increased risk of heart attack, stroke, blood clots and breast cancer. The combination was also linked to reduced risk of colorectal cancer and fewer bone fractures. There was no evidence of protection against mild cognitive impairment and increased dementia risk in the over 65-year-old age group.

When compared with a placebo, estrogen alone showed no link with heart attack risk and colorectal cancer and uncertain correlation with breast cancer risk. It was however linked to elevated risk of stroke and blood clots. And it was linked to reduced risk of bone fracture. Results on memory and cognition in the older age group are not yet available.

Hospitals see fewer admissions for CAD

Though heart disease continues unabated, hospitals say they are admitting fewer patients for coronary artery disease, and the drop coincides with a number of other factors, including the increased use of cholesterol statins and drug-eluting stents. The March 15 edition of the American Journal of Cardiology includes an article by a team of researchers at the University of Michigan Medical Center (Ann Arbor) and the Ann Arbor Medical Center that states that recent advances in treatment “may be shifting patients with coronary artery disease away from the hospital setting despite an aging population.”

Employing the Acute Care Tracker (ACT) database, which contains data on roughly 6 million annual discharges from almost 460 hospitals in the U.S., the number of admissions for acute myocardial infarction (AMI) fell from roughly 661,000 in 2002 to 591,000 in 2005, “primarily due to decreases in transmural AMI,” a severe form of the condition that damages “the whole thickness of the heart, from the endocardium to the epicardium,” according to Stedman’s Medical Dictionary. The incidence of transmural AMI dropped from 118 to 87 per 100,000 over the specified period, a difference of 25 per 100,000, while the overall incidence of infarction 309 to 266 per 100,000, a difference of 43 per 100,000.

AAA repair market predicted to soar

Millennium Research Group (MRG; Waltham, Massachusetts) reported that its analysis of the peripheral vascular device market finds that the second largest segment of the market, abdominal aortic aneurysm (AAA) repair via stent grafts, was valued at $300 million in 2006 and will grow at a compound rate of about 13% annually over the next five years, resulting in a total market value of roughly $550 million by 2011.

It said that a program recently initiated by Medicare called Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act will have a significant impact on the growth of AAA procedures over the next five years.

Medicare on Jan. 1 began offering free, one-time ultrasound screening benefits to check for AAA in qualified seniors linked to their “Welcome to Medicare Physical Exam.” The initiative will cover men ages 65-75 who have a history of smoking, and men and women 65-75 who have a family history of AAA. The conclusions come from MRG’s “US Markets for Peripheral Vascular Devices 2007” report.