Proliferation of PCI centers: Good or bad?

At a time when US PCI procedural volume is declining, most parts of the country are experiencing an increase in the number of PCI centers. Of course, the population is growing and heart disease is still rampant, but how do we define optimal access to PCI in any given community? The downsides to proliferation include dilution of operator volumes and the systemic costs to create and maintain new centers.

Studies have consistently shown that increased operator experience translates into better outcomes. Most recently, Kontos and colleagues evaluated low-, intermediate- and high-volume primary PCI centers in the CathPCI registry from 2006 to 2009. At that time, low-volume centers (<36 cases/year) had worse mortality rates and door-to-balloon times than other centers. Although only 15% of patients received care at low-volume centers, one wonders if this percentage has increased over the past 5 years and if outcomes may suffer as a result.

Chandan Devireddy

Another study, from Langabeer and colleagues, provides further insight into skewed access to PCI across the country. From 2003 to 2011, PCI-capable centers increased 1.5 times faster than population growth, which has led to overcapacity (and undercapacity) in many areas of the country. Unfortunately, procedural volumes were not available in this study. These data suggest that disparities still exist, with many rural or isolated communities lacking adequate access while many urban centers are seeing cath labs built in surprisingly close proximity to one another.

So what does this mean? It’s hard to say, and it depends on one’s perspective. Studies have demonstrated that PCI can be performed safely without on-site cardiac surgery. This has led to hospital administrators and patient advocates demanding services in their community. As new centers are created, the number of high-volume centers is dwindling. Is this acceptable? Academically, the skills of future interventional cardiology trainees could wither from lack of adequate volume for training. Low-volume centers may be especially challenged if inexperienced trainees are hired to staff their programs without dedicated mentorship. Scientifically, access to next-generation devices and therapies in the United States could dry up as new trials increasingly recruit high-volume centers from other areas of the globe where they are more plentiful.

On an operator level, interventional cardiologists seem to be covering more hospitals and carrying more complex call schedules. Prospects in the job market appear tighter for graduating fellows, but this may be due to a lack of interest in living in areas of true need. A survey published in the Journal of the American College of Cardiology in September 2009 suggested that the country actually was at risk of suffering a shortage of interventional cardiologists. Is this still true considering the data above? If so, how do we recruit interventionalists for the underserved?

So what do you think? In an era of increasingly scrutinized health care costs, should the size and experience of cath labs be determined by pure market forces or central oversight? Something in between? Attention will need to be paid to procedural volumes to prevent proliferation of centers low in volume and experience. For the good of our patients, we have to strike the right balance between accessibility, quality and affordability.

References:

Kontos MC. Circ Cardiovasc Qual Outcomes. 2013;6:659-667.

Langabeer JR. J Am Heart Assoc. 2013;doi:10.1161/jaha.113.000370.

Rodgers GP. J Am Coll Cardiol. 2009;54:1195-1208.

Chandan Devireddy, MD, FACC, FSCAI, is an interventional cardiologist, associate professor of medicine and assistant director of the interventional cardiology fellowship program at Emory University, Atlanta. He specializes in coronary, peripheral and structural heart interventions.
Disclosures: Devireddy serves on an advisory board for Medtronic. He is an Emory primary investigator for clinical trials sponsored by Medtronic and Vascular Dynamics.