Md. hospital debate grows over greater access to angioplasty

Health panel to decide which can offer procedure

October 19, 2003|By M. William Salganik | M. William Salganik,SUN STAFF

The patient lies in St. Joseph Medical Center in Towson after being rushed there by ambulance. A heart test at another hospital revealed serious blockages in two arteries leading to his heart - "widow-makers," as some doctors refer to the condition.

Dr. Mark Midei inserts a thin tube into the man's groin while looking at a television-like monitor - a window into the man's heart. The cardiologist threads the tube to the point of the blockage and inflates a tiny balloon at the tip. It expands a minuscule metal scaffolding called a stent, which holds open the artery and clears the blockage.

In 17 minutes, Dr. Midei, who performs 1,000 of these heart repairs a year, is done. This is angioplasty.

The procedure is effective, popular - and at the heart of a debate among hospitals about which should be licensed to perform it and get a piece of what amounted to a $130 million business for Maryland hospitals last year, according to the Maryland Health Services Cost Review Commission.

Almost all of that money went to nine of the state's 47 hospitals. Others want a piece of that business.

The Maryland Health Care Commission, which monitors health costs and quality, will determine whether to grant more hospitals the permission to perform routine angioplasty, after studies and reviews that can last for years.

State regulators are considering a study of whether it is safe for more hospitals to perform the procedure. Traditionally, larger hospitals have performed angioplasty, where operating rooms for heart surgeries provide rapid backup in case the simpler procedure fails. Now, other hospitals that have done angioplasties only in emergencies want approval to schedule them routinely.

The debate can seem arcane and academic outside of medicine, but the language surrounding it is anything but. Critics condemn even the idea of a study, saying it could lead to a change that might endanger patients. The chief executives of three hospitals that perform heart surgery - Sinai, Union Memorial and St. Joseph - argued in a letter to state regulators that the research could violate the Nuremberg Code, a set of standards for experiments on humans used in judging Nazi war criminals.

`Simply about money'

"The reason for doing it is to sustain the hospitals that don't have it, financially. There's no benefit [to patients] other than added convenience," said Midei, who filed a minority dissent against expansion when a committee he was on recommended an angioplasty study to the health care commission.

"This is simply about money," said Dr. Stephen H. Pollock, chief of cardiology at St. Joseph and another critic of broadening the availability of angioplasty. "In other states, any hospitals that can get their hands on them are doing it."

Others say Maryland should study the situation, precisely because of the proliferation of the procedure elsewhere.

"You can bury your head in the sand and hope this goes away, but it won't," said Dr. Thomas Aversano, a cardiologist at Johns Hopkins Hospital. "The way to address it is with a well-designed study that will allow us to determine what health care policy should be."

Talk of harming patients and allusions to war-crime trials haven't sat lightly with regulators.

"I've mellowed quite a bit in the last few years, but for somebody to even imply we would endanger patients really [ticks] me off," said Dr. Donald E. Wilson, dean of the University of Maryland School of Medicine and chairman of the health care commission that would oversee a study.

Like about half the states, Maryland limits the number of hospitals that can perform certain complicated and expensive heart procedures, with the goal of maintaining quality.

For a generation, mounds of regulatory filings, hours of testimony and several rounds of litigation have focused on open-heart surgery and whether more hospitals should have approval to do it to meet patient demand.

In open-heart surgery, also called coronary bypass, doctors open the chest of the patient and direct blood around a blocked artery by attaching a blood vessel from elsewhere in the body.

Shifting debate

But changes in medical technology are shifting the debate, as improvements in angioplasty replace more traditional and complex heart surgeries. Both sides in the angioplasty dispute agree that cases that would have gone to surgery a few years ago are being treated by the less invasive procedure.

Continued improvements - particularly new drug-coated stents that do a better job at keeping vessels open - are expected to hasten the trend.

The state health commission generally allows angioplasty only in hospitals that also can do open-heart surgery. If the angioplasty goes bad - tearing a blood vessel is the most common problem - the patient can be rushed into surgery. The state, however, does allow non-heart-surgery hospitals to perform angioplasties in emergency cases - so-called primary angioplasties.

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