When bigger isn't better

In the early morning hours of April 17, Frank Blake of Everett was roused from slumber by sharp, shooting chest pains. He tried to shake it off, but the ache could not be ignored.

Blake, 54, a computer specialist for the Internal Revenue Service, went with his wife to Melrose-Wakefield Hospital, where a doctor delivered sobering news. Blake, who had suffered a heart attack, needed to have emergency angioplasty, a procedure that threads a balloon-like device into a clogged artery to clear the obstruction.

There was only one issue to decide: Where did Blake want the procedure performed? At the community hospital in Melrose or in Boston at Massachusetts General Hospital? Either way, a cardiologist on staff at Mass. General would be called in.

''In my mind, it wasn't even a question," said Blake. ''If you go to a large hospital like Mass. General, you can get lost in the shuffle. At Melrose-Wakefield, you're a person, not a number. I chose to stay where I was and have the doctor come to me."

As community hospitals across the region jockey for position and prestige, patients like Blake are reaping the rewards. Suburban hospitals from Melrose to Newburyport have formed partnerships with Boston teaching hospitals and are now offering the kind of specialty care once available only in the big city.

''Many hospital experts believe that cardiac services and a number of surgical services offered at teaching hospitals are more profitable," said Dr. Alan Sager, a professor of health services at Boston University School of Public Health. ''Some community hospitals may feel they need to take on more complex and costly services in order to compete. Many hospitals are finding it hard to attract and retain doctors without specialized services and equipment."

As recently as five years ago, Blake and other North Shore patients seeking cardiac care would have had to travel to Boston, a city world-renowned for its four medical schools and 11 teaching hospitals, institutions that spend millions each year to maintain teaching staff and keep pace with technological advancements.

But these days, as state health officials ease restrictions on certain high-risk procedures, a growing number of specialists are leaving the city to take positions at hospitals in places such as Beverly, Lynn, Melrose, Newburyport, and Salem.

''Local care needs to be upgraded to take care of more complex needs," said Donald J. Thieme, executive director of the Massachusetts Council of Community Hospitals, which represents 26 hospitals, including Beverly Hospital, Addison Gilbert Hospital in Gloucester, and Melrose-Wakefield Hospital. ''The real question is whether the community hospitals will have the capital required to respond to those needs."

Massachusetts residents go to urban teaching hospitals three times more often than residents of other states who rely more heavily on community hospitals, Thieme noted. In hopes of boosting their market share, local hospitals have devoted vast sums to improve technology, overhaul surgical units, and upgrade diagnostic equipment.

The North Shore Medical Center, parent of Salem Hospital and Union Hospital in Lynn, has developed an electronic medical records system that enables doctors at Mass. General to instantly access information about NSMC patients. And throughout the northern suburbs, hospitals are making major investments in cardiac care.

In 2003, Hallmark Health spent $1.3 million to upgrade its diagnostic equipment and develop a cardiac catheterization laboratory at its Melrose-Wakefield Hospital. Anna Jaques Hospital in Newburyport and Northeast Hospital Corp., which operates Beverly Hospital, Addison Gilbert Hospital in Gloucester, BayRidge Hospital in Lynn, and the Hunt Center in Danvers, each have invested hundreds of thousands of dollars to establish similar laboratories. Northeast's lab is at Beverly Hospital.

A cardiac catheterization laboratory team includes highly skilled and specialized registered nurses, cardiovascular, and radiological technologists. Some of the procedures typically performed include catheterization (a thin tube is inserted into an artery into the arm or leg and from there advanced into the heart to measure blood pressure and oxygen levels); inserting pacemakers; and implanting cardiac defibrillators.

Partners HealthCare in Boston, parent of Mass. General and NSMC, invested $9 million to develop a 12,000-square-foot, state-of-the-art heart center at Salem Hospital, the region's largest community hospital. North Shore businesses and residents contributed an additional $3 million to build the center.

Cardiac specialists at the NSMC Heart Center can treat patients for a range of disorders, including arrhythmia, angina, congestive heart failure, and coronary or valve disease. Today, NSMC is one of three community hospitals statewide allowed to perform open-heart surgery.

Massachusetts health officials barred community hospitals from performing open heart surgery in 1975, after a high number of patient deaths were reported at now-closed Malden Hospital, but eased the restriction in 2001 under heavy pressure by state lawmakers.

Today, Salem Hospital and Melrose-Wakefield are two of eight suburban hospitals allowed by the state Department of Public Health to perform emergency angioplasty. Melrose-Wakefield is one of several local hospitals seeking permission to perform non-emergency angioplasties, a right that for years has been limited to hospitals authorized to do open heart surgery.

The state is considering adopting a pilot program that would allow a select number of community hospitals to perform the procedure on a non-emergency basis. With ongoing improvements in drugs and technology, it is expected that community hospitals will continue to push for expanding the breadth of their specialty care, often in association with teaching hospitals.

Hallmark Health has teamed up with Tufts-New England Medical Center to provide specialized care for infants, as well as genetic counseling for expectant parents. Meanwhile, Northeast Hospital Corp. has partnered with Beth Israel Deaconess Medical Center to provide cutting edge cancer care, and with Children's Hospital Boston to care for high-risk newborns.

State health officials closely monitor the quality of care delivered at local hospitals. ''Each specialized service that the state Department of Public Health approves has its own set of standards," said Donna Rheaume, spokeswoman for the department. ''Hospitals must comply with these standards in order to be licensed to provide the specialized service."

Recent studies by state health officials have found the quality of obstetric and cardiac care at community hospitals to be equal to or better than that offered at teaching hospitals.

At Salem Hospital, cardiac surgeons perform only four to five procedures a week, allowing them to follow a nontraditional model of patient care. Unlike a large teaching hospital, where patients move from one unit to another as they recover from surgery, patients at the NSMC Heart Center have the same room and cardiac team for the entire length of their stay, and doctors, patients, and family members meet daily to communicate about a patient's care.

''Right from the start, patients have confidence about the care they are receiving, and assume they will do well," said Dr. Thomas Vander Salm, who leads the Salem cardiac team. ''That level of confidence has a direct and positive impact on the outcome."

A similar model of patient care has been adopted at Beverly Hospital, the only community hospital north of Boston to provide the highest level of respiratory care and support to newborns. According to Dr. Tai Tran, a Children's Hospital physician who also serves as director of newborn medicine at Beverly Hospital, parents are encouraged to play an active role in caring for their babies, a practice that benefits both parent and child.

''The second day we were at Beverly Hospital, the nurses had me kangarooing with my triplets, which is skin-on-skin contact with all of them, at the same time," said Denise Townsend of Ipswich, whose babies were born at Beth Israel on May 8 and later transferred to Beverly. ''It was the first time I had been allowed to hold all three of them. It was amazing."

And while some healthcare observers, including Sager, worry that the growth of expensive specialty services at community hospitals could cause Massachusetts medical costs to soar even higher -- health costs in the Bay State are already 27 percent above the national average -- local hospital administrators believe the expansion of services will empower suburban hospitals.

By mining lucrative markets once monopolized by teaching hospitals, administrators think community hospitals will be able to offset the high cost of emergency services, pediatrics, obstetrics, and other core services that do not typically generate a profit.

''There will always be large academic hospitals, facilities that are on the cutting edge, providing the latest specialty procedures," said Mike Summerer, chief medical officer for Hallmark Health. ''But as those procedures become safer, and more physicians are trained to perform them, we have a responsibility to expand our services. By doing so, we can provide a better quality of care to our local communities and support our broader mission."

Brenda J. Buote may be reached at bbuote@globe.com