Small hospitals battle for right to do angioplasties

When Donna MacDonald checked into South Shore Hospital for a routine cardiac test last year, Dr. Anthony Marks instantly spotted trouble. An angiogram showed that scar tissue blocked a major artery, choking off the blood supply to her heart. MacDonald, 57, needed an angioplasty.

But Marks had more bad news for his patient: Massachusetts regulations forbid him to perform the procedure at the suburban hospital in Weymouth. So he left the 4-inch tube holding open an entryway to the artery in her thigh, told her not to move, summoned an ambulance, and transferred her to Tufts-New England Medical Center in Boston, where later that day he did her angioplasty.

The number of angioplasties, a procedure in which a cardiologist inflates a tiny balloon inside an artery to clear a blockage, and often inserts a wire stent to prop it open, is exploding. They are now more common than cardiac bypass surgery, which more than a decade ago was the favored way to treat diseased arteries. But the growth in angioplasty has also sparked battles in many states, including Massachusetts, over who should perform them and where.

In about a dozen states, including Massachusetts, nonemergency angioplasties are allowed only at hospitals with open-heart surgery programs, usually teaching hospitals. As a result, community hospitals like South Shore are trying to persuade Legislatures and state regulatory boards to allow them to take back angioplasty patients like MacDonald. At issue is safety and convenience for patients, but also thousands of dollars in revenue.

"It's one of the most important issues in front of public health officials right now, because the stakes are so high," said Dr. Joseph Carrozza, chief of interventional cardiology at Beth Israel Deaconess Medical Center.

In December, a committee advising the Department of Public Health made up of teaching and community hospital cardiologists voted down a proposal to allow community hospitals to offer angioplasties as part of a study run by a Johns Hopkins Medical Center physician. The group, which meets this week, decided to develop its own study, which could mean community hospitals that qualify could start offering routine, or elective, angioplasties within the year.

"We can deliver this care very, very safely," said Marks, a member of the group. Meanwhile, cardiologists at some academic medical centers believe that allowing the procedure in smaller hospitals without heart surgery on site could put patients at risk; in a small percentage of cases, patients encounter complications during angioplasty and require emergency cardiac surgery.

Nationwide, doctors performed more than 1.2 million angioplasties in 2002, according to the American Heart Association's most recent figures, a three-fold increase in 10 years. In Massachusetts, cardiologists did 17,608 angioplasties last year, a 50 percent jump since 1998. Fourteen Massachusetts hospitals that have heart surgery programs are allowed to offer nonemergency angioplasties, which make up the bulk of the procedures.

Angioplasties are less invasive and less risky than surgery. The procedure's popularity also has been fueled by the development of stents, tiny wire scaffolds that cardiologists place in the arteries to keep them propped open.

In 2001, the American College of Cardiology and American Heart Association recommended against angioplasties at hospitals without open-heart surgery programs. A national advisory committee is now reassessing the issue, in light of new research and the growing use of stents, which have made angioplasty safer.

Since 1998, Massachusetts has allowed emergency angioplasties -- used to treat heart attack patients who could die unless the arteries are immediately cleared -- at certain community hospitals without heart surgery programs, including South Shore, Brockton Hospital, and MetroWest Medical Center.

South Shore executives and doctors have been adamant that the hospital is capable of providing nonemergency procedures too, and agree that a controlled study to monitor results is safest. State Representative James Murphy, a Weymouth Democrat, tried to push through a provision in the state budget last year that would have created an angioplasty pilot program at smaller hospitals. The Legislature defeated the measure, but he plans to resubmit the bill, which would require the public health department to allow nonemergency angioplasty programs in hospitals that do the procedure during emergencies.

"We all have to realize that we have a vested economic interest in the outcome," said Carrozza, who is also a member of the Massachusetts advisory committee. "Beth Israel Deaconess would lose half our cases. Do the math. This is a major hit economically. We also have to have enough cases to train fellows. On the other hand, for community hospitals this is a potential windfall."

Blue Cross and Blue Shield of Massachusetts, the state's largest health insurer, pays hospitals $17,000 to $20,000 for an angioplasty -- about the same as it pays for a hip replacement operation. But Carrozza said that about 40 percent of the fee is profit, making it a particularly lucrative procedure for the hospital.

Marks said profit is not driving South Shore's push. "I've done an awful lot of soul-searching about this issue," he said. "We're trying to do absolutely the right thing for our patients. If there's a profit margin I couldn't care less."

Marks pointed out that the risk of a problem during angioplasty, such as a punctured artery requiring open-heart surgery, has fallen to less than one percent. Even if immediate surgery became necessary, he added, a patient at a teaching hospital would wait an average of two hours for a free operating room, more than enough time for South Shore to transport a patient in an ambulance to Boston.

But other cardiologists said the issue goes beyond whether a suburban hospital has cardiac surgeons on site.

"It's not just surgery, but the whole strength of the institution that's brought to bear when something goes wrong," said Dr. Kenneth Rosenfield, director of cardiac and vascular invasive services at Massachusetts General Hospital. "When something bad happens here, a whole cascade of people arrive on the scene."

While many states don't regulate angioplasties, health officials in states that do are struggling with the decision. One problem is that research comparing outcomes for patients in different types of hospitals is scant.

In a study published last October in the Journal of the American Medical Association, researchers from Dartmouth Medical School and Maine Medical Center reviewed records of 625,854 Medicare patients who had angioplasties. They found that patients who had angioplasties in hospitals without cardiac surgery had a 38 percent higher mortality. But the higher rate mostly was confined to hospitals that performed 50 or fewer case per year, where staff might be less practiced.

Cardiologists said Massachusetts health officials probably will expand access, but may allow angioplasties only in higher-volume community hospitals and on low-risk patients under rules of a strict study that tracks results.

"If we can do a study we would all respect the findings of the study," Carrozza said. "If you can do it in community hospitals safely, then we would not stand in the way of it. If the study turns out the opposite, then their CEOs have to stop pestering the Legislature."

MacDonald, who lives in Rockland, said the situation baffles her. She met Marks when she had a heart attack in September 2003; the ambulance rushed her to South Shore Hospital. A blood clot had closed her right artery. Because her condition was critical, Marks was allowed to perform an angioplasty at South Shore, stretch her artery by inflating a tiny balloon, and insert two stents. "I had 15 minutes to live," she said.

Some patients, knowing they cannot have more routine angioplasties at South Shore, will ask Marks to do their cardiac catheterization at a Boston hospital. But with South Shore so convenient for her family, she decided last March to take the chance that he'd find nothing wrong. But he did; the angiogram, or X-ray of her artery, showed a serious blockage. To make matters worse, the day turned into an ordeal for MacDonald. Because of the transfer, she had to lie on her back for eight hours, trying not to jostle the tube in her artery, because Tufts-NEMC could not schedule her procedure until 4 pm.

"They saved my life with an angioplasty and a stent, yet they had to send me to Boston because I wasn't having a heart attack," she said. "I was like, 'This is ridiculous.' "

Liz Kowalczyk can be reached at kowalczyk@globe.com.