Hospitals Fall Short on Heart Procedure : Medicine: Nearly half of California facilities offering coronary angioplasty fail to do the recommended minimum number of surgeries.
Nearly half of California hospitals offering coronary angioplasty in 1989 did not perform the minimum number of procedures recommended by leading medical speciality groups, according to a Times analysis.
About two-thirds of hospitals in Los Angeles and Orange counties that offer the common heart procedure were below the 200-cases-a-year minimum suggested by the American College of Physicians, the American College of Cardiology and the American Heart Assn.
The number of angioplasties performed at a hospital is an indirect measure of quality-of-care issues, experts say, such as the adequacy of the training of cardiologists who perform the procedure and the ability of physicians to deal with possible complications.
“A significant volume of cases per institution is essential for the maintenance of . . . quality and safe care,” the three medical specialty societies asserted last June in a statement in the medical journal Circulation. Hospitals that do not meet the minimum “should not offer, or should consider discontinuing, angioplasty.”
Angioplasty is a sophisticated technique in which a cardiologist opens clogged arteries with a balloon-tipped hollow tube that is inserted through the skin and threaded through a vein to the heart.
The procedure is designed to prevent heart attacks and to treat angina, chest pain caused by an insufficient blood supply to the heart. Angioplasty is widely accepted as an alternative to coronary bypass surgery. About 27,000 angioplasties were performed in California in 1989.
In total, 53 of the 111 California hospitals offering angioplasty reported fewer than 200, including 25 in Los Angeles County, seven in Orange County and five in San Diego County. The Times analysis was based on a review of data reported by hospitals each year to the Office of Statewide Health Planning and Development.
“Every small hospital is trying very hard to put a cardiac program together,” said Dr. Stephen N. Oesterle, chief of the angioplasty program at the Hospital of the Good Samaritan in Los Angeles. “There are about 60 hospitals (in the Los Angeles-Orange County area) with catheterization labs (where angioplasties are performed.) They are cutting up the pie. No one is going to back away from this.”
But because the overall number of angioplasties reported by many hospitals is small, experts doubt that some cardiologists within those hospitals “are able to keep their competence at a level which provides good quality care,” said Dr. William L. Winters Jr., president of the American College of Cardiology and a member of the task force that drafted the guidelines.
For example, Winters said that after a decade of performing the procedures at Methodist Hospital in Houston, he stopped in 1989 because his duties with the cardiology organization prevented him from doing enough angioplasties “to keep up.”
Task force chairman Dr. Sankey V. Williams of the University of Pennsylvania acknowledged that some cardiologists have complained that the recommended minimum is too high and that some hospitals with small numbers of angioplasties appear to have few problems.
Nevertheless, task force members and others said many cardiologists are inadequately trained to perform angioplasties. The task force recommended that training should include a minimum of 125 procedures, including 75 in which the physician in training takes the primary role. To maintain competence, an annual minimum of 75 procedures was recommended.
Professional standards for angioplasty training “have been breached very widely” and are being taken “lightly by hospitals for whom this is a very significant income,” said Dr. Peter Mahrer, chief of cardiology at Kaiser Permanente Medical Center in Los Angeles. “The hospital has very little interest to enforce the fairly strict regulations that are recommended.”
Cardiologists can achieve their recommended personal minimum by performing angioplasties at more than one hospital. But the statement added that a good practice environment in all hospitals offering the procedure is crucial, including substantial numbers of angioplasties performed by at least several physicians.
Moreover, when angioplasty complications develop, heart surgeons must be ready to perform emergency operations to save patients’ lives. Surgeons in institutions that perform relatively few of the procedures are “probably not as capable of dealing with an emergency procedure resulting from a failed angioplasty” as surgeons in high-volume institutions, said Jonathan Showstack of the Institute for Health Policy Studies at UC San Francisco.
But experts caution that even a large number of angioplasties is no guarantee that a hospital has a good program. The procedures, for instance, may be performed when they are unnecessary. Often the cardiologist who recommends angioplasty also performs the procedure. Such self-referrals may cloud physicians’ judgments.
Hospitals that reported more than 400 of the procedures included five in Los Angeles County, one in San Bernardino County and two in San Diego County. The Hospital of the Good Samaritan, with 692 angioplasties, was the busiest in Southern California.
Since the demise of California’s so-called “certificate of need” program in 1986, hospitals have been free to develop new health-care services and facilities. As a result, the duplication of costly--yet prestigious and potentially lucrative--heart programs has become increasingly common.
The program had required hospitals to both meet state licensing requirements for procedures such as heart surgery and to prove at public hearings that the new services were actually “needed.”
A catheterization laboratory, where angioplasties are performed, costs $1 million to $2 million, depending on the equipment installed, Oesterle said. Hospitals want “to see these things utilized.”
But the state Department of Health Services, concerned that its current standards are antiquated and lax, is moving to tighten its regulations of heart services. Under proposed regulations that are expected to go into effect later this year, California hospitals with high mortality rates or low volumes of heart procedures--such as open heart surgery, angioplasty and catheterizations--would be subject to independent performance reviews and possible revocation of their permit to offer such services.
The Times analysis also revealed that 37, or about one-third, of California hospitals offering open heart surgery in 1989 did not meet the recommended annual minimum of 150 operations established by the Department of Health Services and the American College of Surgeons.
Health-policy experts are particularly concerned by hospitals that fall below the recommended minimums for both angioplasties and open heart surgeries. In 1989, about 30% of the hospitals offering both services did not meet both minimums.
Both angioplasty and open heart surgery can be highly lucrative. Bills for angioplasty, including physician fees and a several-day hospital stay, usually run more than $10,000. Open heart surgery typically costs $30,000 or more.
Angioplasty success and complication rates depend in large part on the extent of a patient’s heart disease and overall health. In general, cardiologists are successful in opening clogged heart arteries in 85% to 90% of cases, experts say.
Patients require emergency heart surgery or suffer heart attacks in fewer than 5% of cases. The typical risk of dying as a result of angioplasty is less than 1%.
ANGIOPLASTY AND HEART SURGERY IN 1989
These were the number of reported coronary angioplasties and adult open heart surgeries at Southern California hospitals in 1989, according to a Times analysis of data compiled by the Office of Statewide Health Planning and Development.
To maintain an adequate standard of practice, the American College of Physicians, the American College of Cardiology and the American Heart Assn. recommend that at least 200 angioplasties be performed annually at each hospital offering the procedure.
For open heart surgery, the American College of Surgeons as well as state Department of Health Services regulations recommend that at least 150 open heart operations be performed annually at each hospital offering such surgery.
OPEN HEART ANGIOPLASTIES SURGERIES STATEWIDE 27,042 29,238
LOS ANGELES COUNTY Less than 200 angioplasties
OPEN HEART ANGIOPLASTIES SURGERIES Queen of Angels/Hollywood Presby Med. Cent. 13 49 Beverly Hospital, Montebello 35 84 Long Beach Community Hospital 46 86 Glendale Memorial Hosp. & Health Center 47 102 St. Francis Med. Center, Lynwood 57 62 Centinela Hospital Med. Center, Inglewood 68 70 Antelope Valley Hosp Med. Cent., Lancaster*+ 73 36 Harbor/UCLA Medical Center, Torrance 75 115 Brotman Medical Center, Culver City 89 103 St. Mary Medical Center, Long Beach 97 105 Downey Community Hospital 100 224 White Memorial Med. Center, Los Angeles 104 85 Inter-Community Medical Center, Covina 105 187 Humana Hospital West Hills, Canoga Park 106 52 Granada Hills Community Hospital 118 65 Garfield Medical Center, Monterey Park 120 62 Presbyterian Intercommun. Hosp., Whittier 123 159 Santa Monica Hospital Medical Center 123 59 Lancaster Community Hospital 132 274 Methodist Hosp. of S. California, Arcadia 132 101 Valley Presbyterian Hospital, Van Nuys 148 139 Glendale Adventist Medical Center 158 163 County-USC Medical Center, Los Angeles 165 175 Northridge Hosp. Medical Center 174 138 Pomona Valley Hosp. Med. Center 195 356
LOS ANGELES COUNTY More than 200 Angioplasties
OPEN HEART ANGIOPLASTIES SURGERIES Hosp. of the Good Samaritan, Los Angeles 692 1,293 Cedars-Sinai Medical Center, Los Angeles 483 665 St. Joseph Medical Center, Burbank 461 142 Kaiser Foundation Hospital, Los Angeles 455 908 Daniel Freeman Memorial Hosp., Inglewood 406 135 Torrance Memorial Hosp. Med Center 377 247 Memorial Medical Center, Long Beach 352 515 Little Company of Mary Hospital, Torrance 351 230 St. John’s Hospital, Santa Monica 327 180 Huntington Memorial Hospital, Pasadena 311 263 St. Vincent Medical Center, Los Angeles 236 657 UCLA Medical Center, Westwood 216 314 Medical Center of La Mirada* 208 151 Encino Hospital 201 193
SOUTHERN CALIFORNIA Less than 200 Angioplasties
OPEN HEART ANGIOPLASTIES SURGERIES Community Hospital of Chula Vista* 0 204 Desert Hospital, Palm Springs 0 130 San Antonio Community Hosp., Upland 22 51 Tri-City Medical Center, Oceanside* 30 201 Comm. Mem. Hosp. of San Buenaventura, Ventura 74 151 St. John’s Regional Med. Center, Oxnard 88 185 Humana Hospital, West Anaheim 109 48 Alvarado Hosp. Med. Center, San Diego 111 382 Grossmont District Hospital, La Mesa* 123 194 Mission Hosp. Reg. Med. Cent., Mission Viejo 126 106 Saddleback Community Hosp., Laguna Hills 137 139 UC Irvine Medical Center, Orange* 147 95 Western Medical Center, Santa Ana 159 166 Riverside Community Hospital 170 207 Fountain Valley Regional Hosp. Med. Cent. 183 187 Mercy Hosp. and Med. Center, San Diego 191 268 Anaheim Memorial Hospital 196 78
SOUTHERN CALIFORNIA More than 200 Angioplasties
OPEN HEART ANGIOPLASTIES SURGERIES St. Bernardine Med. Cent., San Bernardino 524 437 Scripps Memorial Hospital, La Jolla 513 589 Sharp Memorial Hospital, San Diego 411 579 Los Robles Reg. Med. Center, Thousand Oaks 382 287 Loma Linda University Medical Center 366 318 UC San Diego Medical Center, La Jolla 355 219 Green Hosp. of Scripps Clinic, La Jolla 354 251 Western Medical Center, Anaheim 278 197 Palomar Medical Center, Escondido 258 152 St. Jude Hospital & Rehab. Cent., Fullerton 257 255 St. Joseph Hospital, Orange 215 293 Hoag Memorial Hosp Presby, Newport Beach 202 243 Eisenhower Medical Center, Rancho Mirage 200 313
NOTES: Pediatric open heart surgeries and hospitals outside of Southern California are not listed.
* Hospitals that reported no angioplasties for 1988.
+ Hospitals that reported no heart surgeries for 1988.
SOURCE: Office of Statewide Health Planning and Development, Annual Report of Hospitals, 1988 and 1989.
ANGIOPLASTY, HEART SURGERY: THE STATEWIDE STORY
ANGIOPLASTY IN CALIFORNIA: 1989
NUMBER % WITH FEWER THAN OF HOSPITALS 200 ANGIOPLASTIES STATEWIDE 111 50% Los Angeles County 39 64% Orange County 12 67% San Diego County 11 45% Ventura County 3 67% Other Counties 46 35%
ADULT HEART SURGERY IN CALIFORNIA: 1989
% WITH FEWER THAN NUMBER 150 OPEN HEART OF HOSPITALS SURGERIES STATEWIDE 110 35% Los Angeles County 39 51% Orange County 11 45% San Diego County 10 0% Ventura County 3 0% Other Counties 47 30%
SOURCE: Office of Statewide Health Planning and Development, Annual Report of Hospitals.
