Cardiologists at two Ventura County hospitals say they have quality angioplasty programs, even though they are not performing the minimum number of procedures per year recommended by three national medical groups.
“The more you do, the better you get at it, but volume is not the only criterion for quality of care,” said Lynn Huntington, director of the cardiovascular lab at St. John’s Regional Medical Center in Oxnard.
“Numbers are easy for bureaucrats,” said Dr. Dennis Brooks, who performs angioplasties--a nonsurgical way to open clogged arteries--at Community Memorial Hospital in Ventura. “You should look at results.”
Huntington, Brooks and other physicians and hospital officials said numbers alone do not reflect whether an angioplasty was necessary in the first place, whether it worked in clearing the blockage for a significant period or how often complications arose during the procedure.
Neither St. John’s nor Community Memorial is performing the minimum 200 angioplasties per year recommended by the American Heart Assn., the American College of Physicians and the American College of Cardiology. A Times study found that nearly half of California hospitals that offer the procedure did not perform 200 angioplasties in 1989, the most recent year for which figures are available.
The three medical groups issued a joint statement in June saying that hospitals that perform fewer than 200 angioplasties may not be adequately prepared to deal with complications and should consider discontinuing the procedure.
In an angioplasty, a cardiologist first inserts a hollow needle into an artery. Using X-ray images, the physician maneuvers a balloon-tipped tube, or catheter, through the needle and then through various arteries until it reaches the clogged area. The balloon is then inflated and deflated several times to widen the artery.
Complications arise in fewer than 5% of angioplasties, but when they do, the patient usually needs immediate open-heart surgery. For that reason, a surgeon and anesthesiologist are on hand for every angioplasty.
In Ventura County, only Los Robles Regional Medical Center in Thousand Oaks exceeded the recommended minimum, with 382 angioplasties, according to 1989 statistics. St. John’s had 88. Community Memorial had 74 angioplasties, but hospital officials say that was an aberration caused by staffing changes. They said Community Memorial did 167 angioplasties last year.
Dr. George Hubert, the head of Los Robles’ cardiology department, agreed that the 200 figure is arbitrary and that numbers alone can be misleading.
Numbers may become important to the hospitals, however, because the state Department of Health Services is tightening regulation of heart procedures. Under proposed regulations expected to take effect later this year, hospitals with low volumes of procedures such as angioplasty would be subject to independent performance reviews and possible revocation of their permits to offer such services.
One Ventura County cardiologist, who asked not to be identified, said the minimum of 200 is a way for “the big hospitals to bump off the little hospitals.” In addition, he said, the emphasis on numbers encourages hospitals to perform angioplasties unnecessarily.
“I think way too many angioplasties are being done,” he said. Some patients are given angioplasties when medicine might have eased their arterial blockage, he said, while others need open-heart surgery but get an angioplasty first, even though it has little chance of solving the problem.
“Many doctors try it, it fails, but they get a number,” the cardiologist said. “Then the surgeon does the operation and they get another number. I’m not sure the numbers mean what they seem to mean.”
He said numbers do influence family-practice physicians when they refer patients for a cardiology procedure. “People send patients to Los Robles because they do the most,” he said. Several factors contribute to the disparity in angioplasty volume between Los Robles and the other hospitals, physicians and hospital officials say.
Los Robles was the first hospital in Ventura County to do open-heart surgery and other coronary treatments, starting in 1968. The other hospitals began their programs in the mid-1970s.
Also Los Robles has populous eastern Ventura County all to itself and also draws patients from the western San Fernando Valley. By contrast, St. John’s and Community Memorial are only a few miles apart on the county’s west side.
“With two programs in such a small area, it’s hard to build volume,” Huntington said.
Unlike the other hospitals, Los Robles is a for-profit institution. Officials of the other hospitals say Los Robles has aggressively marketed its program to physicians.
Cardiology programs require a huge investment in money, space and staff, hospital officials say. A catheterization lab, where angioplasties are performed, can cost as much as $2 million.
“They are very resource-demanding,” said an official at Ventura County Medical Center, which does not do cardiology. “It’s not every hospital that wants to get into it. But once you are into it, you want volume to offset fixed costs.”
An angioplasty usually costs more than $10,000, including physician fees and hospital charges. The typical bill for open-heart surgery is $30,000 or more.
All three Ventura County hospitals with cardiology departments say that each patient’s records are reviewed by several physicians to make sure that angioplasties are not done unnecessarily.
The cardiologist who asked for anonymity said profit is a factor in many unnecessary angioplasties and said an overemphasis on numbers only aggravates the problem.
“When you have to do more than 200, then you have everybody scrambling to do unnecessary angioplasties. I think that happens,” he said. “We won’t know how many of these procedures are necessary until doctors are paid an annual salary unrelated to the numbers they do.”