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• W2058163062 abstract "HomeJournal of the American Heart AssociationVol. 2, No. 6US Growth in PCI Care—Less than Ideal, but is the Ideal Less? Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBUS Growth in PCI Care—Less than Ideal, but is the Ideal Less? Steven M. Bradley, Evan P. Carey and P. Michael Ho Steven M. BradleySteven M. Bradley VA Eastern Colorado Health Care System, Denver, CO University of Colorado School of Medicine, Aurora, CO Colorado Cardiovascular Outcomes Research Consortium, Denver, CO Search for more papers by this author , Evan P. CareyEvan P. Carey VA Eastern Colorado Health Care System, Denver, CO University of Colorado School of Medicine, Aurora, CO Search for more papers by this author and P. Michael HoP. Michael Ho VA Eastern Colorado Health Care System, Denver, CO University of Colorado School of Medicine, Aurora, CO Colorado Cardiovascular Outcomes Research Consortium, Denver, CO Search for more papers by this author Originally published19 Nov 2013https://doi.org/10.1161/JAHA.113.000552Journal of the American Heart Association. 2013;2:e000552IntroductionAn ideal healthcare system aims to provide care that is safe, effective, efficient, equitable, timely and patient‐centered.1 Translation of these aims into practice for patients suffering from ST‐elevation myocardial infarction (STEMI) could result in an ideal primary percutaneous coronary intervention (PCI) system of care. In this ideal PCI system of care, PCI centers would be equitably distributed for the population at risk to ensure timely access to primary PCI. Further, PCI centers would care for an adequately sized patient population to achieve minimal volume thresholds, and to provide the procedure safely while ensuring efficient use of healthcare resources. Although an ideal PCI system of care is easy to envision, it is possible that the current primary PCI system of care in the US is not ideally configured.It would appear that an ideal PCI system of care could be designed in 1 of 2 ways to achieve high‐quality care. The first approach involves integrated PCI networks that coordinate care among emergency medical services (EMS), non‐PCI‐capable hospitals, and PCI‐capable centers through the use of established processes to ensure timely transfer of STEMI patients to PCI‐capable centers2. An established network may increase access to primary PCI, minimize delays in care, and optimize patient outcomes. An example of this approach is the American Heart Association's Mission: Lifeline that seeks to improve the healthcare system's timely response to patients with STEMI through the creation and improvement of STEMI systems of care.3 Another example comes from Denmark, where the development of a STEMI network has optimized patient access to PCI care for the entire country. As shown in the Figure, through coordination of EMS systems and PCI‐capable centers, nearly all patients in Denmark have access to primary PCI within 120 minutes of EMS contact (red circles represent <120 minutes by helicopter EMS transport; yellow circles represent <120 minutes by ground EMS transport).4Download PowerPointFigure 1. Map over Denmark with geographical zones covered by ground and airborne emergency medical systems. Figure reproduced with permission from Clemmensen et al.4EMS indicates emergency medical services; PCI, percutaneous coronary intervention.A second approach to increasing PCI access is the development of new PCI‐capable centers. Growth in PCI‐capable hospitals would not be haphazard in an ideal PCI system of care. Instead, new PCI‐capable centers would address gaps in current access to timely PCI for STEMI patients by using disease prevalence and geospatial analyses to determine new sites for PCI hospitals. In this approach, geographic regions with a high‐risk patient population for STEMI and without a nearby PCI capable center would be ideal locations for new growth in PCI‐capable hospitals. The study by Langabeer et al5 in this issue of JAHA sought to determine if growth in PCI‐capable centers was consistent with this approach. The importance of this question is highlighted by the dramatic growth in PCI‐capable hospitals over the past decade in the US.Using geospatial analyses, Langabeer et al modeled the temporal growth and access to primary PCI relative to the population density and MI prevalence at the state level. From 2003 to 2011, the authors determined that the number of PCI‐capable hospitals in the US has grown 12.9% from 1750 to 1975 PCI centers. This growth is faster than the population growth (8.3%) and occurred during a period of declining coronary disease prevalence. Furthermore, growth in PCI‐capable centers has not been uniform in relation to MI prevalence and distance between PCI facilities. For example, although the annual MI prevalence in Nevada is higher than the median (51 MIs per 1000 persons), the number of PCI facilities in the state is lower than the median (6.8 facilities per 1 million persons) with very long distances between patients and facilities (16.3 PCI facilities per 100 000 square miles). In contrast, the MI prevalence in the District of Columbia is lower than any state (21 MIs per 1000 persons), and yet the number of facilities is high (8.3 per 1 million persons) with a dramatic geographic concentration of PCI facilities (7316.4 PCI facilities per 100 000 square miles). There are clearly limitations to this type of descriptive analysis given the potential care of patients across state lines when PCI facilities are near state borders, yet these findings still raise a concern of disparate primary PCI access.The findings of Langabeer et al are consistent with those of Concannon et al, which recently demonstrated significant duplication in access to primary PCI.6 The study by Concannon demonstrated 98% of new PCI‐capable centers were introduced in areas that already had a PCI program. Furthermore, new PCI programs were more likely to be located near populations with higher rates of private insurance; suggesting new centers seek procedural dollars, rather than ideal care.These studies clearly implicate less than ideal growth of PCI centers as it relates to care of patients with STEMI. Further, the present study offers a reasonable strategy to increase access to primary PCI through (1) further expansion of PCI networks or (2) development of PCI capable centers that are nonoverlapping with the population of patients served by established centers. Before considering development of nonoverlapping PCI‐capable centers, it is important to acknowledge the population density of currently underserved areas for primary PCI. These areas often lack adequate numbers of STEMI to achieve necessary procedural thresholds for proficiency and efficient use of healthcare resources. Thus, expansion of primary PCI networks may provide a more effective, safe, and efficient strategy to improve primary PCI access for currently underserved regions. In fact, analyses from Mission: Lifeline suggests network STEMI systems provide coverage to many of regions identified as underserved in the Langabeer study.7 Overall, these findings suggest that ideal growth in PCI‐capable centers for STEMI care may be fewer PCI centers rather than more.If the growth in PCI‐capable centers for STEMI care has been less than ideal, is it reasonable to say that overall growth in PCI centers should be less? This is far more challenging, largely due to the other important roles of PCI in clinical care for patients with NSTEMI and chronic stable angina. While time to PCI among patients with NSTEMI is not as urgent when compared with STEMI patients, early invasive therapy (within 12 to 24 hours of hospital admission) may reduce the risk of ischemic complications among high‐risk NSTEMI patients. This contrasts with timely access to elective PCI for chronic stable angina, which is measured in days to weeks. Further, the goals of elective PCI for chronic stable angina are different than they are for MI and primarily focused on symptom relief. In addition, the clinical risk and benefit of PCI for stable ischemic heart disease must be weighed in relation to the benefit of optimal medical therapy for symptom control. Finally, ideal PCI care avoids inappropriate use of the procedure among patients without anticipated benefit (eg, asymptomatic patients).Thus, design of overall PCI care must also ensure equitable access for the symptomatic disease burden of the population without incentivizing inappropriate procedural use. Although the population density and frequency of STEMI may be able to inform the “right” number of PCI‐capable hospitals for primary PCI access, this does not necessarily translate into optimal PCI design to minimize population symptom burden and maximize quality of life. Additionally, as the benefits of PCI for stable ischemic heart disease are not time dependent in the same fashion as NSTEMI or STEMI, close geographic access to PCI centers for nonacute indications may not be necessary. Future work is necessary to understand the prevalence of patient‐reported symptoms on a population level in relation to PCI access to further optimize delivery of PCI care for chronic stable angina.Finally, it is important to consider the implications of new care delivery and reimbursement models in the future growth of PCI access. Previously, fee‐for‐service was the predominant care delivery model. Given widespread concerns that fee‐for‐service care delivery incentivizes overuse without incentivizing quality or outcomes, policymakers have proposed Accountable Care Organizations (ACOs) as an alternative payment and care delivery model.8 In ACOs, provider groups accept responsibility for the coordination, quality, and cost of care for a patient population. In this context, developing new PCI capable centers must be considered in relation to the value (outcomes relative to cost) offered to the patient population.9 If similar survival and symptom burden outcomes can be achieved at lower cost through partnerships between practice groups rather than development of a new PCI‐capable center, this may better serve the interest of payers and patients. Whether ACOs can spur collaboration and integration remains to be seen. Study of provider groups within integrated healthcare settings with capitated reimbursement (eg, VA or Kaiser Permanente) may help to inform the design and implementation of ACOs to strike the ideal balance in PCI care. These provider groups are incentivized and cooperatively organized like ACOs. Identification of provider groups with high quality of care and patient outcomes despite lower costs of care may inform strategies to achieve ideal PCI care.While addressing access to PCI care, we must concurrently work to improve the other domains of high‐quality care (safe, effective, efficient, equitable, and patient‐centered) to achieve ideal care delivery. The safety of PCI can be improved through greater use of radial arterial access—a patient‐preferred approach that remains underused despite benefits of reduced bleeding complications.10, 11 Currently, elective PCI for stable ischemic heart disease is often performed for inappropriate clinical indications (eg, patients without anticipated clinical benefit), suggesting ineffective and inefficient use of resources and unnecessary procedural risk for patients.12, 13 At the same time, we lack population measures of symptom burden that may identify underuse and inequitable use of elective PCI. Work to support proper patient selection in the use of PCI care may ensure the effective, efficient, and equitable use of this important procedure to optimize patient outcomes. Finally, PCI care is not patient‐centered as evidenced by patient misconceptions about the anticipated benefit of elective PCI for stable coronary disease.14 Shared decision making may improve patient engagement and knowledge in support of a patient‐centered treatment decision. Continuous assessment of how PCI care is delivered relative to the ideal is critical to identify future opportunities to close the gap and achieve the best care for patients.DisclosuresThis material is the result of work supported with resources and the use of facilities at the VA Eastern Colorado Health Care System, Denver, CO. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Dr Bradley is supported by a Department of Veterans Affairs, Veterans Health Administration, HSR&D Career Development Award (HSR&D CDA2 10‐199). Dr Ho is supported by a VA HSR&D Center of Innovation (Denver‐Seattle Center for Veteran‐Centered and Value‐Driven Care).Footnotes*Correspondence to: Steven M. Bradley, MD, MPH, VA Eastern Colorado Health Care System, 1055 Clermont St (111B), Denver, CO 80220‐3808. E‐mail: steven.[email protected]govThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.References1 Institute of Medicine, Committee on Quality Health Care in America . Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press; 2001.Google Scholar2 Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST‐elevation myocardial infarction patients: executive summary. Circulation. 2007; 116:217–230.Google Scholar3 Mission: Lifeline Home Page [Internet]. Available at: http://www.heart.org/HEARTORG/HealthcareResearch/MissionLifelineHomePage/Mission-Lifeline-Home-Page_UCM_305495_SubHomePage.jsp. Accessed October 29, 2013.Google Scholar4 Clemmensen P, Schoos MM, Lindholm MG, Rasmussen LS, Steinmetz J, Hesselfeldt R, Pedersen F, Jørgensen E, Holmvang L, Sejersten M. Pre‐hospital diagnosis and transfer of patients with acute myocardial infarction—a decade long experience from one of Europe's largest STEMI networks. J Electrocardiol. 2013; 46:546–552.Google Scholar5 Langabeer JR, Henry TD, Kereiakes DJ, Dellifraine J, Emert J, Wang Z, Stuart L, King R, Segrest W, Moyer P, Jollis JG. Growth in percutaneous coronary intervention capacity relative to population and disease prevalence. J Am Heart Assoc. 2013; 2:e000370 doi: 10.1161/JAHA.113.000370.Google Scholar6 Concannon TW, Nelson J, Kent DM, Griffith JL. Evidence of systematic duplication by new percutaneous coronary intervention programs. Circ Cardiovasc Qual Outcomes. 2013; 6:400–408.Google Scholar7 Jollis JG, Granger CB, Henry TD, Antman EM, Berger PB, Moyer PH, Pratt FD, Rokos IC, Acuña AR, Roettig ML, Jacobs AK. Systems of care for ST‐segment‐elevation myocardial infarction: a report from the American Heart Association's Mission: Lifeline. Circ Cardiovasc Qual Outcomes. 2012; 5:423–428.Google Scholar8 Berwick DM. Launching accountable care organizations—the proposed rule for the Medicare Shared Savings Program. N Engl J Med. 2011; 364:e32.Google Scholar9 Porter ME. What is value in health care?N Engl J Med. 2010; 363:2477–2481.Google Scholar10 Rao SV, Ou FS, Wang TY, Roe MT, Brindis R, Rumsfeld JS, Peterson ED. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008; 1:379–386.Google Scholar11 Maynard C, Bradley SM, Bryson CL. The practice of transradial percutaneous coronary intervention in the Washington State Clinical Outcomes Assessment Program. Am Heart J. 2013; 165:332–337.Google Scholar12 Chan PS, Patel MR, Klein LW, Krone RJ, Dehmer GJ, Kennedy K, Nallamothu BK, Weaver WD, Masoudi FA, Rumsfeld JS, Brindis RG, Spertus JA. Appropriateness of percutaneous coronary intervention. JAMA. 2011; 306:53–61.Google Scholar13 Bradley SM, Maynard C, Bryson CL. Appropriateness of percutaneous coronary interventions in Washington State. Circ Cardiovasc Qual Outcomes. 2012; 5:445–453.Google Scholar14 Rothberg MB, Sivalingam SK, Ashraf J, Visintainer P, Joelson J, Kleppel R, Vallurupalli N, Schweiger MJ. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010; 153:307–313.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited ByShen Y, Krumholz H and Hsia R (2021) Association of Cardiac Care Regionalization With Access, Treatment, and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, Circulation: Cardiovascular Quality and Outcomes, 14:3, Online publication date: 1-Mar-2021. November 18, 2013Vol 2, Issue 6 Article InformationMetrics © 2013 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/JAHA.113.000552PMID: 24252846 Manuscript receivedOctober 30, 2013Manuscript acceptedNovember 1, 2013Originally publishedNovember 19, 2013 KeywordsEditorialspercutaneous transluminal coronary angioplastyPDF download SubjectsEthics and Policy" @default.
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