University of Iowa News
April 7, 2005
UI Study Compares Specialty Cardiac Hospitals and General Hospitals
Specialty hospitals, which solely focus on lucrative areas of medical care such as cardiology or orthopaedics, have generated controversy. This controversy led Congress to establish a temporary moratorium in 2003 on the establishment of new specialty hospitals. However, there has been limited information on the quality of care delivered by these hospitals.
A University of Iowa and Department of Veterans Affairs (VA) study published in the April 7 issue of the New England Journal of Medicine adds new information to this ongoing debate. The study shows that, for angioplasty and heart bypass surgery, specialty cardiac hospitals admit healthier patients and perform more of these two procedures each year, on average, than general hospitals do.
The study showed that patients who underwent angioplasty or heart bypass surgery at specialty cardiac hospitals were less likely to die than patients treated at general hospitals. However, after accounting for the fact that specialty hospitals admitted healthier patients and performed greater numbers of procedures, the researchers found that mortality rates were statistically similar in specialty and general hospitals.
"This is the first study to systematically examine outcomes for patients who receive these procedures at specialty cardiac hospitals," said Peter Cram, M.D., the study's lead author and assistant professor of internal medicine in the UI Roy J. and Lucille A. Carver College of Medicine. "Our study suggests that, on average, specialty hospitals do as good a job as general hospitals, but we found no evidence that they are markedly better or worse."
The investigation focused on records of Medicare beneficiaries, individuals age 65 and older, who received either angioplasty (42,737 cases) or coronary bypass surgery (26,274 cases) in 2000 and 2001. The patients received treatment at either one of 15 cardiac specialty hospitals or one of 80 general hospitals in the same markets as the specialty hospitals.
Patients undergoing angioplasty (use of a balloon catheter to clear a blocked artery) at specialty hospitals were 10 percent less likely to die than patients undergoing the same procedure at general hospitals. However, the difference was not statistically significant when patients' overall health was taken into consideration.
Similarly, while patients undergoing bypass surgery in the specialty hospitals were about 15 percent less likely to die than patients at general hospitals, that finding also did not represent a statistically significant difference, the researchers said.
The study also showed that specialty cardiac hospitals tend to admit patients of a higher socio-economic status.
"This finding, along with the finding that healthier patients tend to be treated at these specialty hospitals, is important because of the contention by some in the health care profession that specialty hospitals target healthier and wealthier patients in an effort to optimize profit margins," said the paper's co-author Gary Rosenthal, M.D., UI professor of internal medicine and director of the UI Division of General Internal Medicine. Rosenthal also is a staff physician and researcher with the VA Iowa City Health Care System and directs the Center for Research in the Implementation of Innovative Strategies in Practice.
Specialty hospitals as a concept are not new. Many of the most prestigious hospitals in the country originally were founded to serve particular patient populations, such as women's or children's hospitals. However, newer specialty hospitals focus on lucrative disease groups and procedures, such as cardiac or orthopaedic care, rather than patient populations, Cram said.
In addition, the researchers found that newer specialty hospitals are much more likely to be for-profit than general hospitals -- 80 percent of specialty hospitals are for profit whereas only 20 percent of general hospitals are for profit.
"Some experts in health policy promoted specialization as a way to improve outcomes. Originally there were ideas to concentrate high-risk procedures such as heart surgery in specific hospitals in major cities and create regional centers of excellence," Cram said. "However, this largely has not happened for a variety of reasons, despite the potential benefits of regionalizing care. The emergence of specialty hospitals may represent the emergence of this long-awaited regionalization, albeit, with some unforeseen twists."
Rosenthal elaborated on the market and policy implications. "General hospitals are concerned that cardiac care may migrate from their centers to specialty hospitals, causing general hospitals to lose revenue and leaving them with only the sickest patients to treat," he said.
He added that some people also are concerned about physician-ownership of specialty care hospitals.
The Stark Law, named after its House of Representatives sponsor, Pete Stark (D-Calif.), prohibits physicians from referring patients to facilities they or family members have a financial interest in except when the facility is a whole hospital. However, specialty hospitals are exempt from this law, although the hospitals are not comprehensive like general hospitals. (An overview of physician-owned specialty hospitals, authored by John Iglehart, appears in the Jan. 6, 2005, issue of the New England Journal of Medicine.)
Most specialty hospitals are located in urban areas in seven states: Arizona, California, Kansas, Louisiana, Oklahoma, South Dakota and Texas. No specialty hospitals are located in Iowa.
The UI authors said that because their own study was limited to analysis of length of stay and mortality, it is possible that specialty cardiac hospitals do better in other respects, compared to general hospitals.
"There may be other endpoints that are important to patients that we did not measure, such as patient satisfaction or health-related quality of life one or more years after treatment," Rosenthal said.
In addition to Cram and Rosenthal, the UI team included Mary Vaughan-Sarrazin, Ph.D., a research scientist with the VA Iowa City Health Care System.
The study was supported in part by a grant from the Health Services Research and Development Service of the Veterans Health Administration. Rosenthal is a senior quality scholar with the Veterans Health Administration.
University of Iowa Health Care describes the partnership between the UI Roy J. and Lucille A. Carver College of Medicine and UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide. Visit UI Health Care online at www.uihealthcare.com.
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