Calls to regionalize the care of patients with heart attacks are premature

Mar 21 2005

Calls to regionalize the care of patients with heart attacks are premature, and do not account for potential unintended consequences, according to a commentary by Yale researchers published in the Journal of the American Medical Association (JAMA).

"Much of the enthusiasm for the regionalization of heart attack care has focused on what its upsides may be, without adequately considering how realistic some of these benefits are or the potential negative implications of such a policy, " notes Harlan M. Krumholz, M.D., professor of internal medicine (cardiology) and Epidemiology and Public Health (Health Policy and Administration).

Calls for the regionalization of acute coronary syndromes (heart attacks as they are more commonly called) are based on recently published studies conducted predominantly in Europe that suggest that transferring patients from smaller hospitals to larger hospitals so they might receive interventional therapies could reduce mortality, Krumholz writes. "The health care system in the United States is clearly not the same as Europe," Krumholz notes. "Patients are farther from hospitals and our EMS doesn't have experience recognizing the specific group of patients who will benefit from these treatments. It only seems reasonable that we should test for ourselves in the United States whether such a system works before we adopt it."

Saif Rathore, the study's first author and a second-year medical student at the Yale School of Medicine, is also concerned about the feasibility of regionalization. "Proponents often compare regionalization of acute coronary syndrome care to trauma, because trauma care is regionalized," Rathore said. "That's an unfair comparison. Any four-year-old can recognize trauma. Recognizing acute coronary syndromes care is much more complicated. There's an impression that real-life heart attacks are like those portrayed on television, where patients clutch their chests and fall to the floor. That's not the case. Proof of this can be found in national studies that indicate more than 80 percent of patients who arrive at a hospital with chest pain symptoms aren't experiencing a heart attack."

Andrew Epstein, assistant professor of Public Health (Health Policy and Administration) believes the adoption of such a system may require a large-scale reorganization of U.S. health care. "Assuming that regionalizing care could be done with perfect clinical accuracy, we estimate that you would need to transfer more than 500,000 Americans from the hospitals at which they are currently treated so that they could have access to interventional treatments like cardiac catheterization and bypass surgery," Epstein said. "That's a huge number and its feasibility is debatable." Epstein also commented on the possible downsides from a regionalization policy, including financial difficulties for hospitals that no longer treat patients with heart attacks and increased costs resulting from a reduction in hospital competition in the cardiovascular procedure market.

Authors include Rathore, Epstein and Krumholz at Yale and Kevin G. M. Volpp, M.D., assistant professor of medicine at the University of Pennsylvania and Staff Physician at the Philadelphia Veterans' Affairs Center for Health Equities Research and Promotion.