Rightsizing Invasive Cardiac Services in the United States

Despite the fact that the United States spends more per capita on health care than any other nation in the world,1 a significant proportion of Americans still lack access to high-quality, modern cardiovascular care. In fact, recent national data suggest that only approximately two thirds of Medicare patients presenting with ST-segment elevation myocardial infarction receive revascularization.2,3 These numbers are even lower in rural communities4,5 and are likely part of the reason why patients in rural areas have worse outcomes after experiencing an acute myocardial infarction than those in more urban areas.6Article see p 803In this light, there is an urgent need to ensure the adequate availability of high-value invasive cardiac services, particularly in rural or semirural areas of the country. With these important concerns as a starting point, Horwitz et al7 examined the introduction of diagnostic angiography, percutaneous coronary intervention, and coronary artery bypass grafting services in the United States between 1996 and 2008. The authors studied whether new offerings of these services were leading to an expansion of access to care in areas that were previously unserved or underserved.7 Simply put, were the new services being offered in the places that needed them most?Unfortunately, the investigators found that the majority of invasive cardiac service expansions took place in areas where access was already established. In fact, during that time period, only 10% of the patients served by the 397 hospitals that newly offered diagnostic angiography were in areas outside a 40-mile radius of an existing catheterization laboratory. The authors report that, despite a 6% to 8% increase in the number of hospitals providing services since 1996, the population increase in geographic access to diagnostic angiography was just 1%, the increase in access to percutaneous coronary intervention …