Thursday, July 7, 2005

Do We Need More Heart Surgeons?
By Brandon Hines

We simply don't have enough surgeons available in every small, rural hospital in the country. They would be twiddling their thumbs idly, though, if we did. Some medical treatments don't need on-site surgical backup, despite guidelines saying otherwise. To maximize treatment and cost efficiency, doctors are trying to find out if percutaneous coronary intervention (PCI) can be successfully performed outside hospitals with surgical facilities.

These days, PCI is being performed in limited numbers on patients with coronary artery disease in community hospitals, where there is no surgical backup. PCI (e.g., angioplasty) involves the insertion of a balloon, stent, or some other object into a coronary artery to fix blockage. However, complications could and do arise from this invasive process. Thus, doctors debate about how safely and legitimately PCI can be done as a routine practice without the assurance of on-site surgeons.

If complications were to occur during PCI, the patients would need to be transported to a hospital that has on-site surgical facilities. This emergency transport, which may last more than an hour, may unnecessarily put the patient at risk.

Some studies have shown that any surgical delays after a failed PCI attempt put patients at serious risk of harm or death. In November of 2003, the DCRI's Dr. Matt Lotfi and his colleagues presented this case to the 76th Annual Scientific Session of the American Heart Association (AHA).

The Duke University News and Communications Office quoted Dr. Lotfi: "The results of our analysis show the unpredictability of the need for emergency surgery and demonstrate that certain patients will undoubtedly be put at increased risk without the immediate availability of cardiac surgery."

So, the question arises: Is it a gamble to perform PCI without on-site surgical backup? A recent study published in The American Journal of Cardiology suggests not. Researchers from Alamance Regional Medical Center, Duke University Medical Center, and the DCRI participated in this joint study led by Dr.Alexander Paraschos. The investigators' data, collected from 1998 to 2002, showed evidence of PCI being safe and practical with off-site surgical backup, under some important conditions.

The authors emphasize that PCI should be elective, meaning the patients should volunteer for the procedure. In other words, PCI with off-site surgical backup should not be performed for emergency cases where the patients have serious symptoms. Thus, the patients must willingly agree to the procedure.

Furthermore, the investigators stress that PCI should be performed without surgical backup only if the patients are at low risk of heart complications. When finding eligible patients, the doctors used selective exclusion criteria; only those patients judged healthy enough were selected. In addition, a well-established transfer plan should be available to get the patient to an on-site surgical hospital of close proximity.

In their study, elective PCI was done at Alamance Regional Medical Center. Duke University Medical Center, 34 miles down the road, provided the surgical backup.

With such a selective process in use, the research results were positive. In those 4 years, a very small percentage of patients had to be rushed to the off-site surgical facility. Most of these patients, moreover, had successful surgery without any further complications.

The main criticism to establishing off-site surgical PCI programs is that there are already plenty of open-heart surgical programs in the U.S. to perform PCI for any patient. Yet, many of these programs are "small-volume", meaning they treat a limited number of patients. Thus, the operating staff members have little routine experience. The authors explained, "Studies have associated worse patient outcomes with small-volume open-heart programs versus institutions that perform greater volumes of surgical procedures."

So, the question is not so much asking if we have enough surgeons, but if we should spread them out across the country into small, unproductive programs, when elective PCI can, in fact, be carried on successfully without them.

A major motive for the study was based on shared feelings that AHA guidelines are unnecessarily enforcing on-site surgical programs. "The impetus to establish a proportion of these programs may have been to legitimize an interventional program rather than to serve actual patient demand," stated the authors.

Dr. Lotfi would agree with this notion. He said at the AHA session, "It is clear from recent studies that selected patients can have an angioplasty in a high-volume center without on-site surgery with acceptable risk." He continued, "However, concern arises when the data from larger and more experienced centers is used to determine risk when in fact many of the centers interested in starting their own programs are low-volume with less experienced operators."

The researchers understand this concern; that is why they chose Alamance Regional Medical Center, a small-volume center, to test their elective PCI success.

Based on their positive results, the authors have proposed an elective PCI program for small community hospitals with off-site surgical backup, on the condition they adhere to strict criteria when selecting appropriate patients for the procedure.

Therefore, the authors suggest that we can save our health care resources by avoiding unnecessary on-site surgical backup in every hospital where elective PCI is performed.

Members of this study team include Alamance Regional Medical Center's Dr. Alexander Paraschos, Dr. Dwayne Callwood, and Ms. Marilyn Wightman, the DCRI's Dr. James E. Tcheng and Mr. John Daniel, and Duke University Medical Center's Dr. Harry Phillips, Dr. Gary Stiles, and Dr. Michael Sketch, Jr.