The American Heart Hospital Journal
where residents and other health professionals train when the added value of patient care justifies its higher costs.”6
Interestingly, there is prior evidence that not only do community physicians see a similar case mix to non-community academic physicians,21
but they also treat
an older patient population and request 50% fewer consultations than non-community physicians.22
Our data
presented here reveal an older patient population (with higher creatinines and similar ejection fractions) and lower rates of complications compared with non-community hospitals. It is duly noted that many facets of chronic care reimbursement are suboptimal and beyond the scope of this report. That said, in an era of increasing cost containment and ‘pay-for-performance,’ more attention needs to be paid to center-dependent outcomes rather than generalization based on historical assumptions.
Our data indicate that a small, non-academic community hospital can provide high-quality and more accessible healthcare to an elderly, ill population.
In addition, recent data suggest that ICDs continue to be underutilized (despite their class I indication after cardiac arrest) with a large discrepancy in utilization by the size of the discharge hospital, which may suggest regional influences and gaps in resource allocations to community hospitals.23
match their definition of major complications, our center had major complications in 1.0% of de novo defibrillator implantations (a 76% relative reduction in major complications). The cost of major complications among Medicare beneficiaries receiving implantable defibrillators was examined in 30,984 patients.25
They found that 10.8%
of patients experienced one or more complications resulting in an increase in length of stay by 3.4 days and costs by $7,251. Superiorly performing ‘niche’ hospitals that reduce major complication rates from defibrillator implants by 76% in the US (conservative estimate of 100,000 yearly implants) could realize an estimated $60 million in cost savings while improving patient safety.
Possible Role of ‘Niche’ Hospitals. Specialty hospitals are under increasing scrutiny, but there may be a role for ‘niche’ hospitals that, while offering the full spectrum of general hospital care, can provide certain procedures at an exceptional level of quality and cost-effectiveness. Recent literature continues to document the paucity of data available on rates and predictors of ICD implantation in routine clinical practice.24,25
The Ontario ICD Database24
revealed major complications related to de novo defibrillator implantations in 4.1% of procedures. Adjusting our data to
Summer 2010
Limitations. This report has a limited sample size, and it may be biased toward higher complication rates because it included the first 250 consecutive device implants from inception of the program. One could argue that the patient population was pre-selected to favor uncomplicated patients. No patients were referred to outside hospitals for device implantation and the demographics of patients in this report indicate older patients with similar ejection fractions and higher creatinines (when available for comparison) than patients included in PASE, MADIT-CRT, and COMPANION. Also, there is no generally accepted definition for an academic hospital, thus a non- community hospital was defined as one that has a medical school, at least one other health professions school or program, and an affiliated teaching hospital. In addition, many studies were not single-center, none was single-
Device Implant Complications in a Community Hospital 37
The outcomes data we present here support the quality and improved access to care that a clinical cardiac EP program provides this community hospital. Current reimbursement schemes favor academic over community centers without regard to outcomes; a nationally recognized academic center in Pennsylvania receives ~39% higher (p=0.019) Medicare reimbursement for an acute myocardial infarction despite 95% of our patients receiving percutaneous coronary intervention (PCI) within 90 minutes of arrival (compared with the academic center’s rate of 81%), with no difference in 30-day mortality.18 Non-community centers have higher care delivery costs than community hospitals due to differences in the intensity with which similar patients are treated rather than the quality of care or graduate medical education per se.19,20
Special Report
Figure 3: Baseline Characteristics and Complications of Patients Undergoing Bi-ventricular Defibrillator Implantation
5 6 7 8 9
3 4
2.2
2 1 0
1.4 1.2 Cr (mg/dl)
0.24 0.24 0.22 EF
0 Major complications (%) Minor complications (%)
Community center (age 74±9 years) MADIT-CRT (age 65±11 years) COMPANION (age 66 years)
A total of 64 patients underwent bi-ventricular defibrillator implantation. Complications at our center (a community center) were compared with those from national trials (MADIT-CRT,12
COMPANION13 reported for the COMPANION Trial. EF = ejection fraction. 3.4 3.1 8.4 6.4
). Creatinine (Cr) was not
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