In the traditional model of care, cardiovascular and thoracic surgery is offered at large, tertiary facilities in cities like Nashville, Memphis or Knoxville. Through clinics established by the larger facilities, or through partnerships with local primary care physicians, cardiologists refer patients back to larger hospitals. Local hospitals provide emergency care—and often administer drugs to slow down the progression of the heart attack—until patients can be transported to a larger facility with a cardiovascular surgery program. An emerging model of care gives rural patients the option to stay closer to home. Increasingly, community hospitals offer full-service heart programs, which include invasive procedures once available only in larger cities.

“Before we did much heart care, everything we did, we essentially referred to Nashville,” says Charles Ball, M.D., medical director at Maury Regional Hospital in Columbia, which began offering open heart surgery just over a year ago. “About three years ago, we realized just by good evidence-based medicine that better care for patients having a heart attack is not to use clot-busting drugs called thrombolytics, but instead take them right to the cath lab and open that artery up.”

Establishing a heart care center that offers open heart surgery is no easy operation. Hospitals must prove they have the critical mass—or case volume—to sustain the costly human and technological resources required for quality care. In Tennessee, that means submitting to the certificate of need (CON) process through the state’s Health Services and Development Agency.

Since 2002, six hospitals have sought certificates of need to offer open heart surgery. Just two were granted: Maury Regional and Gateway Medical Center in Cookeville. Gateway does not currently offer open heart because its cardiovascular surgeon left the hospital, but a spokeswoman says the hospital plans to re-establish its open heart program.

In the CON process, community hospitals often meet substantial resistance from larger, tertiary care hospitals in metropolitan areas. Dr. Joseph Fredi is an interventional cardiologist at Saint Thomas Hospital in Nashville. He says that while “there may be a role for those procedures to be done locally, the caveat is the volume of cases and the outcomes of those cases.”

“We know the more volume an institution does, at least when it comes to cardiac procedures—pacemakers, defibrillators, what- ever it is—the higher the volume, the better the outcome,” Fredi says. “There are studies of heart surgery that suggest if a center is doing three or four hundred a year, the results get better. Saint Thomas does between 1,500 and 2,000 per year.”

Jean Chenoweth is a senior vice president at Solucient, a health care research firm. She oversees the Top 100 Hospitals program, which in 2004 included three Tennessee hospitals in its list of top heart hospitals: Johnson City Medical Center in Kingsport, The University of Tennessee Medical Center in Knoxville and Fort Sanders Parkwest Medical Center in Knoxville.

Chenoweth says there is something to be said for volume, but “volume does not tell you everything. As a new program starts up, if the training has been good, then the outcome will be. It makes a certain amount of common sense that as you do more and more of a certain kind of task, you get better at it. But at a certain point, that levels out and volume is less a factor.”

Jim Ainsworth, vice president of operations for Baptist Memorial Health Care in Memphis, suggests 200 to 300 open heart surgeries are enough to maintain competency among the surgical team. Baptist Memphis offers a unique combination of the two models in open heart surgery for rural patients. It has both a large tertiary facility and smaller, community hospitals that provide invasive cardiac procedures. At the system’s flagship—Baptist Memorial Hospital—surgeons perform about 1,500 a year. Between 250 and 300 invasive cardiac procedures were performed last year in hospitals owned by Baptist in the Mississippi cities of Columbus, Oxford and Southaven. Like Tennessee, Mississippi has a CON process.

In addition to clinical concerns related to volume, Ainsworth says there are financial considerations.‘There is a general rule that will apply here,” Ainsworth says. “Where you have volume, you are able to create efficiencies. You have staff requirements whether you do 10 surgeries a month or 100 a month. You can do it more efficiently if you do 1,000 cases a year. That’s just economies of scale.”

Fredi says he and other physicians at larger tertiary facilities have another frustration related to community hospitals offering invasive heart procedures—one that has both financial and clinical implications.

“We have certainly observed this phenomenon that we call cherry-picking. We take all patients because they’re like anything else in life. They come in different levels of complexity,” Fredi says. “It seems some of the community hospitals deal with the easier cases and send the more complex ones away. The argument is that the others are sent to the larger facilities.

“We try not to think that it’s purely financial. But if you’re opening up a local hospital so people don’t have to travel so far, why only treat the ones that don’t take up as many resources?” Fredi asks. “Is it because you don’t want to expend your resources, or is it because you don’t feel comfortable treating them?”

Fredi says the physician doesn’t necessarily get reimbursed any less for a less complicated procedure versus a more complicated procedure.

“There’s more than financial, of course,” Fredi says. “There’s the satisfaction of treating patients. I hope that’s why we’re all physicians. I think if an oncologist just dealt with pancreatic cancer day in and day out, which has a lower rate of cure, it may affect his degree of professional satisfaction.”

The Heart Center at Cookeville Regional Medical Center started its heart program in 1994, and performed its first open heart surgery in 1998. In 2004, the hospital performed more than 300 open heart surgeries.

The director of Cookeville’s program, Martin Coffey, says the cherry-picking phenomenon Fredi refers to “potentially can, and does happen, in centers that are interested only in the financial outcome.”

“We do not cherry- pick,” Coffey says. “We use what is called the Society of Thoracic Surgery database. One of the things it shows is that we do some of the highest risk patients around. In fact, much less than 1% of our patients are ever transferred out. The key in a full-service center is to do everything. You use these data banks to see what you’re doing right and what you’re doing wrong. It’s a continual monitor of quality.”

Coffey says he came to Cookeville from a larger institution, so he understands Fredi’s point well, particularly because there are more cardiac care programs with catheterization labs in community hospitals, but still relatively few with heart surgery programs.

“If you look at Middle Tennessee alone, it’s hard to find a city that doesn’t have a cardiac cath lab. People who opened up cath labs are giving us very sick people,” Coffey says. “Bigger institutions are now getting those people who would normally die in transport. It could easily feel like selective transport. Referrals are going to be sicker. These are people you never saw before.”

Somewhere between the smaller programs like Maury Regional, which performed 150 open heart procedures last year, and Saint Thomas, there are programs like Erlanger Health System in Chattanooga and Johnson City Medical Center.

Johnson City Medical Center, part of the Mountain States Health Alliance, has 17 staff cardiologists and performed approximately 800 open heart surgeries last year. Cindy Salyer, vice president of cardiovascular and pulmonary services for Mountain States, says the business model they follow is one of collaboration and support with local hospitals in outlying areas.

“We actually have patients from about 90 miles in every direction from the Tri-Cities. We work with affiliate hospitals to reach them. Some are part of Mountain States, but others aren’t,” Salyer says. “If they have a service that’s already in place and they’re doing that, we don’t want to take that away. We want patients to stay in their hometown as much as possible.”

In Chattanooga, Erlanger performed about 450 open heart procedures last year. Wanda Perry, administrator of the heart and vascular center at Erlanger, says 44% of those patients came from outside of Hamilton County.

“We definitely value the role of referral hospitals and rural patients, for economies of scale and to be more efficient,” Perry says.

Solucient’s Chenoweth says the gap is narrow between community hospitals and larger research and teaching facilities. According to numbers gathered in Solucient’s research, the difference between hospitals is rarely more than a couple of thousand dollars for coronary artery bypass surgery. The cost of the procedure starts at around $10,000 and goes up to about $13,000. Chenoweth says hospitals with a cardiovascular residency “where they’re probably using the latest and greatest” have a little higher cost.

“The differences between some of these hospitals may be [the survival of] only one or two patients. Not to minimalize that one or two patients, but it’s much different than trying to compare mortality rates for cancer patients,” Chenoweth says. “This is an area of care that has continued to improve and improve and improve. Good care is being provided across the board and improving across the board.”

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