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Hospital executives and physicians around the state are backing proposed legislation that would permit them to perform elective angioplasties without onsite cardiac surgery backup. The bills – Senate Bill 515 and Assembly Bill 1176 – have been reintroduced after similar measures died at the end of the most recent lame duck session.

Angioplasty, also known as percutaneous coronary intervention or PCI, is a treatment under which interventional cardiologists open narrowed or blocked vessels that supply blood to the heart. Once the blockage is opened, a small metal mesh tube called a stent is often placed in a vessel to maintain the blood flow and reduce the chance of another narrowing. The procedure can be life-saving when performed on a heart attack victim.

New Jersey remains the only state in the nation in which only hospitals that have backup cardiac surgery capabilities can perform the procedure on an elective basis. According to the state Department of Health, 18 hospitals in the state are licensed to preform open-heart surgery while 32 are authorized to perform elective PCI and 45 can do primary PCI.

Opponents of the bills contend that restricting the elective procedure to facilities that have the backup surgery is necessary in the event of an adverse event; for example, if a patient needs bypass surgery.

Supporters cite numerous national studies finding that conducting elective angioplasties at facilities without cardiac surgery is safe and common.

Dr. Lyndon Box, government relations committee chair for the Society for Cardiovascular Angiography and Interventions (SCAI), told NJBIZ that the society is in favor of New Jersey’s legislation.

“It is an issue of access to care. It is important that patients have access in their own community whenever possible to cardiac care,” Box said.

He added that this access is especially important for the more disadvantaged communities because they have less resources to travel. “It is more difficult for them to go 30 miles to 40 miles away to a major center. There is a lot of data and research that shows that it is safe.”

‘Old thinking’

Box acknowledged a perception exists that without all of the safety nets in place, hospitals should not be doing the procedure. “That is really old thinking. The procedure has been refined to the point where the complications rates are very low and the complications that would require a person to have emergency bypass surgery is one in a thousand.”

Last year the Centers for Medicare & Medicaid Services proposed changes to support the addition of percutaneous coronary angioplasty and coronary stenting in ambulatory surgical centers in 2020.

While stent procedures can be lucrative for hospitals – resulting in national average payments of between $12,000 and $20,000, according to CMS – both hospital administrators and cardiologists insist allowing elective procedures to be performed in New Jersey hospitals would benefit patients.

“What’s most important is that we can do it safely in our hospital. Economically you can make that case probably for most procedures, most tests, as in any business if you can do more of them you can create more efficiency along the way and should and could be profitable. But the first driver is always going to be putting the patient first,” said Brian Finestein, chief executive officer of Saint Clare’s Health.

“We have the technology, the skill, the science behind being able to do these procedures in our facility,” Finestein said.

“We can do the STEMI [a type of heart attack] which are the sickest of the sick, however the ones who are elective—the logic doesn’t make sense to me that we shouldn’t be able to do them given that the outcomes support that they can be done in a facility without cardiac surgery backup,” said Finestein.

Finestein said he believes that health care is local and patients want to be taken care of in the facility nearest to where they live.

“We could offer that to a great many of our population in Morris County, Sussex and Warren.”

Dr. Paul DeRenzi, director of the Cardiac Catheterization Lab at Saint Clare’s said, “[i]f a stent procedure has to be stopped to transfer a patient to a tertiary facility with cardiac backup surgery due to our outdated laws, it can involve delays and result in potential further medical developments that may be detrimental to the patient while they are waiting for the intervention at the other facility.

“There can be possible complications in re-establishing the access to the artery once the patient has been transferred to another facility, plus another round of sedation and anesthesia. Additionally, there would be the costs involved for transfer/transport, extra medications, etc. that could all be avoided if the intervention were performed at the initial hospital” said DeRenzi.

Patrick Gavin, CEO of Hunterdon Healthcare System, said the difficulty with current angioplasty regulations is that the affected programs must carry the cost of a full program, including equipment and staff available 24/7.

“This enables the ability to perform emergency angioplasty on patients within 30 minutes of their arrival at our emergency departments. We are now requesting the ability to perform non-emergent angioplasty in our hospitals. That change will enable all programs to be viable for each of their communities well into the future,” Gavin said.

“The time is now for our political leaders to join the other 49 states and adopt this legislation,” he added.

‘It is mind-boggling’

Dr. Harit Desai, medical director of the Cardiac Catheterization Laboratory at Capital Health, said transferring a patient to another facility is a logistical nightmare.

“Arranging for transport, between the two hospitals, the financial burden on the patient. They could have gone home in 24 hours. It is mind-boggling in this day and age that we are among the last few states in the country to not allow this,” said Harit.

“We have the full facility to do the work, we have the data from years of studies that says it is reasonable to do that work – but because of the legislation we have to send that patient out,” said Dr. Kristopher Young, medical director of the Cardiac Rehabilitation Center, located at Capital Health Medical Center-Hopewell.

If a stent procedure has to be stopped to transfer a patient to a tertiary facility with cardiac backup surgery due to our outdated laws, it can involve delays and result in potential further medical developments that may be detrimental to the patient while they are waiting for the intervention at the other facility.
– Dr. Paul DeRenzi.

Other supporters assert that there is solid evidence that angioplasty is safe when performed at a facility without cardiac backup surgery.

The Accreditation of Cardiovascular Excellence — an accrediting organization that provides services in the cardiovascular care arena — commended the commitment of the New Jersey Legislature in ensuring all patients, current and future, have access to the highest level of health care.

“It is vitally important for cardiovascular care to be carefully scrutinized, as heart disease is the number one killer in the United States,” the organization said in a statement. “It is important to recognize, however, that volume alone is not an indicator of high quality care and should not be an automatic trigger to license or NOT to license.”

For some hospitals, the ability to perform elective angioplasties can be serious business.

Al Maghazehe, president and CEO of Capital Health, noted that his facility is in a competitive environment and its competition is not limited to New Jersey but includes Pennsylvania where South Jersey patients often go to seek medical care.

“It’s unacceptable that hospitals like Capital Health can’t do this when the entire country is doing this.”