Money is a pervasive presence in arguments over angioplasties

A push toward allowing more Maryland hospitals to perform a profitable heart procedure triggered fierce arguments yesterday, with cardiologists and lawyers arguing over whether patient care would be helped or endangered.

But bubbling below the surface - and at times breaking through - was a tussle over the millions of dollars in revenue that these procedures generate for hospitals.


"We have been trying for more than 15 years to break into this club," Kenneth H. Bancroft, chief executive officer of St. Agnes HealthCare, told the Maryland Health Care Commission at a public hearing.

He said high-end heart services overall were a half-billion-dollar-a-year business in Maryland and the District of Columbia, and in part because of the opposition from hospitals already doing heart surgery, "we have been unable to break into that business."


At issue are state rules governing which hospitals can perform angioplasty, a heart repair technique in which a tube is inserted into a blood vessel, a tiny balloon is inflated to clear a blockage, and a minuscule metal scaffolding, called a stent, is positioned to keep the blood vessels open.

In an effort to control cost and quality, Maryland regulators allow open-heart surgery in only a few hospitals.

Currently, except for emergency treatment for patients having a heart attack, angioplasties can be done only in the hospitals that can also perform heart surgery.

If a problem develops during the angioplasty, such as a blood vessel tearing, the patient can then be rushed into surgery.

The requirement for surgical backup, however, means that almost all of the angioplasties in the state are done in just nine of the state's 47 hospitals. Each angioplasty can generate $5,000 in profit, according to one hospital source.

About 11,500 procedures were performed in Maryland in 2002, generating $130 million in hospital bills.

The commission is expected to vote next month on a set of rules that would allow it to review and, potentially, approve trials of nonemergency angioplasties in hospitals without on-site surgical backup.

Opponents brought in a cardiologist from New Hampshire and an ethicist from Colorado who testified that a study of expanded angioplasty could endanger patients.


Dr. David J. Malenka, a cardiologist at Dartmouth Medical School, said he had reviewed national Medicare data covering nearly 350,000 nonemergency angioplasties.

At hospitals without on-site surgical backup, he said, the patient died within 30 days 7.7 percent of the time - nearly triple the 2.8 percent mortality rate for angioplasties at hospitals that do heart surgery.

Dr. Luis Mispireta, chief of cardiac surgery at Union Memorial Hospital in Baltimore, said that of the 1,960 angioplasties done in his hospital last year, nine resulted in complications that led to emergency surgery.

Because Union Memorial can do that surgery, he said, the patients were able to get to the operating room in an average of less than 30 minutes - and all nine survived.

Moreover, the risks of a clinical study are not balanced by any potential benefit for patients, other than convenience, argued Barry F. Rosen, an attorney representing the parent corporations of three Baltimore-area hospitals that do heart surgery, Sinai, Union Memorial and St. Joseph.

But Dr. Dennis C. Friedman, a cardiologist at Shady Grove Adventist Hospital in Rockville, said other studies have shown that performing angioplasty without on-site cardiac surgery does not pose additional risk for patients.


It is normal, Friedman testified, for advanced procedures to be done first in academic medical centers, then move to community hospitals as they become more routine.

"All our communities deserve access to the best of care," he said.

The proposed rules that could permit a study were developed by an expert advisory committee, and would assure that any proposed study be reviewed for safety, said Donna L. Jacobs, senior vice president for government and regulatory affairs at University of Maryland Medical System.

The result, she said, was a process that was "smart, sound, thorough and scientific."