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Duke University Health System Aims for More Wake County, N.C., Heart Patients

Posted on: Friday, 30 September 2005, 00:00 CDT

By Jean P. Fisher, The News & Observer, Raleigh, N.C.

Sep. 30--The Duke University Health System is stepping up plans to win more Wake County heart patients, and that worries Raleigh cardiologists who fear the move could cut into their business while lowering the quality of patient care.

Duke plans to start performing angioplasties, stents and other invasive heart procedures at the former Raleigh Community Hospital, which Duke owns, by early next year. But a small number of such procedures result in patients needing emergency heart-bypass surgery -- and Duke can't do such surgery at the hospital. So if a patient went into cardiac arrest, he would likely be put in an ambulance and driven the 29 miles to Duke Hospital for surgery.

In a county with two heart programs that do have on-site heart surgery -- WakeMed and Rex Hospital -- many Raleigh cardiologists can see only one reason for Duke's plans: money. Cardiac care is among the most lucrative specialties in medicine and Wake County's strong population growth makes it a prime market.

"It's a purely financial decision," said Dr. J. Tift Mann, a cardiologist who practices with Wake Heart Associates in Raleigh. "Why else do you do it at a hospital without surgical backup when you have two very large hospitals that do have it two miles away?"

Doing angioplasties, stents and other heart catheterization procedures without an on-site heart surgery program goes against practice guidelines developed by the American College of Cardiology, a national professional organization.

Duke has performed invasive heart procedures successfully without on-site surgical backup at a hospital in Alamance County for years and can do them safely in Raleigh, said Dr. Jim Zidar, a Duke cardiologist who practices at Duke Health Raleigh Hospital, as Raleigh Community is now known. To minimize risk, Duke would not treat the elderly, people with weak hearts or patients with complicated blockages in the Raleigh hospital, he said.

Duke leaders say it makes clinical sense for the system to bring additional cardiac services to Wake County. Heart disease is the No. 1 killer of adults, and Duke operates one of the nation's top five heart programs -- expertise some Wake County patients may want to tap. A stronger heart program at Duke Health Raleigh lets them do that more easily, said Zidar.

"Some patients don't want to come all the way over to big Duke," he said.

Cardiologists opposed to Duke's plans acknowledge that they have a financial stake.

"Anybody can look at this issue and say these WakeMed and Rex doctors are biased," said Dr. Mark E. Leithe, a cardiologist with Raleigh Cardiology Associates.

"But there are some facts no one can argue with. This is not the accepted standard of care."

Duke is well aware of the American College of Cardiology's practice guidelines.

Dr. Pamela Douglas, Duke Hospital's chief of cardiology, is the president of the 33,000-member organization. And several members of the Duke clinical faculty help write the guidelines, which guide the standards of care across the nation.

But medicine evolves, said Zidar. He considers the practice guidelines on cardiac intervention "somewhat outdated." He's not alone. The practice of doing nonemergency heart procedures without an on-site heart surgery program is spreading. The subject is expected to be addressed in an update of the guidelines in November, said Anne Dees, of the American College of Cardiology.

Duke doesn't deny it wants more Wake County heart patients.

Since buying Raleigh Community in 1998, Duke leaders have said they will make cardiac care a signature service at the hospital. It opened a heart-catheterization lab in 2003 for diagnostic procedures.

Normally, Duke would have to seek approval from state hospital regulators before expanding its cardiology facilities. The state tracks demand for different types of care and determines both how many facilities are needed and where they can be built. The review process for new projects allows physicians or rival hospitals to weigh in for or against.

But in this case, Duke is partnering with MedCath, a company that already has the state's OK to open a new heart-catheterization lab, and there will be no public review. MedCath will supply the technology, equipment and staff; Duke cardiologists will perform the procedures.

Zidar is confident that the new program would not put patients in Wake County at undue risk -- so confident he says he would have an angioplasty or stent done at Duke Health Raleigh himself. He said Duke's experience at Alamance Regional Medical Center in Burlington shows that lack of an on-site heart surgery program need not compromise safety.

Since 1998, Duke has partnered with Alamance Regional to offer invasive cardiology procedures to low-risk patients. The program performed 562 nonemergency angioplasties, stents and other invasive procedures between February 1998 and October 2002.

Of those, four patients -- less than 1 percent of all cases -- required urgent transfer for emergency heart-bypass surgery at Duke Hospital. All four had successful surgeries, according to Duke. Nationally, between 1 percent and 2 percent of interventional cardiology procedures result in emergency surgery.

Duke is exploring the possibility of having one of Wake County's existing open-heart surgery programs provide surgical backup to Duke Health Raleigh's cardiology program. The most likely candidate would be Rex, where Duke Health Raleigh refers many patients who need angioplasties or stents.

If Duke can't arrange local surgical backup, it would handle emergency transfers similar to the way they are handled at Alamance Regional. Patients will be taken by ambulance to Duke Hospital for heart-bypass surgery.

Transports from Alamance, which is 34 miles away from Duke Hospital, have worked extremely well, said Dr. Peter Smith, a Duke heart surgeon who provides backup to Alamance Regional.

The hospitals carefully choreograph emergency transports to minimize delays. For example, in an emergency, Alamance calls ahead so Duke can prepare the operating room.

Zidar said Duke Health Raleigh will do all it can to ensure few emergency transports are needed. The hospital will perform procedures only on low-risk patients.

But things can go wrong, and Mann, the doctor with Wake Heart Associates, said patients should understand the difference between Duke's contingency plan and how emergencies are handled at a heart center with an on-site heart surgery program.

On average, it took 83 minutes to get patients in need of emergency heart surgery from Alamance Regional onto the operating room table at Duke. That's well within the 120-minute window that's considered optimal.

At WakeMed, it typically takes two to three minutes to get an emergency heart-bypass patient from the catheterization lab to the operating room table -- and it's never more than five minutes, said Betsy Gaskins-McClaine, executive director of the hospital's heart center.

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Source: The News & Observer

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