By Jean P. Fisher
The News & Observer
Copyright 2007 The News and Observer
WAKE COUNTY, N.C. — Working together to get heart attack patients to life-saving treatment faster seems like the kind of thing all medical providers could get behind.
But a plan among Wake County hospitals to join a statewide treatment effort has sparked a turf war in Johnston County, where the project is seen as a way for large hospitals to siphon away lucrative heart patients.
“It will make us into more of a Band-Aid station,” said Dr. Franklin C. Wefald, a cardiologist and clinical director of the medical intensive care unit at Johnston Memorial Hospital in Smithfield.
At issue is care for patients suffering the most deadly type of heart attacks, which occur when a clot blocks the flow of blood to the heart.
When such an attack strikes, the preferred approach is to open the patient’s artery with emergency angioplasty — a treatment in which a balloon-tipped catheter is threaded into the artery and inflated to clear the blockage. More than 20 years of medical research has established angioplasty as the treatment most likely to save a patient’s life, if performed within 90 minutes.
Another approach, which is about as good as angioplasty if done within 30 minutes, is to give clot-busting drugs. Too often, though, patients don’t get either treatment in time.
To change that, Duke University Medical Center heart specialists launched a statewide effort in 2005 to speed care. The project now includes about two-thirds of the state’s hospitals and is in the early stages of expanding to include the rest of them. It has resulted in patients getting both clot-busting drugs and angioplasty faster.
But a major emphasis is taking patients directly to angioplasty centers whenever possible.
That’s the sticking point for Johnston Memorial Hospital.
It doesn’t do angioplasty. And with Wake County’s 24-hour cardiac care hospitals — WakeMed and Rex — just a short ambulance ride away, the Smithfield hospital’s cardiologists and administrators figure their heart center will end up being cut out of the “improved” system. WakeMed’s new air ambulance, which took flight last month, could cut transport times even further.
Worse, Wefald and other Johnston County critics say, patients may be shipped out of the county despite a lack of evidence that doing so saves lives. They say the Duke-led efforts’ own data prove their point.
Patients treated under the streamlined system that Duke encourages were about as likely to die from their heart attack as patients treated before efforts to cut delays, according to results of the North Carolina project published last month in the Journal of the American Medical Association. The median time-to-treatment for transfer patients was outside the optimal window of 106 minutes, according to the JAMA study.
“The results I have seen are not promising,” said Kevin Rogols, Johnston Memorial’s chief executive.
Dr. James Jollis, a Duke cardiologist and co-director of the heart attack initiative, acknowledged that transfer times need improvement. But he said he is confident the effort will save lives, because it is helping more patients get treatment quickly. The percentage of patients treated with angioplasty within 90 minutes increased to 72 percent, up from 57 percent, according to the JAMA study.
It is “inappropriate” to suggest that rapid angioplasty, where available, is not the best treatment, Jollis said. He noted, however, that decisions about care, including when to transfer patients, are made locally, so Johnston County providers can’t be railroaded into an approach they disagree with.
Jollis also said the JAMA study was not designed to show a survival benefit, which would have required a much larger study with tens of thousands of patients. The JAMA paper looked at care received by about 1,100 patients.
Avoiding a road trip
Wefald and his medical partner, Dr. Eric Janis, don’t disagree that emergency angioplasty is best if patients live near a full-service heart center. Both doctors are partners in Wake Heart Associates, a large private cardiology practice that has physicians on staff at both Rex and WakeMed. But the Johnston doctors still don’t think sending heart attack patients bumping over country roads and down Interstate 40 to Raleigh is the right way to go — especially when they say they are routinely treating patients with clot-busting drugs in less than 30 minutes at Johnston Memorial.
Clot-busting drugs can’t be used in some patients, though, and the drugs fail to clear blockages about a quarter of the time, so most smaller hospitals must transfer patients to angioplasty centers. Johnston Memorial sends such patients to Wake County’s heart hospitals.
Betsy Gaskins-McClaine, director of WakeMed’s heart center, said the WakeMed system stands ready to work with any hospital that wants to make transfers faster and easier. But she said the system has no plans to march into neighboring counties to steal heart patients.
In fact, Gaskins-McClaine said, the WakeMed heart center frequently operates at or above 100 percent capacity, so it has an interest in seeing only those patients who really need its specialized care. Patients suffering the most dangerous type of heart attack, called ST-elevation myocardial infarction, fit that description, as long as they can be transported and treated quickly, she said.
“There’s situations where you can be there, and we feel like we want them to be there,” Gaskins-McClaine said.