Having the latest high tech equipment is usually a good
thing in healthcare. But can too much of a good thing
harm patients? You wouldn't think so but this seems to
be true for cardiac intervention facilities, as a study
published online January 24 in the British Medical
Journal (BMJ) shows. Hospitals equipped with high-tech
tools such as a catheterisation laboratory have been repeatedly
shown to reduce the recurrence of ischemic events in patients
admitted to them. But, as the BMJ study reports, they
also see more of them die.
The study, headed by Dr Frans Van
de Werf of the University Hospital Gasthuisberg in Leuven,
Belgium, followed a multinational registry of patients
with acute coronary syndrome in 106 hospitals in 14
countries including Canada, the US, Australia, New Zealand,
Brazil, Argentina and several European countries. A
statistically robust 28,825 patients participated.
HIGH
TECH SICKENS THE HEART
For the purposes of analysis, patients were divided
between those who were initially admitted to a hospital
with cardiac catheterisation facilities, and those who
were admitted to a hospital without such equipment.
Of course the fact that advanced
cardiac facilities are available doesn't guarantee that
they will be used, but in practice, patients at the
specialist hospitals were far more likely to undergo
these invasive treatments. Forty-one percent of patients
at the high-tech facilities underwent percutaneous coronary
intervention, compared to just 4% of those at non-specialist
hospitals. For artery bypass graft, the figure was 7%
in the specialist units compared to less than 1% in
other hospitals. As the authors note, "in the real world
the choice of a management strategy is often governed
by the facilities available at the hospital."
Sure enough, the patients who had
access to the best equipment were fractionally less
likely to suffer infarction within six months —
but they were 14% more likely to die in the same period.
The main reason for the extra deaths was bleeding, which
was twice as likely in this group. The simplest explanation
for this trend is punctures from percutaneous invasive
procedures.
It may be that longer followup
would eventually reveal a longterm survival benefit
for these expensively treated patients, but the authors
consider it unlikely. "Frequent, and probably unselective,
performance of revascularisation procedures in these
patients is not beneficial," they conclude.
Canada, along with Australia and
New Zealand, had the lowest rate of admissions to hospitals
with catheterisation facilities in the study, at just
66% compared to an international average of 77%. All
three can take comfort in the conclusion of this study:
"a more restrictive selective use of invasive procedures,
as usually applied to patients first admitted to a community
hospital, is at least as effective as a more liberal
routine use."
BMJ
published online Jan 24, 2005
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