More evidence is starting to emerge that the overall volume of cardiovascular procedures in US hospitals is in decline. The trend should come as no surprise to those who have been following news about cardiovascular medicine in recent years, as the field has been repeatedly struck by debate, scandal and controversy related to the potential overuse of expensive and invasive therapies.
A monthly report from Wells Fargo that tracks hospital volume found a 9.37% drop in inpatient cardiovascular surgeries and procedures in July 2011 compared to July 2010. This continues a trend of similar monthly declines in the range of 6%-11% each month this year compared to 2010. The trend is partially offset by a modest increase in some months in outpatient procedures, though in July cardiovascular outpatient procedures also decreased by 6.28%.
The broad trend observed by Wells Fargo is confirmed by HCA, the large hospital company. In its quarterly financial report HCA said that overall demand for its cardiovascular services has been declining by approximately 3% each year for several years, despite a slight growth in the hospital chain’s share of the overall market. Samuel Hazen, the president of HCA, said the decline “appears to be consistent with information from cardiac medical device companies’ public reports.”
In its quarterly report the company included an analysis of a decline in Medicare revenue growth that it attributed to a significant shift from surgical to medical cardiovascular procedures. HCA disclosed that, compared to the same period a year ago, in the second quarter of this year it performed 769 fewer inpatient EP, interventional, cardiothoracic surgery, valve, and vascular surgeries and procedures. By contrast, in the same period it performed 540 more medical procedures. (You can download the HCA slides here, then click on the link to the HCA Second Quarter 2011 Review Presentation Slides.)
I would speculate that a number of major factors play a role in this trend, including:
- Concerns about stent overuse– as indicated most notably in the Mark Midei case, but alsoin more sober academic studies (such as this one) that have served to at least slow down the previous headlong rush to stent implantation. The COURAGE trial undoubtedly has played a key role here, though its immediate effect appeared to be fairly small.
- The DOJ investigation into ICD implants— although few details about this are known, this has undoubtedly had a broad dampening effect on ICD implantation.
- The payoff from preventive therapies like statins, aspirin, and antihypertensive therapy.
- The larger economic climate.