Cardiac care plan sparks turf war

Smaller hospitals could lose patients

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.