Long wait for angiography increases patient risk
No catheterization boom for working poor
Delaying angiography puts patients at higher risk of suffering cardiac events, needing longer hospital stays and even ending up with worse outcomes, according to researchers reporting in the July 14 issue of the Journal of the Ameri-can Medical Association.
The study found caregivers should avoid delays longer than two weeks. Patients found to have a strongly positive stress test or who need two or three medications to treat ischemia should be made the first priority in the group.
The concept of patients having to wait for angiography may draw its share of question marks from caregivers, who, according to the American Heart Association in Dallas, have seen the number of catheterizations increase 315% from 1979 to 1996. At first glance, it seems that everyone who needs a procedure can get one.
"This is a little bit different," says Marschall S. Runge, MD, PhD, who says the picture changes when patients earn enough money to be ineligible for Medicaid but still cannot afford to get insurance themselves.
Runge’s study looked at a group of 381 patients who experienced a pile-up after being referred to what Runge describes as the only state-owned hospital in Texas. Because the patients did not have insurance and were not experiencing a cardiac emergency, they didn’t have many options open to them about where to go to get care.
With these populations of patients, he says, it doesn’t matter how many facilities offer the service for elective treatment. Most patients would have to go to the state hospital at The University of Texas Medical Branch at Galveston.
A tough situation
"It’s sort of a Catch-22," Runge says. "If the patients are having a heart attack, they can go in and get treated [anywhere]. But if it is not an emergency and they don’t have insurance, they can’t have it done."
Runge says between 1993 and 1994, there was an overwhelming number of patients referred to the Galveston facility. Clinicians had to create a waiting list according to the urgency of each case, and they reported the outcome in JAMA. A patient’s outcome was not considered in the study if he or she had the following confounding factors:
- myocardial infarction (MI) less than 30 days from symptom onset;
- potentially life-threatening diseases of the ascending aorta such as aneurism or dissection;
- modified Canadian Cardiovascular Society angina classes IVb or IVc;
- short life expectancy due to illness such as cancer, severe pulmonary, hepatic, or renal disease.
Runge’s group found most patients who had to wait had an acceptable outcome — about 91% of them. But in the remaining patients after the third week, their risk of cardiac episodes increased steadily.
Eight months after the patients were put on the list, there were six deaths, four MIs, and 26 unplanned hospitalizations for heart failure. There were 66 patients removed from the list because their doctors took them off, they refused the procedure, or they were able to go to another hospital. (Two of the deaths, one of the MIs, and one CHF hospitalization were in the subset of the participants taken off the list.)
Out of the initial 381 patients put on the list, 311 went on to angiography at the study hospital and four died before getting the procedure, which showed 64% had significantly diseased coronary arteries. Overall, the patients who had an adverse event tended to have higher incidence of smoking, more than two cardiac risk factors, and prior angioplasty.
Here is the length of time the patients waited to get a procedure:
- Up to two weeks — 8%
- Two to six weeks — 44%
- Six weeks to three months — 32%
- Longer than 3 months — 16%
Runge says the study’s death rate of 1.6% is low, as is the 1% risk of MI, but notes they are about 10 times the risk of the events when they are associated with cardiac catheterization.
Getting the patients off to cardiac catheterization within two weeks, especially for the patients with a strongly positive stress test or those on many medications for their condition seems reasonable, says David Fischman, MD, co-director of cardiac catheterization at Thomas Jefferson University Medical Center in Philadelphia.
But he notes if patients are referred to him because their doctors suspect they have coronary disease, he doesn’t want to wait at all. "I hate putting it off."
Fischman says most hospitals aren’t posed with the situation seen in this study, where so many patients unable to pay pile up and have to be placed on a list. Hospitals are scheduling patients for elective procedures, knowing they are going to be able to pay. So if one of those patients ends up on a long list, he or she would just go elsewhere — and hospitals are very competitive for those patients.
The people in this study, Fischman says, will need more time to find funding through government programs or social services, and that’s where the waiting can come in.
Having a guideline that tells doctors that they should be getting to these patients within two weeks makes sense: If patients’ symptoms are caused by coronary disease, some kind of intervention is needed because chances are good that the situation is not going to improve on its own.
Doctors need to know what exactly is happening with their patients’ coronary arteries so they can begin receiving the right treatment for it.
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