Hospitals and Patients Feel Constricted by NJ’s Angioplasty Rules

Lilo H. Stainton | February 17, 2017 | Health Care
Restrictions on non-emergency heart procedures force some patients to travel far beyond their local hospitals

Interior of the catheterization lab at Hunterdon Medical Center
This past Wednesday marked the eighth time in recent years that Hunterdon County resident John O’Brien and his wife Chris traveled nearly an hour to Morristown Memorial Hospital so one of them could undergo angioplasty, a potentially life-saving outpatient procedure each has undergone on four separate occasions to keep their cardiovascular systems functioning.

And each time, the drive takes the couple right past Hunterdon Medical Center, an acute-care facility just 12 minutes from their home. Despite HMC’s qualified staff, experience, and its $17 million state-of-the-art cardiac catheterization suite, New Jersey regulations don’t permit the hospital to perform angioplasty treatments unless it is an emergency.

Doctors at the Hunterdon facility are allowed to perform diagnostic catheterizations, in which a tiny tube is inserted in a patient’s artery and dye is injected so they can track the blood flow. But they can only fix a problem they discover, using a tiny balloon to enlarge the artery and a stent to prop it open in an effort to prevent stroke, heart attack, or other cardiovascular disaster, if the patient faces imminent danger.

Many rural residents forced to travel for ‘elective angioplasty’

So each year, hundreds of patients diagnosed at HMC with cardiovascular problems that are not deemed an emergency must travel elsewhere for follow-up care — a process that requires them to schedule another appointment, undergo another round of anesthesia, and face additional co-pays and other expenses, the hospital said. Not to mention time and additional stress, which in itself can increase the chance of a stroke.

Then there are patients like the O’Briens who know the drill and choose to drive directly to Morristown Memorial, where they can undergo both the diagnosis and treatment in one visit. “Throughout the county, there’s a perception — you hear it a lot: ‘Oh, yes, my uncle went to Hunterdon and they had to send him to Morristown,’” explained John O’Brien, a longtime newspaper editor and reporter who once led the New Jersey Press Association and now serves on the HMC board.

And Hunterdon County — where heart disease is the leading cause of death — is not alone. Residents of a half-dozen other primarily rural counties — Cape May, Cumberland, Gloucester, Salem, Sussex, and Warren — are in the same boat, forced to travel to hospitals up to 90 minutes away for “elective angioplasty,” as the non-emergency treatment is called. The state now allows 29 hospitals to perform elective procedures, but these are clustered in 14 of the most populous counties.

While many of these seven counties have a single hospital that is not set up to do cardiac catheterization, other facilities — like Inspira Medical Center, with operations in Cumberland and Gloucester counties — are fully equipped to do both the diagnostic and treatment aspects of the procedure. But regulations only permit a select group of hospitals to do both elective and emergency angioplasty, and the state has declined to expand this group, despite years of requests from some hospital leaders and their elected representatives.

Bateman: ‘The haves do not want the have-nots to have’

When cardiac catheterization began, nearly 50 years ago, the risks were higher, so regulators restricted the procedure to hospitals with trained physicians and other resources to perform major heart surgery if something went wrong, according to Dr. William Schafranek, an HMC cardiologist. As the procedure evolved from a diagnostic tool to one that also included effective treatment, it became safer and by the mid-2000s state regulators began to ease the restrictions on which hospitals could offer elective angioplasty.

In 2012, researchers at Johns Hopkins University published in the “New England Journal of Medicine” a landmark study of hospitals in 10 states — including data from 11 Garden State facilities — that confirmed the low risk associated with the contemporary procedure. Shafranek said many states used this as the basis for developing more detailed regulation.

Instead of crafting statewide rules, the New Jersey Department of Health, tasked with licensing hospitals, created an extended demonstration project that has allowed these 11 hospitals to continue performing elective (as well as emergency) angioplasty without having a cardiac surgery unit. (Another 18 facilities with full cardiac surgery capabilities can also perform all angioplasty procedures; the DOH website includes data for all facilities that provide angioplasty, surgery, and other procedures.)

But Hunterdon Medical Center is among the hospitals that haven’t been able to receive the same state blessing, despite its investment in new technology and a strong record of success with the procedure. In 2015, HMC performed more than 550 diagnostic and emergency procedures — often in less time and using less invasive methods than its competitors, Shafranek said.

According to Sen. Christopher “Kip” Bateman (R-Somerset) whose district includes HMC, the hospitals that are able to perform this lucrative procedure don’t want to lose their market share. “The haves do not want the have-nots to have,” Bateman said last week, noting that he is looking to schedule a meeting in the coming weeks with Health Commissioner Cathleen D. Bennett to discuss possible solutions. “It’s an unfair ruling right now,” he said.

Robert Wise, president and CEO of Hunterdon Healthcare, which runs the hospital, agreed, adding, “This is really driven by red tape.”

Construction of the Norman and Denise Guilloud Cardiovascular Center at Hunterdon Medical Center, which opened in 2015
Wise said Hunterdon County has been extremely supportive of its effort to expand its cardiac catheterization services; multiple municipalities have adopted resolutions calling on the DOH to revise its regulations, and residents gave freely to fund the Norman and Denise Guilloud Cardiovascular Center, which includes the catheterization lab and which opened in June 2015.

“They saw the critical community need for this,” Wise said. “They saw the impact that a ride to Morristown [Memorial Hospital] could have on their health.”

Wise said leaders at Morristown Memorial have also been supportive of its bid to expand. And if anything ever went wrong during a procedure at HMC — a 0.2 percent chance, according to the Johns Hopkins angioplasty study — patients could be airlifted to Morristown in minutes, hospital officials said.

Urging DOH to adopt new rules

State lawmakers have also taken up the cry, introducing a handful of bills in recent years to expand the availability of elective angioplasty, especially in underserved counties. The most recent resolution (ACR-218) — introduced by Assemblyman Erik Peterson (R-Hunterdon) in December and Sens. Michael Doherty (R-Somerset) and Steven Oroho (R-Warren) — urges the DOH to adopt new rules to encourage additional hospitals to become licensed.

Over the past 14 months, their efforts have attracted support from others, including Bateman and two South Jersey Democrats, Sen. Jeff Van Drew and Assemblyman Bob Andrzejczak, who represent Cape May County, which lacks any angioplasty options. Assemblyman Herb Conaway Jr. (D-Burlington), who leads the health committee, also signed on to one measure, but none of the proposals have had a hearing in either legislative body.

In 2015, the health department reviewed the results of the 2012 Johns Hopkins study and decided to extend its ongoing demonstration project with the 11 select hospitals for another 18 months. On Wednesday, DOH spokeswoman Donna Leusner said “the state demonstration (project) continues and proposed rules are in development.” She declined to say when these regulations would be finished.