The past and future of heart institutes: having moved beyond the one-trick pony.

Canadian Journal of Cardiology 30 (2014) S478eS482 Viewpoint The Past and Future of Heart Institutes: Having Moved Beyond the One-Trick Pony David D. Waters, MD Division of Cardiology, San Francisco General Hospital, and the Department of Medicine, University of California, San Francisco, San Francisco, California, USA He’s a one-trick pony One trick is all that horse can do He does one trick only It’s the principle source of his revenue 1 Cardiology became relevant as a clinical entity soon after the middle of the 20th century. Although hypertension and valvular heart disease were common, life-threatening, and hardly treatable, in developed countries, coronary artery dis- ease was a raging epidemic that had not yet peaked. The discovery of coronary arteriography in 1958 by Mason Sones, the successes of coronary bypass surgery beginning a decade later, and the spread of coronary care units throughout the 1960s laid the groundwork for successful treatment of coro- nary disease. 2,3 During this era, heart institutes appeared in several major cities including Montreal, Ottawa, Houston, and Sao Paolo. The driving force behind the creation of these institutes was usually 1 charismatic individual, most often a cardiac surgeon. Cardiac surgery was in its infancy then, and outcomes were demonstrably better in high-volume centres where pre- and postoperative care could be optimized and tailored to this new category of patient. Patient selection criteria and cardiac anaesthesia were not well developed, and drugs such as aspirin and b -blockers were not yet in widespread use, yet cardiac surgery, particularly coronary bypass, ﬂourished because of pent up demand. The advent of coronary angioplasty led to a repetition of this cycle. In the beginning, angioplasty was limited to pro- grams in which emergency cardiac surgery was available. The larger volumes of patients at heart institutes facilitated the emergence of interventional “superstars,” analogous to the cardiac surgeons of the preceding generation. When emer- gency percutaneous coronary intervention (PCI) became the Received for publication June 4, 2014. Accepted June 6, 2014. Corresponding author: Dr David D. Waters, Division of Cardiology, Room 5G1, San Francisco General Hospital, 1001 Potrero Ave, San Fran- cisco, California 94965, USA. Tel.: þ1-415-420-6646. E-mail: dwaters@medsfgh.ucsf.edu See page S481 for disclosure information. preferred treatment for myocardial infarction, large centres were able to provide this service on a 24-hour, 7-day per week basis, and smaller centres with fewer interventional cardiolo- gists and limited resources struggled to keep up. The rise of cardiac electrophysiology in the past 2 decades has also favoured heart institutes. Success rates for ablation procedures are operator-dependent, and electrophysiologists with large volumes who work in a group with several others are likely to be more successful than a lone electrophysiologist with small volumes working in a general hospital. During their adolescence, heart institutes tended to be focused on coronary bypass surgery, but the pony has learned new tricks: PCI, electrophysiology, prevention, cardiac reha- bilitation, heart failure management, and clinical research. Heart institutes are large enough to support specialized niche clinics such as for adults with congenital heart disease, cardiac disease in HIV patients, and special cardiology problems in women. Advantages of the Heart Institute Model By concentrating resources and expertise in one place, heart institutes were able to provide better and more cost- effective care. Taking cardiologists out of the Department of Medicine and cardiac surgeons out of the Department of Surgery, and putting them together, with cardiac anaesthesi- ologists and cardiac radiologists, seemed like such an obviously good thing, especially by those involved. Patients with coro- nary disease were much younger then compared with now, and had fewer concomitant diseases, and thus less need for a phalanx of consultants from other specialties. The ﬁnancial success of heart institutes varied depending on the medical system of the country in which they were situated. In the United States, heart institutes that were well managed and had large patient volumes for expensive pro- cedures could generate high revenues. The fame of the insti- tute and its surgeons drew patients from far away, and procedural volumes increased further. Some of the proﬁts were plowed back into improvements in infrastructure and ancillary services, such that the gap between the heart institute and the cardiovascular services of a regular hospital widened. In countries in which governments controlled reimburse- ment for medical services, heart institutes succeeded also, but through somewhat different mechanisms. Governments http://dx.doi.org/10.1016/j.cjca.2014.06.002 0828-282X/O 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.