By Jenney Speicher, Medical Tribune News Service
Waiting lists for diagnostic tests can raise the long-term costs
of illness, both in terms of money and health. The question of who
should be treated first is sometimes even a question of life or
death.
As the ranks of the uninsured and Medicaid-insured grow, more
people are using public hospitals, and waiting lists for certain
potentially lifesaving medical procedures are getting longer,
according to researchers who published a report in the July 14
issue of the Journal of the American Medical Association.
The researchers found that among people who have been referred
to the hospital for a diagnostic heart procedure, waiting for more
than two weeks increased their risk of heart attack and death.
Unplanned hospitalization, longer hospital stay and poorer
prognosis were other results of the delay, according to the
researchers, who investigated the problem at a public hospital in
Texas.
``If you don't have any insurance and show up at the hospital in
the process of a heart attack, you will get taken care of,'' said
Dr. Marschall S. Runge, who is senior author of the study. ``But if
your problem is considered 'stable,' you must either have insurance
or pay upfront,'' unless you go to a public hospital that is
required to treat all patients regardless of ability to pay, he
said.
Runge and colleagues became concerned about a long waiting list
for coronary angiography at the University of Texas Medical Branch
in Galveston, and decided to investigate. They studied a group of
381 heart patients in 1993 and 1994 who were waiting for the
diagnostic procedure, which helps determine the extent of disease
and how it can best be treated.
They found that 36 patients or 9.4 percent experienced adverse
events, including six deaths, four non-fatal heart attacks and 26
unplanned hospitalizations for heart failure or unstable blood
supply to the heart. The latter event, called unstable angina, made
up 58 percent of all adverse events.
``The probability of events was minimal in the first two weeks
and increased steadily between weeks three and 13,'' the
researchers reported.
Runge is director of the division of cardiology at the
University of Texas Medical Branch, and the Sealy Center for
Molecular Cardiology, also at the university.
Coronary angiography uses a long, slender, flexible hollow tube,
or catheter to examine the arteries in the heart to determine the
extent of such problems as artery blockage and narrowing. The tube
is typically inserted into an artery in the groin, and then snaked
up to the heart's arteries. There, a dye is injected that is
visible on x-ray, allowing doctors to see a silhouette of the
artery. Cardiologists then decide what treatment a patient should
receive, or whether an operation is necessary.
The researchers also suggested criteria that can be used to set
priorities among patients who appear to be stable. ``Patients with
strongly positive stress test results and those taking two to three
anti-ischemic [heart] medications should be prioritized for early
intervention,'' they wrote. The stress test involves using a
treadmill.
``Heart catheterization is now the most frequently performed
in-hospital operative procedure in patients older than 65,'' wrote
Dr. Thomas B. Graboys in an editorial in the same issue of the
journal. In 1995, more than 1.6 million people underwent
angiography, and by 2010, 3 million such diagnostic tests are
expected to be performed, according to Graboys, who is cardiology
director at Lown Cardiovascular Center in Brookline, Mass.
Graboys maintained that the increase in invasive heart
procedures is ``attributable to several non-clinical factors that
were detailed a decade ago.'' Among them, economics, overtraining
of cardiologists, patients' fear of sudden heart attack, research
conflicts of interest, and a requirement that interventional
cardiologists must perform a minimum number of procedures to
maintain certification.
Delaying catheterization in patients with unstable symptoms is
``unconscionable,'' he wrote. But it is ``equally unconscionable''
to recommend catheterization, ``which might result in unforeseen
morbidity or death,'' just because of ``a failed exercise treadmill
test.''
Runge said he does not disagree that in many instances invasive
heart procedures are unnecessary, and that economic reasons are
often an incentive. However, he said, early catheterization may be
more important than Graboys contends. New research on medical
therapy versus early catheterization in less stable patients was
not mentioned in Graboys editorial, he added.
And Graboys ``missed the point of our research,'' he said. ``Not
all cardiac patients are coveted by hospitals.'' For instance, in
the area surrounding the University of Texas hospital, ``many other
hospitals were not available to these patients.'' In fact, 40
percent of the Medicaid and uninsured patients lived more than 50
miles from the hospital, a factor in the delayed treatment. Only 11
percent of privately insured patients had trouble making
appointments, compared with 38 percent of the Medicaid and
uninsured patients. Runge estimated that 35 percent of patients at
the Texas hospital do not have insurance.
The waiting-list problem at the hospital was resolved quickly,
he said. ``We haven't had a problem since 1994.'' More faculty were
hired and everyone put in extra hours, he said. But Runge said the
problem is more widespread in the U.S. than realized.
``This is not an inconsequential problem,'' said Runge. ``We
have to ration care in one way or another.''
