title: Expansion of invasive cardiac services in the United States.
abstract: BACKGROUND
  The number of hospitals offering invasive cardiac services (diagnostic angiography, percutaneous coronary intervention, and coronary artery bypass grafting) has expanded, yet national patterns of service diffusion and their effect on geographic access to care are unknown.
  
  
  RESULTS
  This is a retrospective cohort study of all hospitals in fee-for-service Medicare, 1996 to 2008. Logistic regression identified the relationship between cardiac service adoption and the proportion of neighboring hospitals within 40 miles already offering the service. From 1996 to 2008, 397 hospitals began offering diagnostic angiography, 387 percutaneous coronary intervention, and 298 coronary artery bypass grafting (increasing the proportion with services by 3%, 11%, and 4%, respectively). This capacity increase led to little new geographic access to care; the population increase in geographic access to diagnostic angiography was 1 percentage point; percutaneous coronary intervention 5 percentage points, and coronary artery bypass grafting 4 percentage points. Controlling for hospital and market characteristics, a 10 percentage point increase in the proportion of nearby hospitals already offering the service increased the odds by 10% that a hospital would add diagnostic angiography (odds ratio, 1.102; 95% confidence interval, 1.018-1.193), increased the odds by 79% that it would add percutaneous coronary intervention (odds ratio, 1.794; 95% confidence interval, 1.288-2.498), and had no significant effect on adding coronary artery bypass grafting (odds ratio, 0.929; 95% confidence interval, 0.608-1.420).
  
  
  CONCLUSIONS
  Hospitals are most likely to introduce new invasive cardiac services when neighboring hospitals already offer such services. Increases in the number of hospitals offering invasive cardiac services have not led to corresponding increases in geographic access.
authors.affiliation: School of Law, University of California Los Angeles, Los Angeles, CA 90095, USA. Horwitz@law.ucla.edu
authors.forename: Jill R
authors.initials: JR
authors.lastname: Horwitz
authors.forename: Austin
authors.initials: A
authors.lastname: Nichols
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.forename: Comilla
authors.initials: C
authors.lastname: Sasson
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Iwashyna
mesh_terms: D016507:Cardiology Service, Hospital / Q000706:statistics & numerical data / Q000639:trends*; D015331:Cohort Studies; D017023:Coronary Angiography / Q000706:statistics & numerical data / Q000639:trends*; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data / Q000639:trends*; D003952:Diagnostic Imaging / Q000639:trends*; D018588:Fee-for-Service Plans; D006801:Humans; D016015:Logistic Models; D006278:Medicare / Q000706:statistics & numerical data / Q000639:trends; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data / Q000639:trends*; D012189:Retrospective Studies; D014481:United States
keywords: access to care; diffusion of innovation; geographic variation; percutaneous coronary intervention