Is more health care access always better?

Opening a new hospital capable of percutaneous coronary intervention (PCI) improves survival for heart attack patients only when it fills a gap in access, according to new research from the University of California, San Francisco.

The study, published in JAMA Network Open, found that when a PCI-capable facility opened within a 30-minute drive of communities that previously lacked timely access, 30-day mortality fell 20% and one-year mortality fell 15%. In communities that already had PCI available within 30 minutes, adding another facility produced only small increases in treatment and no significant change in mortality.

"Americans tend to think more is better, but where you put these services really matters," said Renee Y. Hsia, MD, MSc, a UCSF professor of emergency medicine and the study's senior author.

Researchers analyzed 590,282 heart attack hospitalizations in California from 2011 through 2022, comparing what happened after a new PCI-capable facility opened in communities with and without prior timely access to the procedure.

In communities without prior access, a new facility was associated with a 53% relative increase in admission to a PCI-capable hospital and a 16% increase in patients receiving the procedure.

Where PCI was already available within 30 minutes, a new facility increased admission to a PCI-capable hospital by 2% and use of the procedure by 3%, according to the study.

Rural communities faced the widest gap

The access gap was most pronounced in rural California. Of the 52,756 heart attack patients from rural communities included in the study, 81% lived in places without a PCI-capable facility within 30 minutes at the start of the study period.

The findings add to the long-running debate over how to sustain specialized services in rural areas, where hospitals often lack the patient volume to justify the cost of cardiac catheterization labs, specialized equipment and dedicated staff.

Hsia compared the dynamic to gas stations. Adding one to a neighborhood that already has several offers marginal convenience, she said, but putting one where residents previously had to drive 30 miles meets a real need.

"With emergency care, filling that gap can save lives," Hsia said.

Building on earlier capacity research

The study builds on prior work by Hsia and colleagues examining what happens when hospitals add capacity for specialized procedures.

That earlier research found the number of PCI procedures performed in a community rose 7.5% after a new facility opened. The increase was nearly 20% in communities that previously lacked timely access, compared with about 8% in communities where PCI was already available.

The new study takes the next step by asking whether the added capacity translates into better outcomes. According to the researchers, the answer depends on location: When a new facility filled a geographic gap, patients were more likely to receive specialized care and survive. When PCI was already nearby, another facility led to modest increases in treatment without improving survival.

Market forces vs. population health

The researchers said the distinction matters because decisions about where to establish specialized services are often driven by market demand, procedure volume and a hospital's expected return on investment. Those forces may not steer new services toward the communities where they would produce the greatest population health benefit, they said.

"When we invest millions of dollars in specialized health care infrastructure, the question shouldn't just be whether we can provide more services," Hsia said. "We should be asking where those services will do the most good. We want to expand access, but we need to expand it wisely."

What it means for physicians

For primary care physicians and other clinicians in underserved areas, the findings underscore how much geography shapes outcomes after a heart attack. Patients in communities without timely PCI access face measurably higher mortality risk, which places added weight on prevention, risk-factor management and coordinated transfer protocols with regional cardiac centers.

The study also offers evidence for health system leaders and policymakers weighing where to direct limited capital. According to the researchers, adding capacity can produce significant benefits when it closes a critical access gap, while expanding services in communities that are already well served may do little to improve patient outcomes.