Percutaneous coronary intervention, commonly known as PCI, is the definitive emergency treatment for many heart attacks. The procedure involves threading a catheter, usually through an artery in the wrist or groin, up to the blocked coronary artery that is starving heart muscle of oxygen. Cardiologists then inflate a small balloon and typically deploy a stent, a tiny metal scaffold, to prop the vessel open and restore blood flow. The intervention is exquisitely time-sensitive: the longer the artery stays occluded, the more heart muscle dies, and the greater the risk of fatal arrhythmias, heart failure, and death. That time dependence is why emergency medicine guidelines emphasize rapid door-to-balloon intervals, and why the geographic distance between a patient and a PCI-capable hospital can be a matter of life and death. Establishing a PCI program is also expensive and demanding, requiring specialized catheterization suites, imaging equipment, and a round-the-clock team of interventional cardiologists, nurses, and technicians.

The research team, led by Yu-Chu Shen of the Naval Postgraduate School and the National Bureau of Economic Research and Renee Y. Hsia, professor of emergency medicine at UCSF, took advantage of a natural experiment embedded in California’s health care landscape. Between 2011 and 2022, various hospitals across the state opened new PCI-capable facilities at different times and in different places. The researchers identified 590,282 hospitalizations for acute myocardial infarction, the medical term for heart attack, and asked a deceptively simple question: what happened to patients in a community after a PCI-capable facility opened within a 30-minute drive? Crucially, they separated communities into two groups based on their starting point, comparing places that had never had timely PCI access with places that already had a capable hospital within the same 30-minute radius.

The contrast between the two groups was stark. In communities that previously lacked timely access, the opening of a new facility was associated with a 53 percent relative increase in the likelihood that a heart attack patient would be admitted to a hospital capable of performing PCI, and a 16 percent increase in the likelihood that the patient would actually receive the procedure. Those changes in treatment were accompanied by substantial changes in survival: thirty-day mortality among heart attack patients fell by 20 percent, and one-year mortality fell by 15 percent. In communities where PCI was already available within 30 minutes, by contrast, the opening of yet another facility increased admission to a PCI-capable hospital by only 2 percent and use of the procedure by only 3 percent, and the study detected no significant change in mortality at either time horizon.

The pattern reveals a fundamental asymmetry in how health care capacity behaves. Where a service is absent, adding it changes clinical behavior profoundly, rerouting patients who would otherwise have received less definitive therapy toward the lifesaving procedure. Where the service already exists, an additional facility mostly reshuffles existing patterns of care, drawing some patients from one capable hospital to another without meaningfully changing who gets treated or how quickly. In economic terms, the marginal benefit of the first facility within reach of a population is enormous, while the marginal benefit of the second or third approaches zero. Hsia illustrated the point with a deliberately mundane analogy: adding another gas station to a neighborhood that already has five may make refueling slightly more convenient, but building one where residents previously had to drive 30 miles meets a genuine need. With emergency cardiac care, she noted, filling that kind of gap can save lives.

The geographic dimension of the problem was most acute in rural California. Among the 52,756 heart attack patients in the study who came from rural communities, 81 percent lived in places without a PCI-capable facility within a 30-minute drive at the beginning of the study period. That figure captures a structural vulnerability of rural health systems: specialized services that require high volumes, expensive equipment, and scarce subspecialists tend to concentrate in urban and suburban population centers, leaving rural patients with long transport times precisely when minutes matter most. For these communities, the study’s findings suggest that even a single new PCI-capable facility could produce mortality reductions on the order of 15 to 20 percent, an effect size that few other health system interventions can match.

The new analysis builds directly on earlier work by Hsia and colleagues, which had examined the supply side of the same question. That previous study found that the total number of PCI procedures performed in a community rose by 7.5 percent after a new facility opened, but the increase was far from uniform: it approached 20 percent in communities that had previously lacked timely access, compared with roughly 8 percent in communities where PCI was already available. In other words, new capacity reliably generates more procedures, but the increase partly reflects redistribution of existing patients among competing hospitals rather than genuinely new treatment for people who would otherwise have gone without. The current study extends that logic to the outcome that ultimately matters, asking whether the additional procedures improved survival, and finding that the answer depends entirely on whether the capacity filled a gap or duplicated an existing service.

That distinction carries weight because of how decisions about specialized services are actually made in the American health system. The researchers point out that the placement of new facilities is frequently driven by market demand, expected procedure volumes, and hospitals’ anticipated return on investment rather than by systematic assessments of population need. A hospital system may find it financially attractive to open a second PCI laboratory in a well-served suburban corridor where it can capture market share from a competitor, while no institution finds it profitable to establish one in a rural county with a small and dispersed population. The result, the study implies, is a systematic misallocation: capital flows toward communities where the clinical benefit of additional capacity is smallest, while the places where a new facility would save the most lives remain unserved. Market forces, in this domain, do not naturally point resources toward maximal population health benefit.

For policymakers, the findings suggest a concrete principle for allocating scarce health care infrastructure investment: measure access before adding capacity. Rather than asking whether a region can support more specialized services, planners could ask whether residents can already reach those services within the critical treatment window, and direct new facilities and support programs toward the communities that cannot. Hsia framed the principle as a question of priorities. When millions of dollars are invested in specialized health care infrastructure, she argued, the question should not simply be whether more services can be provided, but where those services will do the most good. Expanding access, she said, needs to be done wisely. The study’s mortality figures give that advice quantitative teeth: the same investment that yields no measurable survival benefit in a saturated market can cut heart attack deaths by a fifth in a community that has been going without.

The research also carries a broader lesson for how the public and the press evaluate health care expansion announcements. A ribbon-cutting for a new specialty facility is often reported as an unambiguous improvement in local care, and in a community with no existing access, that framing is accurate. But the California data show that in well-served areas, additional capacity may increase treatment rates only marginally while leaving survival untouched, meaning the true value of such investments is far smaller than the rhetoric suggests. As health systems, insurers, and governments confront rising costs and finite resources, the study offers a reminder that in medicine, as in geography, position matters. The lifesaving power of a procedure like PCI is not just a property of the catheter and the stent; it is a property of the distance between the patient and the door.

Subject of Research: Geographic access to percutaneous coronary intervention facilities and heart attack survival outcomes

Article Title: When it comes to health care access, more isn't always better

Article References: When it comes to health care access, more isn't always better. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: heart attack, percutaneous coronary intervention, health care access, rural health, mortality, emergency care, health policy, hospital capacity, California, JAMA Network Open, cardiovascular disease, health care infrastructure