More Confirmation Stents Overused

July 6, 2011
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Another day, another study showing that invasive cardiologists overuse angioplasty and insert unneeded stents in patients without acute symptoms of coronary artery disease. The latest study, which appeared in today’s Journal of the American Medical Association, deemed 15 percent of the 600,000 angioplasties done every year are either inappropriate or their necessity is uncertain.

Another day, another study showing that invasive cardiologists overuse angioplasty and insert unneeded stents in patients without acute symptoms of coronary artery disease. The latest study, which appeared in today’s Journal of the American Medical Association, deemed 15 percent of the 600,000 angioplasties done every year are either inappropriate or their necessity is uncertain.

Since the COURAGE trial results were released in 2007, cardiologists have known that drug intervention (primarily statins) works just as well or better than angioplasty in patients with stable coronary artery disease (cost: $1,000 a year or less if generics are used compared to $20,000 for the stent operation). A study that came out two months ago showed there had been no change in cariology practice in the wake of the COURAGE trial. This latest study confirms that invasive cardiology is largely an evidence-free zone where the self-interest of the surgeons and the hospitals trumps the needs of patients, who have no clue as to what’s going on. “Thank God the doctor did that operation. I could have died tomorrow.”

Dr. Mark Midei, the Maryland cardiologist once feted by Medtronic with a pig roast for inserting 30 stents in a single day, remains the poster child for invasive cardiology overutilization. His story was the subect of a Congressional investigation, and is repeated in today’s Wall Street Journal (subscription required). 

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What’s the solution? I presume the American Heart Association or American College of Cardiology guidelines recommend medical therapy before angioplasty in patients with stable coronary artery disease (no one questions the use of angioplasty in the 70 percent of patients who present at their physicians or at the emergency room with acute symptoms — anywhere from a heart attack to extremely labored breathing — from coronary blockages). Insurers, including Medicare, could create post-operative review boards to review medical charts and apply these guidelines before making payments. Obviously some cases will be borderline. For those cases, insurers could create an appeals process. In clearcut cases of overutilization, no one gets paid by insurance. Let them try to collect from the patients. When word of that gets out, you’ll see a lot more questions being asked in the emergency room before walk-ins agree to get whisked off to the cath lab.

Call it rationing if you’d like. I prefer to call it the application of scientific medicine to payment policy. Anybody got a better idea?