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TECH/QUALITY: Stents–it’s even worse than we thought, WITH UPDATE from The Industry Veteran

Note: I put this up late last night–but it’s such a huge story (and as one emailer says, can you think of a recent study that so blatantly points out all the flaws in the health care industry better than this?) that I’ve moved it to the top today

Man. This is no fun for Boston Scientific and the rest. Most angioplasties unneeded, study finds. This is even worse than was thought. Non-emergency angioplasties with stents are not even any good at reducing chest pain (angina) compared to drugs over 5 years:

The stunning results found that angioplasty did not save lives or prevent heart attacks in non-emergency heart patients. An even bigger surprise: Angioplasty gave only slight and temporary relief from chest pain, the main reason it is done. "By five years, there was really no significant difference" in symptoms, said Dr. William Boden of Buffalo General Hospital in New York. "Few would have expected such results."

<SNIP>

About 1.2 million angioplasties are done in the United States each year. Through a blood vessel in the groin, doctors snake a tube to a blocked heart artery. A tiny balloon is inflated to flatten the clog and a mesh scaffold stent is usually placed. The procedure already has lost some popularity because of emerging evidence that popular drug-coated stents can raise the risk of blood clots months later. The new study shifts the argument from which type of stent to use to whether to do the procedure at all. It involved 2,287 patients throughout the U.S. and Canada who had substantial blockages, typically in two arteries, but were medically stable. They had an average of 10 chest pain episodes a week — moderately severe. About 40 percent had a prior heart attack.

Live by the stent and potentially die by it. BSX was down around 6% at the close. And it would be un-THCB like to say “I told you so”, but I told you so.

UPDATE: Meanwhile, all the analysts MarketWatch polled don’t think that this study will make any difference, even though BSX barely got a dead-cat bounce today after its mauling yesterday. And then, well you knew this was coming….here’s what The Industry Veteran thinks about my pussyfooting around the issue:

The NEJM study on stents versus medical therapy, publicized this week in connection with the American College of Cardiology meeting, is not really “worse than what we thought” in terms of what it reveals about the larger health care system. It demonstrates exactly what we thought and what I’ve made explicit on this site several times. Ed Silverman over at Pharmalot nails it squarely when he writes that a large segment of cardiologists feel threatened by the study’s results because there are financial incentives for them to insert stents. In other words, the big problems facing health care will not be adequately addressed by digitalizing medical records, adopting treatment algorithms or any other technical tweaks. As long as the public remains hostage to obsessively greedy manufacturers, equally greedy physicians and third-party payers that are capital aggregators, we will continue to pay more than the rest of the world for our health care and, for the population as a whole, derive fewer benefits. Too many middlemen are allowed to extract too much economic rent from the health care system.

As the ACC meeting in New Orleans winds down, I’m reminded of a conversation I had at a previous meeting with a cardiologist from Westchester County, New York. American society, in his considered opinion, must guarantee practitioners who choose to start in his field a minimum yearly salary of $250,000 in return for their willingness to “give up the decade of their twenties.” Until then I still held the naive notion that while nationally acclaimed investigators working in academic medicine are exalted whores and crooks, the garden variety specialists in solo offices maintain genuine concerns for their patients as they work to obtain a secure but not unconscionable livelihood. In a pig’s eye!! Specialty practice in the United States today attracts people with the souls of Tony Soprano or “Chainsaw” Al Dunlop and it refines their predatory instincts through an arduous indoctrination process. Debating whether they or the pharma and stent companies do more to corrupt the system remains pointless, similar to arguing whether local politicians or the road contractors who bribe them are worse crooks.

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4 replies »

  1. Walter’s comments are well founded, although all in fairness his concerns also highlight the fact that there were a significant number of really sick folks in the medical arm, the lack of whom has been a source of serious criticism of other studies.
    What we are about to see is the influence of $$$ on the science of medicine. There will be a pushback study which will mitigate or contravene these results. It too will have flaws, but there is simply too much cash in the system for this state of knowlege to stand. My own greedy, souless non-for-profit hospital has just built a 30 million dollar cardiac hospital and spend nearly as much co-opting the local cardiologists. Their whole system applies industrial-like efficiency tools to whisk patients from chest pain to stent with the minimum fuss and time. There is such monetary gain to feed the beast, there is no incentive, or even attempt, to evaluate in which patients “time is myocardium” is important.
    The benefit of this study from my little primary care standpoint is that folks around here are a bit more hesistant to undergo intervention than average. This study protects me from lawyers. I can now respond to “isn’t stenting the standard of care” so well that the question will not be asked. I can also respond to all the nervous nurses who naturally want to transfer all the sick and therefore labor-intensive/scary patients to the city. I be able to keep ’em here in our relatively low-tech ICU instead.
    Truth is that we have known for sometime that stent and medical therapy are probably equivalent from a number of studies all with their relative flaws and all in second tier journals. The big news here is that stents are in no way better than medical therapy, even in ways we though they might be, in a better than average designed study that passed the editorial muster of the NEJM. The Cardio-Industrial complex will push back but some damage has been done.

  2. I think the holes in this study will be its undoing. How can you trust a stucdy that pulls people from the drug only group and puts them in the stent group when it becomes apparent they are dying and need a stent?

  3. <>
    Barry,
    Begs the question, given these findings, of doing the angiogram in the first place. (or the stress test for that matter.) Just treat everyone’s risk factors and that’s that, until they have their heart attack.
    The bypass question is another issue. However, much evidence has shown stenting to be roughly equivalent to bypass.
    So if bypass equals stenting and if stenting equals medical therapy, then….
    Bottom line, even the suggestion that stenting (and therefore bypass?) is no better than medical therapy is revolutionary. It’s an understatement to say it will be interesting to see how this settles out.

  4. I wonder how many angiograms are performed each year.
    The problem, I think, is that often patients who complain of chest discomfort undergo either a regular stress test, thalium stress, stress echo or PET scan and the results are inconclusive. The gold standard test to find out what is really going on is the angiogram. This is the only way to find out for sure how serious the blockage is and how many there are. If a blockage sufficient to justify a stent is found, the team is already there and ready to go. The stent can be inserted easily in about 15 minutes (if only one is needed). The path of least resistance is to go ahead and fix the problem that you just found.
    What’s the alternative when the blockage is there and identified? Do nothing and just treat it with drugs? What if the patient is already on all the drugs? What about the fear of a lawsuit if you do nothing and the patient later has a heart attack? It seems that the whole system (including the legal system) is stacked in favor of stenting.

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