The never ending stent-bypass debate

A new study – a big one ($50 MM) – was recently released that compared the short and long term effects of drug eluding stents to bypass surgery for patients with serious heart disease.  The headlines — “Heart Surgery Bests Stents” — pretty much told the story.  In this particular case, 18% of those patients who had stents installed to treat their disease ended up either dying or needing another treatment over the next twelve months.  Only 12% of bypass patients ended up with complications or passing on.  The death rate in both instances was the same – 8%.

Stents — the tool of choice for interventional cardiologists — and bypass surgery — the technique of choice for cardiothoracic surgeons — have been playing this “which is better” game for almost ten years. Needless to say, both sides were represented in the stories that ran covering the results of this study. The bypass surgeons said, “More people should have bypass surgery instead of stents.” The stent docs said this study proved that stenting – which involves a much less aggressive and invasive procedure than bypass surgery — comes in a close second to bypass surgery, even in patients with complex conditions.

And if one chooses to read the comments underneath these articles at various online news sources, it’s pretty clear that both sides are doing the best they can to make their case, based on these results.  To use a stupid sports analogy, it’s a lot like watching Federer and Nadal hit tennis balls at one another.

But what’s really interesting to me about all this is not one article – and not one comment – says anything about the cost of either procedure.  For what it’s worth, stent procedures cost about a third of what bypass surgery costs – $20,000 vs. $60,000.  These numbers can and do vary with every case – and may cost more or less based on the patient’s condition, where the service is delivered, and what part of the country you’re in.  But around here, these procedures will average – for privately insured patients – somewhere around $20,000 and $60,000.

On some level, this is as it should be.  Stents are often used for diagnoses that don’t require something as aggressive as bypass surgery, which is a far more invasive procedure.  Stents generally serve a “less sick” population.  But it still amazes me that when we talk about the relative performance of one service over another to treat illness in health care, we rarely talk about the cost of either one.

And just to complicate matters a little more, if you were to ask the CDC about why the per capita mortality rate for heart disease in this country has dropped by 50% over the past twenty years, they would say that improved surgical techniques could take about 5% of the credit.  The lion’s share of the credit would go to advances in pharmacology (blood pressure meds and cholesterol lowering meds – like statins), and a huge drop in smoking.

This is why we need to make the collection and distribution of health care cost and quality data a national priority.  We will never improve quality and reduce costs if we play this game one study at a time.  Back when she was running for President, Democratic candidate Hillary Clinton talked a lot about creating a National Best Practices Institute for Health Care.  I hope the folks that are left in that race pick up on this very fine idea and pursue it.

2 replies »

  1. It is obvious to me that as a brother of a stent patent holder and being a healthcare consultant and from Boston, we all knew for years what physicians are just publishing. There is no real better outcomes whether with bare metal or DES and CABGs are often the better procedure to produce higher quality outcomes with overall lower cost over the life time of the patient. So pick your poison because at the end of it all plaque build up could and may cause restinosis. And any interventionalist who says people have a better quality with 12 or 13 stents should come to my family gatherings and see the evidence. The truth is medicine is a business and often repition of procedures brings greater value to a physician and the stent manufacturers bottom line rather then one major invasive procedure that may use no stents. The other dilemma is interventionalists are often not cardiologists or cardiothoracic surgeons. I often here physicians talk about how minimially interventional stenting needs better monitoring but we dont hear that in the studies only over dinner at the medical conventions.

  2. I fear that health care will once again fall by the wayside in the political discussion, overwhelmed by larger economic concerns and the trivia to which Presidential campaigns usually fall prey (like lipstick).
    However, I do have one quibble with your comment that stents are cheaper than bypass. If one has to keep redoing the stents, which happens frequently, then the costs add up fast. A more useful statistic would include this factor.