You can lead a horse to evidenced-based medicine but …

Note: This post first appeared at Goozner’s blog, Gooznews.

A new important and depressing study appeared last week in the Journal of the American Medical Association. Researchers who poured over Medicare records found that
less than half of seniors (44.5 percent) with stable coronary artery
disease who complained of symptoms like angina were whisked off to the
catherization lab for percutaneous coronary interventions (PCI) like
balloon angioplasty and stenting without first confirming by a stress
test that they were indeed suffering from reduced blood flow to the
heart (ischemia). Guidelines published by American College of
Cardiology, the American Heart Association and, significantly, the
Society for Cardiology Angiography and Intervention call for the tests.

Previous studies among the commercially-insured population are even
worse. Only a third of patients in the under-65 crowd with stable heart
disease but having symptoms are likely to have gotten a stress test
before getting PCI.

Why is this important? Let us count the ways:

* PCIs have increased 300 percent over the past decade and
accounted for at least 10 percent of the increase in Medicare spending
since the mid-1990s.

* Medicare spends $10,000 to $15,000 per PCI.

* While PCI may reduce ischemia and angina more effectively than
drugs, more than a half dozen studies conducted over the past decade
have established that in terms of reducing deaths or heart attacks, PCI
is no better than drugs alone.

* Patients who fail a stress test and then get PCI do better and have shorter hospital stays; and

* Patients who get PCI with minimal symptoms, with or without the
stress test, are at increased risk of repeat procedures and may
experience a deterioration in their overall quality of life going

So who is responsible for this mass defection from established
clinical practice guidelines? According to the study, which reviewed
the records of 23,887 Medicare patients, younger physicians and those
who conducted lots of PCIs were more likely to eschew ordering the
stress test before moving straight to PCI. The study also found huge
geographic differences. Those areas with the fewest facilities and
cardiologists who perform the PCI procedures ordered the required test
in as much as 70 percent of cases, while those with more labs and
intervention cardiologists fell well below the 44.5 percent average.

“Physician decision making regarding PCI was influenced less by
presence of ischemia, as PCI guidelines suggest, and more by
physicians’ own biases and community practice patterns,” the study
authors suggested.

Despite its own guidelines, the Society for Cardiovascular
Angiography and Interventions, which represents the cardiologists who
do the PCIs, immediately issued a press release
attacking the study. “The guidelines are important, but they are meant
to guide physicians based on the data available at the time of their
development, not serve as a substitute for clinical judgment,” said Dr.
Bonnie H. Weiner, SCAI immediate past president. “The message from the
interventional cardiology community is that for these patients, who may
not be able to walk across a parking lot without pain, angioplasty and
stents improve health and quality of life substantially.”

Here in a nutshell is the heart of the health care cost crisis.
Physicians, in this case intervention cardiologists, claim their
personal judgments, which are obviously clouded by their financial
interests, are superior to and must hold sway over the statistical
evidence gathered by impartial researchers.

It would appear that we can lead the horses to evidence-based
medicine, but we can’t make them drink. If the crisis caused by rising
medical bills reaches the point where frustrated payers impose payment
guidelines that require adherence to guidelines, the physicians, who
will complain bitterly about “cook book medicine” and insurer
straightjackets, will have no one to blame but themselves.

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7 replies »

  1. Dr. rbar writes:
    > Who suggested what you refute?
    The very first italicized point taken in the context of the piece suggested it. Shouted it, actually.
    > To my knowledge, the stress test is done
    > for risk stratification prior to an intervention
    I get that the stress test is disgnostic — “will stenting help this patient (much)”? But either way, if it ought to be done and it isn’t being done, the interventionists need an intervention. If the recipe is wrong, it should be corrected.
    > If you mean the ACC or the AHA when you
    > are referring to the “guild”, those are
    > at the end funded by cardiologists, who
    > are funded via patient care …
    When I say “The Guild” I mean doctors generally, but acting through whichever professional associations make the most sense. In a slightly different context, I talked about how I see The Guild’s responsibility over here. In my opinion, The Guild have shirked their responsibility to hold their own members accountable.
    > and finally, is “the bitter complaint” justified,
    > in your opinion?
    To the extent the recipes are good, no.

  2. My question is, are evidence-based guidelines easily accessible? Medicine is a complex profession because it deals with the human body, which is also complex. I agree that adherence to EBM guidelines should be the goal, but as a non-physician I’ve always wondered how to make that happen.

  3. This is a very interesting, and disturbing study. The organization I work for, Research!America, recently presented the Economic Impact of Health Research Award to a team of researchers who addressed a related issue. Chandra and Staiger analyzed the effects of “productivity spillover” which occurs when areas specialize in a new procedure, leading to existing treatments being used less effectively. To read more about this study, and listen to a podcast of the awards ceremony (including a talk by the study’s authors), visit http://www.researchamerica.org, or http://www.researchamerica.blogspot.com.

  4. Tom,
    I am not a PCP (nor a cardiologist) and relatively ignorant re. this issue … but I did some reading and I got the feeling that you might be, too.
    Ad 1) – this is a straw man. Who suggested what you refute?
    Ad 2) – this is a good point, but the benefit in the COURAGE trial is not impressive (angina free: at 1 year 55 (medical) versus 66, at 3 years: 67 versus 72 percent, at 5 years: ns). One could even argue that there may be a placebo effect and/or bias from the intervention.
    Ad 3) – I think we need a cardiologist here to clean things up. To my knowledge, the stress test is done for risk stratification prior to an intervention, and this seems quite well established.
    And what do you mean by your last 2 paragraphs? If you mean the ACC or the AHA when you are referring to the “guild”, those are at the end funded by cardiologists, who are funded via patient care …
    and finally, is “the bitter complaint” justified, in your opinion?

  5. With increasing medicare costs doctors there is a need to move towards innovative healthcare solutions like telemedicine and other other advanced technologies. One service thats gaining more importance is Web 2.0 technologies that can help a patient get their queries answered by an expert online. These can be either through postings or online live. There are sites that do provide a live phone in facility for the patients.

  6. What is wrong with this critique? I count three ways:
    1) Increasing utilization is not an argument against utilization.
    2) Death and heart attack certainly are endpoints and they’re cheap/easy to measure, but the SCAI viewpoint is also important — there is more to medicine than the delay of death. The impartial researchers may be lazy or (more likely) seriously underfunded. Let them research other endpoints, like the relationship between PCI and patients who can’t walk across a parking lot becoming patients who can walk across parking lots.
    3) A test does not an outcome make. Let the impartial researchers figure out whether patients who actually have stress tests (failing them or no) have better doctors, and whether this is what leads to the superior outcomes noted. Let them also figure out whether doctors who perform PCI on patients having minimal symptoms are poor doctors, and this is what leads to the poor outcomes noted.
    Ideally, The Guild will do this research itself, and pay for the research. But if they don’t, they who pay the bills will do the research and develop the cookbook. This will probably be suboptimal, but also an improvement.
    Now it seems to me that physicians are leading the way on EBM and Practice variation research, and physicians (especially academic physicians) are developing the cookbook. The bitter complaint is that adherence to the recipes may now be supervised and the contract between the insurer and the patient (yes, I know) thereby enforced. Even if the cookbook were perfect, this complaint would still be made…

  7. Completely agree. It is the old formula of a well reimbursed procedure being overused.
    Many physicians (I don’t know how the others practice) I have heard complaining of “cookbook medicine” like to do nonsense without much evidence – costly at best and dangerous at worst.
    Other than directly enforcing guidelines, a potential fix would be to decrease reimbursement for the overused procedure. Medicare (and other payors’) reimbursement should not be erratically fluctuating, but sthg like 5% adjustments/year (to be repeated based on the degree of overuse and the estimated material/labor cost and physician time) seems reasonable.