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
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.