When the same cardiologist diagnose the problem prescribe
the procedure and does the surgery the potential for abuse is enormous. Around 300K unnecessary stent
are inserted annually in the USA. This is a big business and you should ne aware that they want money,
and do not actually care much about your health. Health care industry (aka medical industrial
complex) that seems to be driven by the quantity of procedures, rather than the quality of patient
care. Number of cardiologists sentenced to jail terms in the USA is counted in dozens. And they are
just the tip of the iceberg -- neoliberal perversion of health care. Making profit motive central.
Profit motives is the primary driver ("greed is good") for many medical practices, who abandon
Hippocratic oath. Among one of the notable types of abuse is cardiac stenting (which is a mass practice
in the USA). Per-conditions for inserting the sent are fuzzy. Insurance companies do not require the
proof that arteries are clogged using independent diagnostic method. So greed dominated (and cost
insurance companies and Medicare a lot of money).
Especially abhorrent is behaviour of some cardiologists who abuse patient who get into emergency
with completely different problem (say arrhythmia).
this is the area where control of of "proper preconditions" is very difficult as the same doctor
recommends the procedure and later does the surgery. no one requres consilium in non-acute cases. Which
encourages corruption.
When youre a hammer everything looks like a nail.
I
n the early 2000s
Terry Mitchell's dentist retired. For a while,
Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to
ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient
10-minute walk from Mitchell's home, in San Jose, California. Lund's practice was situated in a one-story building with
clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was
small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows,
round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and
Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars.
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Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or
new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root
canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell's
insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and
cost of the treatments did not trouble him. He had no idea that it was
unusual to undergo so many root canals
-- he thought they were just as common as fillings. The payments were spread out
over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he
might as well get them before things grew worse.
Meanwhile, another of Lund's patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s,
had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund
for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly
healthy, although she'd had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth
trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and
telling her she needed root canals and crowns.
Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she
expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to
treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he
explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a
doctor's daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent,
so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also
chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the
work cost her about $70,000.
In early 2012, Lund retired. Brendon Zeidler, a
young dentist looking to expand his business, bought Lund's practice and assumed responsibility for his patients. Within a
few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly
successful, but Zeidler was making only 10 to 25 percent of Lund's reported earnings each month. As Zeidler met more of
Lund's former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work -- a much larger
proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn't need any
additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he
checked thoroughly?
In the summer, Zeidler decided to take a closer look at Lund's career. He gathered years' worth of dental records and
bills for Lund's patients and began to scrutinize them, one by one. The process took him months to complete. What he
uncovered was appalling.
W
e have a fraught relationship
with dentists as
authority figures. In casual conversation we often dismiss them as "not real doctors," regarding them more as mechanics for
the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to
torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are
so anxious that they avoid the dentist almost entirely, and a smaller percentage have
a genuine phobia
requiring psychiatric intervention.
When you're in the dentist's chair, the power imbalance between practitioner and patient becomes palpable. A masked
figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you
cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously
invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like
a personal failure. When a dentist declares that there is a problem, that something must be done before it's too late, who
has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what's true?
In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking
a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist's
office -- perhaps because we both dread dental procedures and belittle their medical significance -- the impulse is to comply
without much consideration, to get the whole thing over with as quickly as possible.
The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental
procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet
applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. "We are
isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of
the equation," says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the
American Dental Association's Center for Evidence-Based Dentistry
, which was established in 2007. "We're kind of behind
the times, but increasingly we are trying to move the needle forward."
Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such
a young age, that we've internalized it as truth. But this supposed commandment of oral health has no scientific grounding.
Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an
illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of
dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.
Many standard dental treatments -- to say nothing of all the recent innovations and cosmetic extravagances -- are likewise not
well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available
are not always reassuring.
The Cochrane organization
, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of
oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental
intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given
procedure. For example, dental sealants -- liquid plastics painted onto the pits and grooves of teeth like nail polish -- reduce
tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too
simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening
conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there
is simply not enough research to say anything substantive one way or another.
Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it
does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but
there is only "weak, very unreliable" evidence that it combats plaque. As for common but invasive dental procedures, an
increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to
monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of
tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don't clearly indicate
whether it's better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine
whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.
"The body of evidence for dentistry is disappointing," says
Derek Richards
, the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland.
"Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a
little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don't test them properly in a
good-quality trial."
The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients.
Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she
would probably not find much to help her. When we submit to a dentist's examination, we are putting a great deal of trust
in that dentist's experience and intuition -- and, of course, integrity.
When Zeidler purchased Lund's
practice,
in February 2012, he inherited a massive collection of patients' dental histories and bills, a
mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain
the alarmingly abundant dental work in the mouths of Lund's patients, he would find it in those records. He spent every
weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a
giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical
analyses.
The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates.
Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was
performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly,
and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry
Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it.
Dental crowns were one of Lund's most frequent treatments.
A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so
its new shell will fit.
Crowns
typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace
them every five years -- the minimum interval of time before insurance companies will cover the procedure again.
More than 50 of Lund's patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has
32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural
teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that
a root canal is a "quick, comfortable procedure" that is "very similar to a routine filling." In truth, a root canal is a
much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple
trips to a dentist or specialist. It's also much more costly.
Root canals are typically used to treat infections of the pulp -- the soft living core of a tooth. A dentist drills a hole
through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective
tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living
tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes
one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In
the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery.
Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage,
known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is
awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in
place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections,
which occur in a minority of cases. Yet they were extremely common in Lund's practice. In 2009, for example, Lund billed
his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would
almost certainly have been a memorable experience.
In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical
complications, and further operations, Lund had apparently billed patients for treatments he had never administered.
Zeidler was alarmed and distressed. "We go into this profession to care for patients," he told me. "That is why we become
doctors. To find, I felt, someone was doing the exact opposite of that -- it was very hard, very hard to accept that someone
was willing to do that."
Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront
Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible
explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell
them that the man to whom they had entrusted their care -- some of them for two decades -- had apparently deceived them for his
own profit.
Arsh
Raziuddin
The idea of the dentist as potential
charlatan
has a long and rich history. In medieval Europe, barbers didn't just trim hair and
shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of
enemas, and tooth extraction.
Barber surgeons
, and the more specialized "tooth drawers," would wrench, smash, and knock teeth out of people's mouths
with an intimidating metal instrument called a
dental key
: Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s,
Thomas Berdmore, King George III's "Operator for the Teeth,"
described one woman
who lost "a piece of jawbone as big as a walnut and three neighbouring molars" at the hands of a
local barber.
Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies
as a trade akin to blacksmithing (
Paul
Revere
was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage
with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into
them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic,
nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen -- who genuinely believed in the therapeutic power of
bloodsucking worms -- were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged
them extra to stuff their pitted molars with homemade gunk of dubious benefit.
In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From
1839 to 1840,
Horace Hayden and Chapin Harris
established dentistry's first college, scientific journal, and national association.
Some historical accounts claim that Hayden and Harris approached the University of Maryland's School of Medicine about
adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry
was of little consequence. But no definitive proof of this encounter has ever surfaced.
Whatever happened, from that point on, "the professions of dentistry and medicine would develop along separate paths,"
writes Mary Otto, a health journalist, in her recent book,
Teeth
. Becoming a practicing physician requires four
years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a
degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating
patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When
physicians complete their residency, they typically work for a hospital, university, or large health-care organization with
substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the
nation's 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically
don't have the same level of oversight.
Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral
health is somehow divorced from one's overall well-being is absurd; the two are inextricably linked. Oral bacteria and the
toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral
health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a
complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign
of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation.
Dentistry's academic and professional isolation has been especially detrimental to its own scientific inquiry. Most
major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away
from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the
phrase
evidence-based medicine
was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some
scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having
similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based
medicine, but only a handful devoted to evidence-based dentistry.
In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting
workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that
curate useful resources. But its adoption "has been a relatively slow process," as a
2016 commentary
in the
Contemporary Clinical Dentistry
journal put it. Part of the problem is funding: Because
dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and
industry to tackle these issues. "At a recent conference, very few practitioners were even aware of the existence of
evidence-based clinical guidelines," says Elliot Abt, a professor of oral medicine at the University of Illinois. "You can
publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change."
Among other problems, dentistry's struggle to embrace scientific inquiry has left dentists with considerable latitude to
advise unnecessary procedures -- whether intentionally or not. The standard euphemism for this proclivity is
overtreatment
.
Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and
veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for "microcavities" -- incipient lesions that do not
require immediate treatment -- and superfluous restorations and replacements, such as swapping old metal fillings for modern
resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and
misguided treatment, dentistry is lagging behind. It remains "largely focused upon surgical procedures to treat the
symptoms of disease," Mary Otto writes. "America's dental care system continues to reward those surgical procedures far
more than it does prevention."
"Excessive diagnosis and treatment are endemic," says Jeffrey H. Camm, a dentist of more than 35 years who wryly
described his peers' penchant for "
creative
diagnosis
" in a 2013 commentary published by the American Dental Association. "I don't want to be damning. I think the
majority of dentists are pretty good." But many have "this attitude of 'Oh, here's a spot, I've got to do something.' I've
been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or
12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the
procedure."
Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband
in Texas, recalls many troubling cases: "We would see patients seeking a second opinion, and they had treatment plans
telling them they need eight fillings in virgin teeth. We would look at X-rays and say, 'You've got to be kidding me.' It
was blatantly overtreatment -- drilling into teeth that did not need it whatsoever."
Studies that explicitly focus on overtreatment in dentistry
are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a
Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in
Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should
monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180
dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists
singled out 13 different teeth for drilling; each advised one to six fillings. Similarly,
in
an investigation for
Reader's Digest
, the writer William Ecenbarger visited 50 dentists in 28 states in the U.S.
and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about
$500 and going up to nearly $30,000.
A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in
dentistry. In addition to dentistry's seclusion from the greater medical community, its traditional emphasis on procedure
rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of
entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than
$200,000. And then there's the expense of finding an office, buying new equipment, and hiring staff to set up a private
practice. A dentist's income is entirely dependent on the number and type of procedures he or she performs; a routine
cleaning and examination earns only a baseline fee of about $200.
In parallel with the rising cost of dental school, the amount of tooth decay in many countries' populations has declined
dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the
1950s and '60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing
industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts,
and veneers. It's easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and
proactive treatments -- a small filling here, a new crown there -- even when waiting and watching would be better. It's equally
easy to imagine how that behavior might escalate.
"If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward
this attitude of 'I've got tools so I've got to fix something' much too often," says Jeffrey Camm. "Maybe it's greed, or
paying off debt, or maybe it's someone's training. It's easy to lose sight of the fact that even something that seems
minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician
feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad."
Arsh
Raziuddin
In the summer of 2013,
Zeidler
asked several other
dentists to review Lund's records. They all agreed with his conclusions. The likelihood that Lund's patients genuinely
needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund's decisions or to
explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I
asked Zeidler how those meetings went, he offered a single sentence -- "I decided shortly thereafter to take legal action" -- and
declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither
responded.)
One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund's care, explaining
what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his
diagnoses and treatments were meant to keep them healthy. Isn't that what doctors do? "It makes you feel like you have been
violated," Terry Mitchell says -- "somebody performing stuff on your body that doesn't need to be done." Joyce Cordi recalls a
"moment of absolute fury" when she first learned of Lund's deceit. On top of all the needless operations, "there were all
kinds of drains and things that I paid for and the insurance company paid for that never happened," she says. "But you
can't read the dentalese."
"A lot of them felt,
How can I be so stupid?
Or
Why didn't I go elsewhere?
" Zeidler says. "But this is not
about intellect. It's about betrayal of trust."
In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit,
Zeidler and his lawyers argued that Lund's reported practice income of $729,000 to $988,000 a year was "a result of
fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never
performed." The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund's former patients, including
Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They
collectively reached a nearly $3 million settlement, paid out by Lund's insurance company. (Lund did not admit to any
wrongdoing.)
Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney's office is
prosecuting a criminal case against him
based on 26 counts of insurance fraud. At the time of his arraignment, he said
he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund's license, which is
currently inactive.
Many of Lund's former patients worry about their future health. A root canal is not a permanent fix. It requires
maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell's root canals has already
failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was
extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a
crown were fixed in place. "I don't know how much these root canals are going to cost me down the line," Mitchell says.
"Six thousand dollars a pop for an implant -- it adds up pretty quick."
Joyce Cordi's new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a
car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday
chewing. "It hurts like hell," she says. She has to wear a mouth guard every night.
What some of Lund's former patients regret most are the psychological repercussions of his alleged duplicity: the
erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. "You lose your trust,"
Mitchell says. "You become cynical. I have become more that way, and I don't like it."
"He damaged the trust I need to have in the people who take care of me," Cordi says. "He damaged my trust in mankind.
That's an unforgivable crime."
"... One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session). ..."
"... I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight. ..."
"... Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy ..."
"... Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes." ..."
"... Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. ..."
"... ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines: ..."
"... Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea. ..."
"... Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system. ..."
"... EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies" ..."
"... I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child ..."
"... And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on. ..."
"... And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's ..."
"... I think, what this article alludes to is that medicine is complex and not easily algorithmic ..."
"... The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency. ..."
"... My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience. ..."
"... Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized. ..."
"... My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care ..."
Interesting article and a couple of clarifications:
Psychologists have studied the accuracy of risk assessments made by statistical
predictors and by clinicians, but they have not done similar studies of the accuracy of
evaluations of patient preferences over health outcomes.
True but health economists have
done so . And they got so scared by the results that some (Dolan) left the field to do
something else. This particular example is that whilst the general population reckons
"extreme pain" to be worse than "extreme depression/anxiety", those members of the population
who'd experienced them both put them the other way round. Which has profound implications for
the UK values assigned to health outcomes. Of course other countries might do things in
different ways and this is NOT some veiled attack on what the US might do if single payer
gets onto the playing field. It's merely adding to the warning in the paper about how to do
it. Which leads to a second warning I'd make – averages. They conceal a lot.
Mental health is the archetypal example and, again, maybe the paper is right that
something like maximin is warranted, given that "living by averages" means some groups
automatically lose out. Just some thoughts, which hopefully are constructive this time round
and expand on points made.
One thing this article doesn't distinguish between are hospital doctors and solo
practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a
huge issue with doctors simply not keeping up with current research if they don't have the
peer pressure and oversight that you would expect in a well run hospital. I was a victim of
this as for years as a child I was repeatedly given antibiotics by my family doctor for
'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only
diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport
session).
I talked much later to a family member who is a specialist in prescribing practice who
said that this was by far the most common misdiagnosis/treatment and as late as the 1990's in
the UK (where he did research on the subject), he found that 25% of GP's (family doctors)
were not identifying asthma correctly. Very often, pharmacists are the only gatekeepers to
identify bad prescribing practices.
I've also heard numerous stories about terrible practices by specialists in small
hospitals, who can become mini-emperors with nobody to contradict their professional
opinions. This is one reason why all doctors will generally advise that the best place when
you are ill is a large teaching hospital (definitely not a small private hospital). Bad
diagnostic practice is much more likely to be stamped out in the biggest hospitals where
there is greater peer oversight.
I'd ask what the author assumes is the best model for doctor-patient interaction, what
"patient care" means. To me it should be two or maybe more (including nurses and family
members and other caregivers) people, ones with more knowledge of physiology and systems,
others with more knowledge and experience of whatever the "presenting condition" happens to
be, interacting to increase longevity, reduce pain, repair damaged structures, correct
physiological malfunctions and problems with homeostatic functions and so forth, to maximize
function, independence and comfort -- an incomplete definition of a very complex notion.
Physicians aren't bots. There are different reasons people go into medicine, not all
of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare
of others behavior by not beneficial to or may be harmful to itself but that benefits others
of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the
burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von
Muchausen's by proxy
Always, the smart kids in the room want to systematize and organize every kind of
function, and in the neoliberal universe, reduce complexity to profit-generating,
"management"-centric forms. Sometimes that application of rationalization is a good thing, it
can help focus attention wisely and lead to those often undefined "good outcomes."
But there's almost an infinite number of ways humans can get injured, sickened and die.
Human physiology is vastly complex. The interaction pathways are likewise near infinite.
Medicine is an art of observation compounded over time, and a lot of the knowledge base (I
personally hate that term) is just wrong, from a wide variety of causes including bias,
sample size, things like referred pain, atypical "presentations," "normal variation" and so
forth. When what to me is a semi-mystical interaction between practitioner and person works
well, it is a thing of beauty and kindness. As with anything human-created and -mediated, too
often the result is far worse -- most of us can insert one or more anecdotes here, on either
extreme.
Constant mechanization of medicine results in stuff like the ICD-10 classification thing,
which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about
70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about
13,000 diagnosis codes in ICD-9. It's a "whole new way of doing business:"
ICD-9 is widely considered to be based on outdated technology, with codes unable to
reflect the use of new equipment. ICD-10 offers far more integration with modern technology,
with an emphasis on devices that are actually being used for various procedures. The
additional spaces available are partly designed to allow for new technology to be seamlessly
integrated into codes, which means fewer concerns about the ability to accurately report
information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The
structural changes throughout the entire coding system are very significant, and the
increased level of complexity requires coders to be even more thoroughly trained than before.
However, it is possible to prepare for the changes by remembering a few simple
guidelines:
Train early- The more familiar your staff are with ICD-10, the better. While currently
scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea.
Understand the ICD-10- The structural changes require a change in the way people think about
coding, and understanding it will help to break current coding habits. Medical professionals
used to reporting things a certain way so they can be coded may need to change what they say
in order to work well with the new system.
EBM is just another management buzz(kill)word, like "total quality management" and
"zero defects" and "zero-based budgeting." All supported by proponents who rationalize and
argue in the language of squishy "disciplines" like psychology and economics, using
"specialized" lexicons that often are cloudy restatements of commonplaces in arcane
terminologies, and the creation of intellectual artifacts that have tenuous or little
relationship to the reality most "uneducated" observers perceive -- yes, sometimes
incorrectly as more acute observations might show, but more often accurately than the
modeling and force-fitting that "experts" soar off on. How many of the articles cited as
authoritative on various points have anything other than presence in peer-reviewed land as
proof of the claimed "findings" both of the original researchers and authors, or acuteness
and accuracy of the proposition for which they are offered subsequently? And how much fraud
and selectiveness (like medication trials that exclude likely non-responders to the
therapies) and purblindness fills the vast swath of "published studies"
I've personally experienced and seen lots of misdiagnoses and clinician blindness and
tunnel vision, starting as a child when the family doctor, a partisan of allergies as the
most common source of disease, and who patch-tested me and my sisters unmercifully,
supposedly told my mom that my broken right forearm was the result of an allergy. And our
favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a
common failing given vagueness of symptoms) for a year or more after her original office
visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved
largely into "industrial medicine," doing workers comp and employment physicals -- a
wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into
narrow channels– totally understandable, given human nature -- channels that get
reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like
the vast and geometrically growing pile of "medical knowledge" of more or less validity, on
and on.
These observations only touch on an enormously complex and painfully meaningful subject.
Seems to me that the best "we" patients and patients-to-be can expect is that we connect with
clinicians that still start from "Do no harm" and aspire to better the lives of we who seek
and depend on their expertise -- a notably, and inevitably, ever smaller fraction of the
available "knowledge base." And "we" can hope that AI and EBM and the horrors wrought by the
other false gods of "modern medical practice" like "Electronic Medical Records" don't
intermediate and leverage their way into the care we mopes need and hope for. EBM from what I
have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as
universal as Murphy's
Yeah I agree entirely . But more holistic approaches (judging medicine by overall quality
of life) get into areas that have got a little Shall we say Controversial So I'm keeping my
comments focused to stay within site guidelines.
There are two reasons why patient care adhering to guidelines may differ from the care
that clinicians provide:
Guideline developers may differ from clinicians in their ability to predict how decisions
affect patient outcomes; or
Guideline developers and clinicians may differ in how they evaluate patient outcomes.
I think, what this article alludes to is that medicine is complex and not easily
algorithmic. The concerns in medical decision making as noted by Yves and others is that if
your data/knowledge you base your treatment choices on is outdated, or flat out wrong, you
will be doing your patient's a disservice at best and harm at worse. In these situations
evidence based medicine should be used as a guide. Where evidence based medicine runs into
trouble, is two fold. One, when the guidelines are based on flawed evidence/data, and two,
when they are no longer used as a guide, but as the law.
So in that case you may
statistically help the population at large, based on the data at hand, but at the cost of
doing preventable harm to a large cohort that could have been picked up by rational
clinical decision making. This is where the "Art of Medicine" should theoretically be
superior. The problem with the art of medicine, is that it takes time as it comes with
experience. Much more experience that one can learn in medical school or residency.
My suspicion is that those early in their careers would benefit from practicing a high
level of guideline based medicine until they gain experience.
With experience, the guidelines should still be understood but there is more flexibility
to stray from the guidelines for individual patients based on patient preference and
physician experience.
For those in the late stages of their careers, it is again important to understand and
try to follow the guidelines so as to not become outdated in your practice knowledge.
At all three stages, one must understand the rational and methodology of the guidelines
figure out which guidelines are to be used for most cases and which guidelines are just
that, a guide.
Above, I speak of how to practice medicine without consideration of how to pay for it.
Now when you start adding payments, reimbursements, and insurance claims, you add another
level of complexity, bias, and incentive. It appears the free market insurance model is not
working, as well as the fee for service model. Here the trick is to change the way medicine
is reimbursed and incentivized.
I am a practicing internal medicine hospitalist in a major US city. While in the past,
there were large delays in physicians taking evidence-based practice and turning it into new
habit and too much unwanted variation in clinical practice -- I feel like in the US, the
pendulum is swinging too far the other way -- and in unintelligent ways, forcing clinicians
into care protocols without regard for individual circumstance. Now there are clinical care
guidelines from Medicare, the American Heart Association, the CDC, and others around major
disease states (like stroke, heart failure, sepsis) that hospitals must follow for
reimbursement -- yet the guidelines do not keep pace with current peer-reviewed evidence.
My point is that there are mandates and financial incentive for hospitals to pressure
physicians into adhering to guidelines which are not universally good for patients or for
cost of care (sepsis guidelines now are a good example of this). Often these expectations are
negotiated by bureaucrats, not clinicians. The healthcare industry needs a better way of
giving physicians real-time feedback about their clinical practice habits in relation to
their peers -- - and having some common-sense expectations around unwanted variations in
practice.
Hopefully you can get yourself on some committees dealing with these issues. Very
important to have physician input.
Economics is definitely important, not only for improving the hospitals bottom line but
for making medicine economically responsible generally.
Single payer, I think would be great but we still need to watch what we are paying for. No
need for pharmaceutical companies to make outrageous profits.
One interesting area now is that many very expensive tests are becoming available for
cancer testing. These need to be ordered responsibly and that takes physician, social and
admin input. And at a deeper level needs to examine why the tests, drugs etc are so
expensive.
Tranylcypromine – first generation antidepressant and still the gold standard for
effectiveness (the "cheese effect" side effect has been overblown as numerous studies have
more recently shown – I'm on it and can confirm this) costs the NHS over £1000
per month for me. It's been off patent for 50 years. However there is a monopoly supplier
(price gouger). Why don't generic suppliers move in? Because the market is too small. Two
generations of doctors have been taught that this class (MAOIs) are akin to leech therapy.
Thus the assumption is that most people on them will be old and will die off. Scandalous, as
any psychiatrist worth their salt will tell you (never mind the health economist like
me).
Prime case of cr*pification in medicine if you ask me. Doctors bowled over by the drug
companies selling SSRIs/SNRIs which let's not forget don't even work as the pharmacology says
they should – they should show benefits at day 4/5 like MAOIs if their original
pharmacological justification is paid attention to. Now does that mean they don't work? No
I'm not saying that. But their method of action is clearly odd and not in line with the
original pharmacological data and models.
Health economics 102 is derived demand – patients rely on doctors to enunciate their
demand function. But when doctors have effectively undergone the medical equivalent of
regulatory capture then Houston we have a problem.
Thanks for the reply. The problem here is that patient advocacy requires systemic change:
change in the medical curriculum along with a concerted effort to tell GPs about the new data
on "old" drugs And they are already overburdened with stuff "coming at them from on
high".
Plus even if (say) they learn the real data concerning MAOIs they still can't prescribe
them straight off A psychiatrist must initiate it (then GP can carry on) And mental health
services are close to breaking point. My local service is at critical levels. Austerity yet
again .
I was going to a physical therapist practice for spasticity and weakness and pain related
to a pretty radical cervical laminectomy and progressive spine problems. I was a Medicare
patient and they insisted on using the guidelines for rehabilitation after operation, even
though my operation took place 12 years earlier. This consisted of exercises which only made
my spasticity worse and aggravated my arthritis. What I needed was to have my chest and arms
worked on to counteract the contraction of muscles caused by spasticity, which the therapist
knew how to do. But she refused and told me that If I did not do the exercises, she would no
longer treat me as I was violating the "guidelines", which did not apply to my circumstance.
There was apparently nothing to allow treatment for chronic problems (except opiods, which I
refused).
Sorry to hear that. I had reason to look at the UK guidelines on a range of conditions
(from NICE). I was actually pleasantly surprised: although they do in many cases follow
"stepped care" functions from medicine, there were a surprising number of "get outs"
regarding if the patient cannot tolerate /has good reason to reject the official guidance.
Patient preferences have begun to get recognised in the UK.
Of course whether austerity allows the doctors to *afford* differences is another sad
story .
I guess that what I need now is what amounts to palliative care (non-pharmaceutical). I
find now that I have discovered high-CBD hemp (Otto II strain) which I can grow myself, I can
actually slow down the progressive effects of my condition. Ironically, though I qualify for
the medical marijuana card, I can't afford to buy from the dispensaries, and they mainly
offer high THC strains anyway. I am lucky to have found a way to treat myself!
American Family Physicians defines
overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of
a clinically meaningful net benefit, where net benefit equals benefit minus harm. "
Over-treatment involves actual procedures performed on a patient, often surgically.
Unnecessary cardiac stents is one example and is a real epidemic due to excessive green and
pervert incentives.
Notable quotes:
"... By Lambert Strether of Corrente. ..."
"... Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments. ..."
"... The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast. ..."
Over the past, oh, decade or so I've been so consumed with the battle to get everybody into
the heatlh care system -- "Everybody in, nobody out," as Quentin Young puts it
-- that I haven't put much energy into thinking about the heatlh care itself. After all, just
because a house is energy inefficient doesn't mean that it's OK to leave people out in the
cold. Now that single payer is no longer
"never, ever," but a program that could actually be achieved with (an enormous) level of
effort, KHN's new series, "Treatment Overkill," which starts with Liz Szabo's
"So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients' Ills,"
provides me with a change to broaden my scope a bit, with a survey post like this one.
So I'm going to look at two issues: (1) Is overtreatment a real problem? and (2) What are
the causes of overtreatment? Spoilers: Yes, and it's complicated.
Confession time: I'm the sort of person who doesn't get the idea of deductibles at all; I
can't understand why anyone would seek out medical treatment unless they were
absolutely sure they needed it. And the reason I fear the health care system is, in fact, the
prospect (painful) overtreatment; the dental clinic that was going to give me full anesthesia
to remove a wisdom tooth; or my nightmare of "end of life care" hooked up to a machine in a
nursing home in a room with a television I can't turn off.
Overtreatment Is Real Problem
Evidence for overtreatment[1] falls into two categories: Anecdotes, and studies and surveys.
I'll look at anecdotes first.
"Anecdotes" isn't really a fair word, though; most of the stories are more about entire
vertical markets (for example, stents, as we shall see). Szabo starts out with this
example:
When Annie Dennison was diagnosed with breast cancer last year, she readily followed
advice from her medical team, agreeing to harsh treatments in the hope of curing her
disease.
"In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent
six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she
said, because she had no idea there was another option.
Medical research published in The New England Journal of Medicine
in 2010 -- six years before her diagnosis -- showed that a condensed, three-week radiation
course works just as well as the longer regimen. A year later, the American Society for Radiation
Oncology , which writes medical guidelines, endorsed the shorter course.
In
2013 , the society went further and specifically told doctors not to begin radiation on
women like Dennison -- who was over 50, with a small cancer that hadn't spread -- without
considering the shorter therapy.
"It's disturbing to think that I might have been overtreated," Dennison said. "I would
like to make sure that other women and men know this is an option."
(Note, sadly, that Dennison immediately puts the onus on the consumer patient to
be informed; an obvious tax on time, to be paid with the patient has the least time or energy
to spare, instead of looking for the systemic solution she vaguely hints at with "would like to
make sure." This impulse is a topic for another post.)
Nobel Prize Winner Bernard Lowns gives a second example
in this interview (after demolishing "bed rest" for heart attack patients as "a form of
medieval torture" as well):
[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Women's Hospital in
Boston] in 1960, I was asked to see a patient who was in her late 70s, demented, and had
burns over 60 percent of her body. She had been smoking in bed. They asked me to consult
about putting in a pacemaker, which she did not need. Furthermore, she was clearly dying, and
implanting a pacemaker would only have increased her suffering without prolonging her life. I
was mortified. I wrote a note urging against a pacemaker. It created quite a rumpus. If that
were an isolated episode, it would be tragic. But that kind of thing happened daily.
Here is a third, and egregious example, from Health
Beat :
Over the weekend, the New York Times published a
head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in
Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially
dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A
hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to
2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.
The Baltimore Sun broke Dr. Midei's story in January. In February the U.S. Senate
Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the
Finance Committee released a 1200-page report..
The report reveals that Midei was a favorite son of Abbott Laboratories, the company that
manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy
doctor had inserted 30 of the company's cardiac stents into trusting patients in a single
day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked
pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees
from St. Joseph's attended the feast.
(It may seem that I'm stacking the deck on causality here, but I'm really not, although it
would be foolish to deny that such cases exist.)
Note again that these examples all involve treatment : Radiation treatment, a
pacemaker, and stents. We're not talking about ordering a few two many tests. ( The American Family Physican
supplies numerous classes of overtreatment, not just anecdotes. See Table I.) Now to
the studies and surveys.
"Overtreatment in the United
States," by Heather Lyu, et al (from the Public Library of Science, and thus peer-reviewed)
has induced a good deal of discusson since its publication in September 2017. From the
Findings:
The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of
overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of
tests, and 11.1% of procedures.
Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot
of stress and fear induced for no reason. And if one out of every ten treatments is unncessary,
that's rather a lot of people going to Pain City because their number came up, and not for any
medical reason. Those odds aren't quite as bad as Russian roulette, but they'e in the ballpark!
I haven't (yet) been able to find figures on the costs of overtreatment, but there have been
studies done on the costs of unnecessay care. Health
Affairs :
Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of
total health care spending. Even the lower estimate,
from the Institute of Medicine , amounts to nearly $300 billion a year. No specialty is
immune from practices that lead to overuse, as a recent spate of papers in medical journals
can attest. In cardiology, even using criteria that are relatively permissive, an estimated
11 percent of stents are delivered to " inappropriate patients ." At some hospitals,
that rate is closer to 20 percent.
(Note that the figure of 11% unnecessary stents jibes well with Lyu's figure of 11.1% of all
procedures being unnecessary.)
I'm sure none of this is new to any medical professionals in the NC readership, but it was
new to me, and may well be new to NC readers -- especially those who received treatments that
they retrospectively, or just now, understood to be unnecessary.
The Causes of Overtreatment
It's clear that one cause for overtreatment is the profit motive. (I would
speculate that individuals like Midei, the stent dude, are edge cases, and that the real causes
are more subtle and systemic.) Quoting again from Lyu, et al. :
The top three cited reasons for overtreatment were "fear of malpractice" (84.7%), "patient
pressure/request" (59.0%), and "difficulty accessing prior medical records" (38.2%)
Seventy-one percent of respondents believed that physicians are more likely to perform
unnecessary procedures when they profit from them. The interpolated median response for the
percentage of physicians who perform unnecessary procedures with a profit motive was 16.7%;
28.1% of respondents believed that at least 30–45% of physicians do so (Fig 2).
Respondents who were attending physicians with at least 10 years of experience (OR 1.89
(1.43–2.50) vs trainees) and specialists (OR 1.29 (1.06–1.57)) were more likely
to believe that physicians perform unnecessary procedures when they profit from them
Respondents' compensation method and hospital characteristics were not associated with
differences in perceptions on the profit motive associated with unnecessary care.
So, the more experienced the doctor is, the more likely the doctor is to believe that profit
drives unnecessary procedures. However, the profit motive imputed to individuals cannot be the
sole driver (see "DICE: Nonclinical
Causes of Overtreatment" for a model that includes "Economics" without being reductive) as
this letter in the
British Medical Journal shows :
As a person who follows the evolution of health care policy from the vantage point of the
United States, I found BMJ's May 12 article on "Choosing Wisely in the UK" [see here ; CW is an "informed consumer" model]
very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a
culture of "more is better" fostered by such factors as "defensive medicine," "patient
pressures," "commercial conflicts of interest," "payment by activity," and the demands of
"pay for performance."
Many critics of the American health care scene ascribe the problem of irrational
overtreatment unsupported by available evidence in the U.S. to precisely the same causes, and
argue that the key to rationalizing American medical practice lies in adoption of the UK's
single payer, universal coverage health care system and the UK's system of civil justice. The
fact that a Choosing Wisely program is necessary in the UK, and for most of the same
underlying reasons as apply in the U.S., proves that the UK has not found the panacea to
achieving rational medical practice and that emulation of the UK methods of health insurance,
physician payment, and civil justice will not work as a panacea in the U.S. either.
So, sadly, single payer as such is unlikely to solve overtreatment (although I
can't think of an advocate who ever said it would).
Conclusion
If there were one kind of doctor-patient relationship that I would like to see incentivized
when single payer comes to pass, it's this one.
Again Dr. Lown :
U.S. News: Problems with America's health care system are economic, but they are also
human. What's been lost in modern medicine?
[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health
care system. I think that you cannot heal the health care system without restoring the art of
listening and of compassion. You cannot ignore the patient as a human being. A doctor must be
a good listener. A doctor must be cultured in order to understand where the patient lives,
why he lives like that, and also realize that the leading cause of disease in the world is
poverty.
Call me Polyanna, but I think if the health care system started treating patients like human
beings, that a good deal of overtreatment would be avoided.
NOTES
[1] Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves
actual procedures performed on a patient, often surgically. In other words, lots of pain and
suffering imposed to no good purpose. (Szabo's article considers all three, but I am focusing
only on overtreatment.) American Family Physicians defines
overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of
a clinically meaningful net benefit, where net benefit equals benefit minus harm. "
I worked as a disability advocate for years, which is a high volume practice. I read
literally tens of thousands of medical records during that time. I can say, unequivocally,
overtreatment is an issue.
Causes are far more difficult to deal with. The high cost of medical care is a reflection
of the low quality of life many USAians are living. Listening is a good start, but far from
the answer. Getting everyone in the system, so that more preventative medicine can work,
avoiding patient demanded surgeries with low-probabilities of success would help as well. But
even these two are just the tip of the iceberg.
In disability, chronic physical ailments mix with unemployment to form a deep pool of
depressed individuals. Even with access to great healthcare (which few have), the advice to
exercise, stretch, and eat healthy that would improve many conditions (spinal stenosis, other
arthritis and orthopedic issues, obesity, heart disease) is worth very little. In a depressed
state, changing long term habits into healthy ones is very difficult, and the prevalence of
patients seeing a professional to make behavioral adjustments in concert with their disease
treatment is few, not counting those that show up to the psychiatrist for medication
regularly.
This is why single payer, jobs guarantee, and redistribution tax policy are necessary
together.
After a car wreck, both of my parents were hospitalized for a week. During that time, I
got a lot of phone calls from the hospital, and many of them related to getting my permission
for this, that, and the other test on my mother. Dad had Alzheimers, and, lucky for him, he
evaded the endless tests. I guess the doctors figured that he wasn't going to live much
longer, so what was the point? (He died nine months later.)
One of the phone calls really stood out. Mom was anemic, and the doctors wanted to do a
colonoscopy to find out why. "Malnutrition!" I said. Loudly.
This had been a problem for years. Mom and Dad simply weren't eating enough. I'll get back
to that point in a minute. But let me say that I refused the colonoscopy for my mother. In
addition to being very invasive, I thought it was unnecessary.
Anyway, Mom got sent home and Dad was discharged to a nursing home. Once he was separated
from my mother, he started eating like a horse. Gained 15 pounds in less than three months.
Then he started losing weight and the nursing home sent him to hospice. In his case, that was
the correct call.
Let's just say that my mother still has issues with food. Not a new problem. I remember it
from my childhood. But she does have caregivers who insist on proper nutrition. And she
complies.
Last time I spoke with Mom's doctor, he didn't say anything about anemia. Sounds like
that's no longer a problem.
General Practice doctors are hugely important in the healthcare system. They are the
traffic cops that direct patients to the appropriate specialist. They do most of the
listening.
I think specialists are more likely to zero in on the "problem"
Call me skeptic after being a practioner of Medicine over 40 years! I was a GP before got
trained as Diagnostic Radiologist after nearly 5 years of residency. I also worked as ER
Physician in early years. I am also licensed to practice in Ontario(Canada) but practiced
only in USA after the residency training!
A Diagnostic Radiologist is called ' a doctor's doctor" since the myriad of imaging exists to
help the clinical diagnosis. I came across virtually all kind of specialists, medical and
surgical kind! Ifound out to whom I wouldn't even send my 'dog' for treatment!
There are ethical and morally conscious docs, but they are in the minority!VERY FEW!
A specialist is like a HAMMER, s/he sees everything as if it is just problem of NAIL!
Surgeon thinks through SCALPEL. Go to Pulmonologist, more likely you get bronchoscoped
(needed or not), Gastroenterologist – gastro or colonoscopy, so on!
Imagine going to a restaurant where the waiter got to order for you.
"You want the steak? OK better start off with these two appetizers I think you'll
like.
You'll need some wine too. There's a 1994 Cabernet that will pair great with this. I'll
mark
that down. The cost? Oh don't worry about that, your dining insurance will cover it.
Now for dessert. They're all so good, I have picked out three for you. You don't need
to finish them. Now I'll just add in my customary 25% tip (I am highly trained) and we'll
call it a meal."
As a regular lurker here, it's great to see you on this beat Lambert. We've been on this
for awhile now at the Lown Institute. I refer you and the rest of the commentariat to a
series we did in the Lancet which is here:
The Drivers paper is pertinent as a description of the ecosystem of bad care.
If the patient is the one who controls the payment, things may improve. Right now with
insurance, there is no one to one relationship between the patient and the health provider.
Insurance companies stand between the patient and payment. Even in the case of single payer,
if the patient is given incentives to get second opinions and refuse unnecessary treatment,
things may work better.
Single payer is likley to require second and if need be third opinions for non emergency
surgery. Most insurance pays for a second opinion if you want one (and would be a fool not to
get) and if need be a third opinion if the first and second don't agree.
Kip Sullivan unequivocally disputes the "overtreatment" meme To the contrary, we are under
treated in the US ..
Please read:
"The Health Care Mess: How we got into it and how we'll get out of it" by Kip Sullivan ..
Over treatment: My mom's story. From several years ago.
So I was the guardian for my very (VERY) demented mom whom we kept at home, at great cost
but also great benefit to her. She had a basal cell tumor on her forehead. About the size of
a nickel. She was 90 at the time. I live in one state, she the next state over about 2 hours
away. She had full time help at home.
So one of my innumerable trips to help out and oversee, involved taking her to her md
appointment at Brigham and Women's. She had a wonderful gerontologist, who referred me to a
dermatologist affiliated with B &W. Her care giver took her a few weeks later and I got a
call from the dermatologist, a young woman. Now I'm an old woman but a trained m.d. in
Internal Medicine. I also knew (by then ) a great deal about dementia. And especially
dementia in my particular mother.
So when the dermatologist called me she said "your mom needs a MOHS procedure". Well, a
Mohs procedure is an 8 hour stop and go procedure. They keep cutting until the margins are
clean. They cut, send the specimen to the lab, wait for the result and cut again. Patient is
awake the whole time so there's no anesthesia risk, but 8 hours on a table for a woman with
advanced Alzheimer's was not going to work. I told the dermatologist that there's no way my
mom could tolerate that. The dermatologist got irate. Tried to scare me by saying, "the tumor
could grow into her brain!". I said, "mom's 90, she'll be dead b/f the tumor goes
anywhere!"
They were so intent on this procedure and challenged my right to speak on mom's behalf. so
.. I had to fax PROOF of my guardianship for them to let me have the last say. I was pretty
discharged. And complained bitterly to the referring doc when we saw him next . and he
mentioned that my complaint wasn't the first.
Then I found out that the MOHS surgeons get a ton of money at the places they work, like
$700,000.00 / year.
Thank you for sharing. It helps to know I am not alone in such experiences.
I often wonder how epidemic stories like yours are. I feel like I could write a whole book
based on personal experiences along with those of family and friends. A person really has to
educate oneself just to avoid being robbed blind or worse yet harmed, and you at least have
the fortune of a medical education. To have to education oneself (trying to filter all the
misleading 'marketing' information and quacks out there) on complex medical procedures on top
of everything else is exasperating beyond words.
How long do we, and those we care about, have to continue suffering the indignities and
malfeasance of a broken and corrupt (not worth using euphemisms to debate the issues at this
point anymore) healthcare system?
The underlying premise of "modern medicine" is flawed. It dumber than Medieval
bloodletting.
Allopathic medicine is brilliant for catastrophic events. In the case of paraplegic
injuries, over the last 50 years, their survival rate, in the first two years after the
injury, has increased dramatically. However their long term life expectancy is about the same
as it was 50 years ago.
Trends in Life Expectancy After Spinal Cord Injury
"Results
Other factors being equal, over the last 3 decades there has been a 40% decline in mortality
during the critical first 2 years after injury. However, the decline in mortality over time
in the post–2-year period is small and not statistically significant ."
We are bamboozled by the "complexity" of the modern medicine model, BUT, "it" is stupidly
simple. They define a "normal" range of numbers. This range is arbitrary and always changing.
What is normal cholesterol? PSA? Blood sugar? ferritin? vitamin D?
Then they subject the patient to an array of blood tests, x rays, scans, urine tests
Then, the allopatic doctors use drugs or surgery in order to get your test numbers in the
normal range.
Before you know it, the patient is on 15 drugs. They cannot sleep so they are prescribed
sleeping pills. Then they are depressed, so anti-psychotics- Finally Oxycontin for the
constant unbearable pain.
Allopathic care in NZ is cheap, readily available, but a death trap for the trusting
(except for catastrophic events). USAians pays hundreds of thousands of dollars for misery
and drug induced ill-health.
If cat poop (feces) were cheap and available in one place (NZ), but outrageously expensive
and rationed in another (USA), it is still, basically, just cat shite.
The problem is for profit healthcare. The more tests and treatments, the higher the
managers bonuses. There is no regulation except for the insurance companies who are only
interested in their own bottom line. The patient is not in a position to rationally oversee
their care by themselves. All that matters today is profits; no matter how they are achieved.
That is why American life expectancy is decreasing. Besides giving everyone healthcare; a
system of primary physicians, government oversight of hospitals and care facilities plus jail
time for criminals are also needed.
I have relatives by marriage who live in southern Indiana near the Kentucky border. They
are "respectable working class," and I guess they must have good health insurance. I have
never known anyone to have so many surgeries. It is astounding. Cardiac surgeries and
orthopedic surgeries, for the most part. The ones I have in mind are 58 and 62 years old;
they have never smoked; they go to Mass every Sunday, they have been happily married since
they were young and while they don't eat health food they don't eat every meal at McDonald's.
But it is surgery after surgery after surgery. They never question the doctors; they never
hesitate. And now, unfortunately, some consequences of the surgeries are coming due; the guy
is in the hospital with infections both in his pacemaker and in his heart valve (they just
replaced both; he'll probably be okay). No-one else I know has surgeries like this. I think
it is a regional scam. It's true that my dad in CT has had a number of vascular surgeries,
but he smoked for decades and the dire need for them has been very apparent.
Here in northern CA, I have a friend whose girlfriend's son went to the emergency room a
number of years ago for a bad finger cut. He was told he needed amputation. Then they found
out he had no insurance. He was told to use a salve, and in fact it worked fine. I also have
a friend here in Silicon Valley who recently had digestive problems. The MRIs, CAT scans, lab
tests and probings under sedation were endless. Finally she was told to stop eating acidic
food.
Reducing the profit motive as much as possible is why I would prefer a National Health
Service (call it VA for all). Insurance, even if it's single payer, is still open to fraud
and overtreatment. Let's try to think of medical practitioners as professionals rather than
entrepreneurs, and get them to think of themselves that way. I also see it as a possible way
to reduce the very high premium given to specialists, so that more would go into primary
care.
In modern Medical practice, PROCEDURALISTS ( Surgeons of all kind, Cardiologists,
orthopods, Pulmonologists, gastro enterologists anfd of course, invasive and diagnostic
Radiologists etc ) always get compensated more than the primary care providers!
There are more CPT codes to charge for specialists than the GPs or FPs
Medicine is business run by 3rd parties! Vested interests won't allow any challenges to
status quo, just the banking system and the FIRE Economy!
With all due respect, if the UK system has embraced, "commercial conflicts of interest,"
"payment by activity," and the demands of "pay for performance" then that means they have a
substantial set of profit incentives already in place, rendering their medical system *more*,
not *less*, similar to America's. They may have single payer but that just captures the
monopoly rents by regulating the cartel/monopoly/utility or whatever you want to call the
medical establisment (it's per se difficult to even talk about market competition when
there's only one drug or treatment that will save a patient).
The unregulated private provision of public goods like medical care always leads to
extortion for profit. If you privatize fire-fighting, entire cities will burn to the ground.
If you privatize schools, you get ignorance. If you privatize prisons, you get
kidnapping-for-profit and the highest incarceration rate in the civilized world.
If you privatize the military, you get endless war. Why would a for-profit business ever
win a war? For that matter, why would they ever lose? The war's over and they'd be out of
money. You think it's just a coincidence that in the age of corporate personhood (Citizens
United) and unlimited bribery of public officials, you've had two of the longest, most
expensive and least determinative conflicts in our history in Iraq and Afghanistan?
You think it's a coincidence that the more unregulated "markets" we through at medicine,
the more expensive our medical care becomes and the sicker we all get?
Cures don't make money. Repeat customers do.
Show me a for-profit business that's in business to go out of business and I'll show you
the perfect company for insuring against social hazards.
It's simple middle-manager fraud. Politicians love privatizing government because they get
to pocket the public budget. When the marines or public school principals hand tax dollars
back to politicians and their cronies, everybody goes to prison. Privatize it and then you
can have the contractor or charter school give you "campaign donations" – no doubt
celebrating your economic genius in the process. They can hire your spouse and cousins. The
contractor can even bid up the real estate and then rent it back to themselves at exorbitant
prices. There are a million ways to launder the money.
Why do you think there is no transparent public accounting on most of this stuff? The
budget disappears into a black hole – which, incidentally, you'll discover the minute
you're in a hospital, dealing with a pharmacy benefit manager (PBM) or health insurer. That
was the true purpose of MERS – to make good mortgage information disappear so CDO
purchasers would never know what was in the mystery meat.
This is the great unraveling of Progressive Era controls on public corruption.
If you pay a dotor for every surgical screw he installs, is it any surprise then that a
diabetic winds up getting several in his spine he never needed?
This is also how we have set up the aluminum and copper markets, letting speculators buy
and horde commodities to drive up the price. It's also how we run drug distribution under the
PBMs. PBMs provide a kickback in the form of a "stocking fee" to pharmacies which would get
people sent to prison in other industries. When derivatives traders are not end consumers or
producers of a commodity, they bid up prices the same way. We actually give pharmacies a
profit incentive to drive cheap, effective, public domain chemicals off the market in favor
of expensive, privately patented medicines. Because they are expensive, they pay a greater
kickback so the pharmacy has greater incentives to stock and push it.
When railroads charged both farmers and consumers shipping and receiving food, it
bankrupted both sides of the transaction by creating incentives to reduce supply in the
monopoly transportation network. Reducing rail capacity bid up transportation prices and
saved the company on investment. That's how you raise profits: raise prices, lower expenses.
They had no rival to compete. That's why these kickbacks were outlawed. Imagine if the post
office made you buy a stamp for every letter you receive. Oh, wait. We have that with the end
of net neutrality. The ISPs get paid both by the service supplier (e.g., Netflix) and by
their "customer" (you and I).
You this same "rationing" take place now with drugs. Since legalizing PBM kickbacks, drug
prices have soared and we've lived through some of the greatest drug shortages since the
Soviet Union went bankrupt. Hundreds of chemotherapy patients per year have died because
cartels control supply and they don't like patients getting cheap, efective, public domain
treatments. Go look at the availability of methotrexate over the last ten years or your
platinum-based compounds. No one tells you this. It's a blip on the back page of a newspaper
(and pretty soon we won't even have those). Do you think TV "news" – making its profits
off drug ads – will ever talk about this?
It's a new war of enclosure – and it's far more extensive than simply drug markets.
The privatizers are confiscating clean air, potable water, healthy food, public education,
public policing and a host of other "general welfare" functions of the government promised us
in the preamble. It all traces back to the ideology of for-profit government – which,
in technical political science terms, is called fascism – when businesses own and
operate the government for private gain.
By the way, we don't need less testing in medicine. We need more. I don't know a single
idiot in Silicon Valley who ever said we need less data collection. The simple fact is we
need to test everything in a patient and compare everything we collect across thousands of
diseases. The cost of sensors and DNA sequencing, imaging and protein detection – not
to mention data processing – has been falling dramatically and yet "reformers" always
stress "rationing" as the cure for health care prices. It's partly because we ration
preventative medicine and diagnostics that we're in this situation.
Another great place to start would be separating diagnostics (evaluation) and treatment.
Would you let the bank's chief loan officer also serve as the chief auditor? Yet we let the
same doctor diagnose, treat and evaluate his own work.
As someone with serious chronic illness from these frauds, listen to me when I tell you we
should be practicing medicine thousands of patients at a time with transparent public
auditing and big data model building. Building my own private model of genetics from public
research saved my life. Nobody does that for you in medicine. Nobody is paid anywhere in the
system based on whether you get the cheapest, most effective and safest treatment; in fact,
I've heard of people getting fired for exactly that.
You've answered your own question. No single measurement, in isolation, is 100% accurate.
That's why we need thousands.
We need a cheap gene array chip that measures 10,000 markers in the blood and we need a
big data project to match those measurements against a baseline. We need cheap, safe whole
body scans. We need measurements of what every cell is up to and how they deviate from the
norm.
Nobody's very angry that cell phone cameras keep getting better, yet somehow we're always
upset that doctors want plenty of tests. That camera is a sensor that measures our
environment and the chip gets better and cheaper each year. We need the same attitude in
medicine. But then cardiologists might get upset that an immuno-assay shows you're at risk
for atherosclerosis. These guys still don't want to accept that clogged arteries are an
immune system problem and the immune specialists don't want to accept that it mostly gets
started in the gut. And the gut guys don't want to have anything to do with immunology or
cardiology.
I'll have to read the post this evening, but I have something to add to the theme:
I was in a meeting where a prominent local single-payer advocate, an emergency room
doctor, told us, passionately, that administrative costs were only half the problem,. or
less. Overtreatment and overtesting were the bigger part. He blamed the doctors, but of
course their billing practices are a big factor.
A big advantage of single-payer is that it creates an institution with the power and
motive to change medical practice. Iatrogenic illness is a big factor; overtreatment can
kill.
My wife has some chronic health issues and is a regular visitor at–and occasional
guest of– the Mayo Clinic, traditionally seen as the home of "integrated medicine"
(i.e. the various specialties speak with each other). We count ourselves ridiculously,
ridiculously fortunate to be able to so often and easily rely on the oft-named best hospital
system in the world. That said, it's amazing to both of us, even there, how silo-ed medicine
has become. This silo-ing HAS to create an inordinate amount of overtreatment. The
generalists, however, are left far behind in the community practices, often not able to do
much beyond prescribing antibiotics and making referrals. There is a LOT of need for more
holistic thinking about the patient that modern western medicine has lost, likely
inadvertently, as greater knowledge leads to the need for greater specialization. The gap of
some type of "master generalist" (which would of course be another layer of expense in the
healthcare system) is filled either by the patient (of patient's family) or left void. As a
result, there's either a huge tax of time, stress, frustration spent searching internet chat
boards and medical reference sites to understand topics because it seems like no single
doctor "gets it", or a hugely inefficient and potentially quite harmful medical treatment
experience as each specialty chips away at their corner of the patient. I'm not sure what the
answer is, but if this is the experience of a frequent Mayo Clinic patient, I'd wager that
the question posed is a pretty fundamental one to the entire practice of modern medicine.
I would add an extra 'over' to your list – overdiagnosis.
One of the the few bright spots in published stats for the US compared to other countries
is an apparent higher survival rate from cancers. I mentioned this to a relative who is a
medical specialist and he just laughed. 'its not surprising' he said 'since an amazing number
of those treated in the US for cancer don't actually have cancer'. Quite simply, overuse of
dubious 'tests' results in a huge number of false positives for cancer. This leads to
'successful' treatments. There are many tests in the US which are simply not permitted in
countries with public systems because they produce far too many false positives to justify
their use, either because the cancer doesn't exist, or it is not sufficiently malignant to
justify treatment (apparently there are cancers that lie dormant without ever threatening
life). I'm not aware, however, if this has ever been quantified, but its certainly true that
there are many testing protocols commonly used in the US which are actively recommended
against in most European health systems as they are considered not just a waste of money, but
actively harmful.
A relative of mine who is a very highly regarded specialist in drug prescribing practice
in Europe is currently doing a one year study on practice in the US (focusing on opiates, as
it happens). He said that one of the initial findings is that there is a different culture
around prescribing in the US to what he is familiar with. Quite simply, US doctors are not
taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been
given a brush off.
Someone mentioned overuse of heart operations above. In Ireland, they developed what are
called ' Sli
na Slainte ' walks, which have spread worldwide. These were developed by the Irish Heart
Association following complains that patients were asking for too many drugs and treatments,
and not doing the simple thing which was shown to help in the aftermath of heart attacks
– exercise. They are way marked walks of set distance – doctors simply prescribe
the walk instead of drugs. They are hugely successful. But there is no money in it, so guess
where they haven't been adopted?
*disclaimer* I should say I'm not a medical professional, but I do have an interest in the
topic.
Thank you, PK. Very interesting, and follows from a thoughtful and insightful post from
Lambert, but I guess it makes common sense to strengthen heart muscle and accelerate the
body's natural ability to heal itself through exercise. Pity about the commonness of common
sense though, but I digress.
We all know we can live longer and avoid or postpone chronic ailments by maintaining a
healthy weight and doing some exercise, particularly cardio. And our arms and legs may look
the same over our declining years, but if you don't use them, you will lose them, those
muscles that is.
I post. that such an ideal is too far when you are time and money poor, constantly worried
and depressed
Poverty and sickness and lower mortality – they're all linked to one another.
Designed and baked into the dying system
None or too little, or too much, and very occasionally just the right amount of medical
care for the lucky few. What a mess.
I'll add that the elderly, and the poor's, opinions seem to be discounted by caretakers as
if you are lucky enough to be old or unlucky enough to be destitute means you're soft in the
head. So if a patient can understand and communicate what they want and realistically need
they have to fight to be listened too.
Four years ago my father who was 78 at the time began having difficulty eating. He had
been diagnosed with parkinson's a couple years earlier but the meds he was on were acceptable
and effective for him. He was a brilliant physicist. Well they did a colonoscopy and found
tiny tumors. One couldn't be taken care of at the time and the process to his death began. No
one knew how long the tumor had been there or at what speed it would grow but chemo and
radiation were prescribed to make it easier to remove. This became a very long sad story
which I will not go into detail on right now. The chemo made my Dad horribly sick. The
radiation to pin point a tiny area less than the size of a quarter ended damaging all his
organs. He died in pain on Thanksgiving morning 2 years ago. The radiation had done too much
damage. When he asked questions about treatment he was shuffled to diffident doctors or just
not answered. These were very high end NE Medical facilities. The reason he went in for
digestive problems never were fixed. Had the tumors never been addressed he could very well
be alive today. To date I have over 5 friends who have had a parent die not from the
condition they sought help for but the radiation treatment.
For me the problems start with the routine physicals which are "free" courtesy of
Obamacare. The doctors run tests and find problems with this and that, and after ultrasounds
and CT scans and little surgeries to get rid of benign little thingies, before you know it
you've spent thousands of dollars (courtesy of high deductibles ) for basically nothing. This
last time around my GP didn't like a few things in my lab results and I ended up with a
specialist. He started off with "why are you here to see me today?" After questioning me for
a little while about my (lack of) symptoms, I finally told him, "I never would have come here
on my own if my doctor hadn't have sent me here."
[DR. LOWN: In my view the lost art of listening is a quintessential failure of our
health care system. I think that you cannot heal the health care system without restoring
the art of listening and of compassion. You cannot ignore the patient as a human being. A
doctor must be a good listener. A doctor must be cultured in order to understand where the
patient lives, why he lives like that, and also realize that the leading cause of disease
in the world is poverty.
Medicine is becoming more dehumanizing. This is not only structural due to shorter patient
visits, less face to face interaction, fewer family physicians treating the whole family,
visiting the patient at their home, to see what their environment/neighborhood is like. It is
also the way physicians practice medicine, treating patient's as mere data sets. I'm not
trying to minimize data in medical decision making, but taken out of context from the human
element, treating data may be misleading and may not be treating the patient's ills.
In my experience, when I see a patient coming in over and over for the same complaints, it
is likley due to one of three main reasons. One, they are either being misdiagnosed and
mistreated, two, they are seeking a special test or drug, or three, their symptoms are not
due to an organic medical cause, but due to some sort of somatization secondary to life
stressors. Trying to figure out which it is requires the clinician to listen to the patient
and understand where they are coming from. Unfortunately, when a primary care physician only
has 10 minutes per visit, it is much easier to order a battery of tests to not miss any
important diagnoses, or to just capitulate to patient demands than to listen, and in many
cases take the time to give the patient some much needed reassurance.
That being said, the patient is not always an innocent bystander in this. There are also
many times that the clinician will pick up on the dynamics mentioned above, but reassurance
will not satisfy the patient. The patient will demand more be done for a number of reasons.
These are mostly anecdotal, such as I read an article and think I need such and such a test,
or my friend/family member had this procedure done and I need it two. It sometimes takes me
twice as long to explain to a patient why they don't need something done as it does as to why
they do. This is a societal thing and this is linked to the problem of defensive medicine. I
like to joke, that physicians always get sued for not ordering a test that may have been
indicated, but rarely if ever get sued for over treating someone and then causing harm.
Perhaps it has something to do with the ethos that it's better to do something and look like
you're trying that to do nothing, even though that may be the best course for the
patient.
In the end, I think physicians need to be better trained to listen, remember the mantra of
"first do no harm", and treat each patient as if they were their close family member. The
incentive structure in medicine has to also change, including the way physicians are
reimbursed, as well as the way information and clinical data is sourced and distributed to
avoid excess industry bias. And finally, patient's have to understand that more is not
necessarily better, they or their relative do not have a god given right to every
experimental, and outrageously expensive treatment available if it does not apply to them
clinically and if the chances of it prolonging life are minimal.
Overtreatment can't possibly be as big a problem as undertreatment, at least certainly not
in the world of crappy insurance or subsidized care our experience was definitely a solid
reluctance to order expensive tests or to consider that the problem might be complicated and
costly. Which it turned out to be, and the eventual surgery was scheduled as late as
possible, as a last resort, and we had to insist on more thorough testing to get a proper
diagnosis. They just wanted to save money. The tumor grew all the while this organization was
hoping it was something minor. I don't want to hear about overtreatment, thanks -- it seems
to always get distorted into blaming the patients for greedily consuming too much
healthcare!
Very interesting discussion of how the project of mass surveillance of internet traffic started
and what were the major challenges. that's probably where the idea of collecting "envelopes" and correlating
them to create social network. Similar to what was done in civil War.
The idea to prevent corruption of medical establishment to prevent Medicare fraud is very interesting.
Notable quotes:
"... I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere early on the good cops are weeded out and cannot complete training unless they compromise their integrity. ..."
"... 500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance, they also do it to crush dissent, and then give a false rationale for why they're doing it. ..."
"... People are so worried about NSA don't be fooled that private companies are doing the same thing. ..."
"... In communism the people learned quick they were being watched. The reaction was not to go to protest. ..."
"... Just not be productive and work the system and not listen to their crap. this is all that was required to bring them down. watching people, arresting does not do shit for their cause ..."
"People who believe in these rights very much are forced into compromising their integrity"
I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere
early on the good cops are weeded out and cannot complete training unless they compromise their
integrity.
500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance,
they also do it to crush dissent, and then give a false rationale for why they're doing it.
I am wondering how much damage your spying did to the Foreign Countries, I am wondering how
you changed regimes around the world, how many refugees you helped to create around the world.
Don Kantner, 2 weeks ago
People are so worried about NSA don't be fooled that private companies are doing the same
thing. Plus, the truth is if the NSA wasn't watching any fool with a computer could potentially
cause an worldwide economic crisis.
Bettor in Vegas 1 year ago
In communism the people learned quick they were being watched. The reaction was not to go to
protest.
Just not be productive and work the system and not listen to their crap. this is all that was
required to bring them down. watching people, arresting does not do shit for their cause......
"... Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. ..."
"... It found that atenolol didn't prevent heart attacks or extend life at all; it just lowered blood pressure. ..."
"... Of course, myriad medical innovations improve and save lives, but even as scientists push the cutting edge (and expense) of medicine, the National Center for Health Statistics reported last month that American life expectancy dropped, slightly. There is, though, something that does powerfully and assuredly bolster life expectancy: sustained public-health initiatives... ..."
If you are looking for a World Class Global Scam - you found
it documented below
"Stents for stable patients prevent
zero heart attacks and extend the lives of patients a grand
total of not at all"
My takeaway: There are HERO Physicians doing WORLD CLASS
MEDICINE (read article) but they are greatly outnumbered by
those who put the health of their wallet ahead of patient
health...so beware and be aware
'Years after research contradicts common practices,
patients continue to demand them and doctors continue to
deliver. The result is an epidemic of unnecessary and
unhelpful treatment'
by David Epstein, ProPublica...February 22, 2017
*This story was co-published with The Atlantic
"The 21st Century Cures Act - a rare bipartisan bill,
pushed by more than 1,400 lobbyists and signed into law in
December - lowers evidentiary standards for new uses of drugs
and for marketing and approval of some medical devices.
Furthermore, last month President Donald Trump scolded the
FDA for what he characterized as withholding drugs from dying
patients. He promised to slash regulations "big league. It
could even be up to 80 percent" of current FDA regulations,
he said. To that end, one of the president's top candidates
to head the FDA, tech investor Jim O'Neill, has openly
advocated for drugs to be approved before they're shown to
work. "Let people start using them at their own risk,"
O'Neill has argued.
Stents for stable patients prevent zero heart attacks
and extend the lives of patients a grand total of not at all.
So, while Americans can expect to see more drugs and
devices sped to those who need them, they should also expect
the problem of therapies based on flimsy evidence to
accelerate...
...it's not hard to understand why Sir James Black won a
Nobel Prize largely for his 1960s discovery of beta-blockers,
which slow the heart rate and reduce blood pressure. The
Nobel committee lauded the discovery as the "greatest
breakthrough when it comes to pharmaceuticals against heart
illness since the discovery of digitalis 200 years ago." In
1981, the FDA approved one of the first beta-blockers,
atenolol, after it was shown to dramatically lower blood
pressure. Atenolol became such a standard treatment that it
was used as a reference drug for comparison with other
blood-pressure drugs.
In 1997, a Swedish hospital began a trial of more than
9,000 patients with high blood pressure who were randomly
assigned to take either atenolol or a competitor drug that
was designed to lower blood pressure for at least four years.
The competitor-drug group had fewer deaths (204) than the
atenolol group (234) and fewer strokes (232 compared with
309). But the study also found that both drugs lowered blood
pressure by the exact same amount, so why wasn't the vaunted
atenolol saving more people? That odd result prompted a
subsequent study, which compared atenolol with sugar pills.
It found that atenolol didn't prevent heart attacks or
extend life at all; it just lowered blood pressure.
A
2004 analysis of clinical trials - including eight randomized
controlled trials comprising more than 24,000 patients -
concluded that atenolol did not reduce heart attacks or
deaths compared with using no treatment whatsoever; patients
on atenolol just had better blood-pressure numbers when they
died...
...Replication of results in science was a cause-cιlθbre
last year, due to the growing realization that researchers
have been unable to duplicate a lot of high-profile results.
A decade ago, Stanford's Ioannidis published a paper warning
the scientific community that "Most Published Research
Findings Are False." (In 2012, he coauthored a paper showing
that pretty much everything in your fridge has been found to
both cause and prevent cancer - except bacon, which
apparently only causes cancer.) Ioannidis's prescience led
his paper to be cited in other scientific articles more than
800 times in 2016 alone. Point being, sensitivity in the
scientific community to replication problems is at an
all-time high...
Of course, myriad medical innovations improve and save
lives, but even as scientists push the cutting edge (and
expense) of medicine, the National Center for Health
Statistics reported last month that American life expectancy
dropped, slightly. There is, though, something that does
powerfully and assuredly bolster life expectancy: sustained
public-health initiatives...
"Relative risk is just another way of lying."
At the same time, patients and even doctors themselves are
sometimes unsure of just how effective common treatments are,
or how to appropriately measure and express such things.
Graham Walker, an emergency physician in San Francisco,
co-runs a website staffed by doctor volunteers called the NNT
that helps doctors and patients understand how impactful
drugs are - and often are not. "NNT" is an abbreviation for
"number needed to treat," as in: How many patients need to be
treated with a drug or procedure for one patient to get the
hoped-for benefit? In almost all popular media, the effects
of a drug are reported by relative risk reduction. To use a
fictional illness, for example, say you hear on the radio
that a drug reduces your risk of dying from Hogwart's disease
by 20 percent, which sounds pretty good. Except, that means
if 10 in 1,000 people who get Hogwart's disease normally die
from it, and every single patient goes on the drug, eight in
1,000 will die from Hogwart's disease. So, for every 500
patients who get the drug, one will be spared death by
Hogwart's disease. Hence, the NNT is 500. That might sound
fine, but if the drug's "NNH" - "number needed to harm" - is,
say, 20 and the unwanted side effect is severe, then 25
patients suffer serious harm for each one who is saved.
Suddenly, the trade-off looks grim.
Now, consider a real and familiar drug: aspirin. For
elderly women who take it daily for a year to prevent a first
heart attack, aspirin has an estimated NNT of 872 and an NNH
of 436. That means if 1,000 elderly women take aspirin daily
for a decade, 11 of them will avoid a heart attack;
meanwhile, twice that many will suffer a major
gastrointestinal bleeding event that would not have occurred
if they hadn't been taking aspirin. As with most drugs,
though, aspirin will not cause anything particularly good or
bad for the vast majority of people who take it. That is the
theme of the medicine in your cabinet: It likely isn't
significantly harming or helping you. "Most people struggle
with the idea that medicine is all about probability," says
Aron Sousa, an internist and senior associate dean at
Michigan State University's medical school. As to the more
common metric, relative risk, "it's horrible," Sousa says.
"It's not just drug companies that use it; physicians use it,
too. They want their work to look more useful, and they
genuinely think patients need to take this [drug], and
relative risk is more compelling than NNT. Relative risk is
just another way of lying."
A Different Way to Think About Medicine
For every 100 older adults who take a sleep aid, 7 will
experience improved sleep, while 17 will suffer side effects
that range widely in severity, from simple morning "hangover"
to memory loss and serious accidents. As with many
medications, most who take a sleep aid will experience
neither benefit nor harm...
"There's this cognitive dissonance, or almost professional
depression," Walker says. "You think, 'Oh my gosh, I'm a
doctor, I'm going to give all these drugs because they help
people.' But I've almost become more fatalistic, especially
in emergency medicine." If we really wanted to make a big
impact on a large number of people, Walker says, "we'd be
doing a lot more diet and exercise and lifestyle stuff. That
was by far the hardest thing for me to conceptually
appreciate before I really started looking at studies
critically."...
In the 1990s, the American Cancer Society's board of
directors put out a national challenge to cut cancer rates
from a peak in 1990. Encouragingly, deaths in the United
States from all types of cancer since then have been falling.
Still, American men have a ways to go to return to 1930s
levels. Medical innovation has certainly helped; it's just
that public health has more often been the society-wide game
changer. Most people just don't believe it.
In 2014, two researchers at Brigham Young University
surveyed Americans and found that typical adults attributed
about 80 percent of the increase in life expectancy since the
mid-1800s to modern medicine. "The public grossly
overestimates how much of our increased life expectancy
should be attributed to medical care," they wrote, "and is
largely unaware of the critical role played by public health
and improved social conditions determinants." This
perception, they continued, might hinder funding for public
health, and it "may also contribute to overfunding the
medical sector of the economy and impede efforts to contain
health care costs."
It is a loaded claim. But consider the $6.3 billion 21st
Century Cures Act, which recently passed Congress to
widespread acclaim. Who can argue with a law created in part
to bolster cancer research? Among others, the heads of the
American Academy of Family Physicians and the American Public
Health Association. They argue against the new law because it
will take $3.5 billion away from public-health efforts in
order to fund research on new medical technology and drugs,
including former Vice President Joe Biden's "cancer moonshot."
The new law takes money from programs - like vaccination and
smoking-cessation efforts - that are known to prevent disease
and moves it to work that might, eventually, treat disease.
The bill will also allow the FDA to approve new uses for
drugs based on observational studies or even "summary-level
reviews" of data submitted by pharmaceutical companies.
Prasad has been a particularly trenchant and public critic,
tweeting that "the only people who don't like the bill are
people who study drug approval, safety, and who aren't paid
by Pharma."..."
"... People with any form of diabetes are at greater risk of developing cardiovascular conditions than people without the disease. Moreover, if they undergo an operation to open up a clogged artery by inserting a "stent" surgical tube, the artery is much more likely to clog up again. ..."
"... Surgical stents for artery repair are typically coated with slow-releasing drugs that aim to suppress excessive regrowth of the surrounding smooth muscle cells. This approach to release drugs locally might work for drugs that boost SHP-1 expression, King speculates. ..."
BOSTON - (January 4, 2017) -
People with any form of diabetes are at greater
risk of developing cardiovascular conditions than people without the disease.
Moreover, if they undergo an operation to open up a clogged artery by inserting a
"stent" surgical tube, the artery is much more likely to clog up again.
However, researchers at Joslin Diabetes Centers now have uncovered an
explanation for why these procedures often fail, which may lead toward better
alternatives.
An enzyme known as SHP-1, which can suppress the growth of smooth muscle cells
lining the inside of blood vessels, plays a crucial role in stent failure, says
George King, M.D., Joslin's Chief Scientific Officer and senior author on a paper
in the journal
Diabetologia
describing the work.
Stents coated with a drug that activates SHP-1, and thus slows the accelerated
growth of these vascular cells, might help in treating arterial disease in
diabetes, says King, who is also Professor of Medicine at Harvard Medical School.
His team's research began with experiments among mice fed a high-fat diet and
rats that were genetically modified to display insulin resistance and related
metabolic conditions related to diabetes. "We found that SHP-1 expression was
decreased in the arteries from all of these animal models," says Weier (Glorian)
Qi, co-lead author on the paper. "We also found that SHP-1 expression dropped in
the arteries of patients with type 2 diabetes."
Next, the scientists created mice that were genetically engineered to
over-express the protein in their vascular smooth muscle cells. When the
scientists fed these mice a high-fat diet that clogged their arteries and
performed a procedure similar to stent insertion, they found that the arteries in
these animals were less clogged than in normal mice given the same procedure.
The researchers went on to demonstrate that SHP-1 is reduced in mouse vascular
smooth muscle cells primarily by the high levels of lipids in the blood associated
with diabetes and related conditions, rather than the high levels of glucose also
present in those conditions.
Following up on these findings may help to address a major research puzzle in
diabetic complications, says King: Each type of tissue seems to react differently
to the disease.
For example, he explains, smooth muscle cells grow thicker in large blood
vessels like arteries, but similar type of contractile cells begin to die off in
tiny blood vessels in the eye.
"These opposite cell growth patterns are an enigma," King comments. "They also
make it difficult to develop therapeutics, because we would want to deactivate
SHP-1 in the eye and activate it in large arteries."
Surgical stents for artery repair are typically coated with slow-releasing
drugs that aim to suppress excessive regrowth of the surrounding smooth muscle
cells. This approach to release drugs locally might work for drugs that boost
SHP-1 expression, King speculates.
"We hope our research encourages ideas about how to address this problem for
people with diabetes," he adds. ""The more ideas that come up, the greater the
chances that we can achieve such a needed treatment."
Joslin's Qian Li1 was the other co-lead author on the paper. Joslin
contributors also included Christian Rask-Madsen, Samuel Lockhart, Yu Xia,
Xuanchun Wang and Mogher Khamaisi. Chong Wee Liew of the University of Illinois at
Chicago; Lars Melholt Rasmussen of Odense University Hospital in Odense, Denmark;
and Kevin Croce of Brigham and Women's Hospital also were co-authors. Lead
research support came from the JDRF, the American Diabetes Association and the
National Institute of Diabetes and Digestive and Kidney Diseases.
"... The goal of the majority of providers is to increase total "sales" by ordering many procedures and or drugs that are not needed. Much of this is done from ignorance and is not necessarily indicative of a purely capitalistic motive. ..."
I was a practicing cardiologist in the US for over 30 years. I, as most other practicing cardiologist,
was trained and fully believed the prevailing methods of diagnosis and treatment were not only
correct but absolutely necessary. Several decades of experience taught me this is not close to
being accurate. The majority of medical tests, and much of the treatment, is not only unnecessary,
but harmful and/or dangerous. The goal of the majority of providers is to increase total "sales"
by ordering many procedures and or drugs that are not needed. Much of this is done from ignorance
and is not necessarily indicative of a purely capitalistic motive.
David Goldhill is one of the few authors that have experienced this travesty and is educated
and intelligent enough to understand the consequences of this nationwide epidemic and the needless,
wasteful, and dangerous care. His ability to sort through all of the "noise" prevalent in the
governmental and media diatribe and isolate the real problem as full insurance for everyone is
unique. This system is doomed for failure. There will never be enough resources to fund medical
care as long as the consumer is not the payer. They will always demand more and the providers
are happy to accommodate them.
I have left the US and am presently living in Beijing, China, attempting to establish purely
preventive heartcare clinics. This is more general education regarding diet, smoking, sedentary
lifestyle, and alcohol abuse. than traditional western medicine. Less income, but certainly more
satisfying.
About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist David
Brown of Stony Brook University School of Medicine
Notable quotes:
"... About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents a year, and controversy surrounding this practice has spurred nationwide litigation and a federal investigation into several cases involving illegal kickbacks and allegations of cardiac stent malpractice. ..."
"... Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing once again. In some cases, the blood vessel can become completely blocked a condition called in-stent thrombosis. ..."
"... Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure to ensure such events don't occur. ..."
"... Cardiac stents are big business for hospitals and their staff, with the average private insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can restore blood flow that has been compromised in heart attack patients, or give help to patients at risk for future heart attack. But when misused or overused in patients, cardiac stents can prove fatal, as they did for former postal service worker Bruce Peterson. ..."
"... Peterson developed several blood clots and blockages due to his weakened heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson. ..."
"... Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on" because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries" and doesn't want to sacrifice the revenue, he said. ..."
About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist
David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents
a year, and controversy surrounding this practice has spurred nationwide litigation and a federal
investigation into several cases involving illegal kickbacks and allegations of cardiac stent malpractice.
For the most part, stenting procedures are relatively low in risk and moderately safe. However,
as with any surgical procedure even a minimally invasive one there is a risk of developing complications.
Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing
once again. In some cases, the blood vessel can become completely blocked a condition called in-stent
thrombosis.
Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure
to ensure such events don't occur.
Additionally, manipulating arteries with a stent or any other sort of medical procedure can lead
to the walls of the blood vessel becoming injured or damaged. The innermost layer of coronary arteries,
known as the endothelium, is particularly susceptible to this sort of damage; the result can be the
formation of scar tissue in the area of the stent, and this too can lead to the artery re-narrowing
in a process known as restenosis. Treating Restenosis can involve an additional stenting procedure,
though in severe cases where a stented artery recloses it may be necessary to have a patient undergo
a coronary artery bypass to remedy the condition.
Overuse of cardiac stents leads to patient deaths
Cardiac stents are big business for hospitals and their staff, with the average private insurance
reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can
restore blood flow that has been compromised in heart attack patients, or give help to patients at
risk for future heart attack. But when misused or overused in patients, cardiac stents can prove
fatal, as they did for former postal service worker Bruce Peterson.
After suffering chest pain, Peterson paid a visit to cardiologist Dr. Samuel DeMaio, who inserted
21 stents in his patient's chest over a period of eight months, including five mesh tubes in a single
artery. Peterson developed several blood clots and blockages due to his weakened heart, which
ultimately caused his untimely demise, argues his widow Shirlee Peterson.
She later sued DeMaio for cardiac stent malpractice an increasingly common charge in a Dr. Darshan
P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal Medicine Healthgrades.comqaDr.
Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal Medicine
Healthgrades.com
Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs
to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on"
because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries"
and doesn't want to sacrifice the revenue, he said.
Cardiac stent problems cost $2.4 billion a year
The U.S. health care system spends an estimated $2.4 billion a year caring for patients that received
unnecessary cardiac stents, says Dr. Sanjay Kaul, of Cedars-Sinai Medical Center. Patients face a
much greater risk for complications like coronary scar tissue, blood clots and uncontrolled bleeding
from anticoagulant medications all of which can be life-threatening. Jim Simecek told Bloomberg
that he is on blood-thinning medicine for the rest of his life to prevent clots in the cardiac stents
he received from a Cleveland doctor who is currently the subject of a federal probe.
Sixty-four year old Monica Crabtree's cardiac stent problems caused a torn artery, which resulted
in an infection and her death, according to her husband. He also pursued legal action after it was
determined by another cardiologist that Monica's stent was completely needless. The surviving spouse
recovered $240,000 in a malpractice settlement brought against the surgeon.
FDA reports hundreds of deaths attributed to cardiac stents
Some 773 patient deaths linked with cardiac stents were logged with the FDA last year, according
to Bloomberg. Though this figure has jumped more than 70 percent since 2008, with recent media coverage
on cardiac stent overuse and ongoing federal investigations, cardiologists may be using fewer stents
and only on suitable patients.
John Harold, president of the American College of Cardiology said the doctors who have been charged
with cardiac stent malpractice or fraud are essentially "outliers" in their community, and that these
surgeons fail to represent the "overwhelming majority."
"... Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation to Mehmood Patel). ..."
"... The suit alleged Patel implanted needless stents in at least two patients, including one that led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the government's attention. ..."
"... "It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she didn't need, which killed her." ..."
"... "I do believe that Bruce was a guinea pig," she said. "That was the way it was done." ..."
When Bruce Peterson left the U.S. Postal Service after 24 years delivering mail, he started a
travel agency. It was his dream career, his wife Shirlee said.
Then he went to see cardiologist Samuel DeMaio for chest pain. DeMaio put 21 coronary stents in Peterson's
chest over eight months, and in one procedure tore a blood vessel and placed five of the metal-mesh
tubes in a single artery, the Texas Medical Board staff said in a complaint. Unneeded stents weakened
Peterson's heart and exposed him to complications including clots, blockages "and ultimately his
death," the complaint said.
DeMaio paid $10,000 and agreed to two years' oversight to settle the complaint over Peterson and
other patients in 2011. He said his treatment didn't contribute to Peterson's death.
"We've learned a lot since Bruce died," Shirlee Peterson said. "Too many stents can kill you."
Peterson's case is part of the expanding impact of U.S. medicine's binge on cardiac stents -- implants
used to prop open the arteries of 7 million Americans in the last decade at a cost of more than $110
billion.
When stents are used to restore blood flow in heart attack patients, few dispute they are beneficial.
These and other acute cases account for about half of the 700,000 stent procedures in the U.S. annually.
Among the other half -- elective-surgery patients in stable condition -- overuse, death, injury
and fraud have accompanied the devices' use as a go-to treatment, according to thousands of pages
of court documents and regulatory filings, interviews with 37 cardiologists and 33 heart patients
or their survivors, and more than a dozen medical studies.
'Marching On'
These sources point to stent practices that underscore the waste and patient vulnerability in
a U.S. health care system that rewards doctors based on volume of procedures rather than quality
of care. Cardiologists get paid less than $250 to talk to patients about stents' risks and alternative
measures, and an average of four times that fee for putting in a stent.
"Stenting belongs to one of the bleakest chapters in the history of Western medicine," said Nortin
Hadler, a professor of medicine at the University of North Carolina at Chapel Hill. Cardiologists
"are marching on" because "the interventional cardiology industry has a cash flow comparable to the
GDP of many countries" and doesn't want to lose it, he said.
Stenting abuse is by no means the norm, but neither is it a rarity. Federal cases have extended
from regional medical centers in Louisiana, Kentucky and Georgia to a top-ranked metropolitan hospital
system in Ohio.
Asset Seizure
A doctor practicing at a hospital owned by the Cleveland Clinic, rated the premier heart center
in the country by U.S. News and World Report, had his assets seized by federal agents in a stent
investigation, according to federal court filings in April. The Clinic has not been accused of wrongdoing,
and says it's cooperating with the investigation.
Two out of three elective stents, or more than 200,000 procedures a year, are unnecessary, according
to David Brown, a cardiologist at Stony Brook University School of Medicine in New York. That works
out to about a third of all stents.
Brown said his estimate is based on eight clinical trials of 7,000 patients in the last decade,
which he analyzed in the Archives of Internal Medicine last year. Two cardiology researchers who
have studied the use of stents say the number could be as low as about half Brown's estimate, and
one said it is probably larger.
Costs, Risks
Even the low end of these estimates translates into more than a million Americans in the past
decade with implants in their coronary arteries they didn't need, said William Boden, chief of medicine
at a Veterans Administration hospital in Albany, New York. Boden was the principal investigator of
a 2007 study known as Courage that found stents added no benefit over medicines, exercise and dietary
changes in stable patients.
Unnecessary stents cost the U.S. health care system $2.4 billion a year, according to Sanjay Kaul,
a cardiologist and researcher at Cedars-Sinai Medical Center in Los Angeles. Patients who received
them are living with risks including blood clots, bleeding from anti-clotting medicine and blockages
from coronary scar tissue, any of which can be fatal, Kaul said.
Monica Crabtree died at age 64 after one of her arteries was torn in a stent procedure that led
to infection, according to her widower, Gary Crabtree. He received at least $240,000 from a 2011
settlement of his lawsuit against her doctor, after a second cardiologist reviewed the case and told
him the stent wasn't needed. Crabtree choked up speaking about his late wife and showed pictures
of their 47 years together.
Worried Shaving
"It wasn't just a simple mistake," said the retired auto worker in Largo, Florida. "If the stent
was something she really needed, I could have handled it. But it was a total loss of life that didn't
need to happen."
Jim Simecek, of Medina, Ohio, said he worries every morning that a nick from shaving could bleed
out of control. Simecek, who works at a Ford dealership, said he has to take blood-thinning medicine
for life to ward off clots in the six stents he received from a Cleveland-area cardiologist who's
under federal investigation for his stent work.
"It's as if your heart was open and somebody was sticking a knife in," said Rhonda McClure, 54,
referring to eight stents she received from a Kentucky cardiologist who agreed in June to plead guilty
to a federal Medicaid-fraud charge for falsifying records used to justify a stent he placed.
Patient Letters
Cardiac stents were linked to at least 773 deaths in incident reports to the U.S. Food and Drug
Administration last year, according to a review by Bloomberg News. That was 71 percent higher than
the number found in the FDA's public files for 2008. The 4,135 non-fatal stent injuries reported
to the FDA last year -- including perforated arteries, blood clots and other incidents -- were 33
percent higher than 2008 levels.
The FDA declined to comment on whether the reports were a cause for concern. It said adverse-event
reports tied to medical devices have increased overall due to agency efforts. It also said the data
can contain incomplete and unverified accounts from reporting parties.
More than 1,500 patients have gotten letters from hospitals since 2010 alerting them that their
stents may have been unnecessary. In Philadelphia, the University of Pennsylvania Health System sent
700 such notices in April.
Stenting Decline
At least 11 hospitals have settled federal allegations of charging for needless stenting and other
misdeeds in the catheterization labs where the procedures are performed. Federal probes of stenting
practices continue in at least five states. In Louisiana and Maryland, cardiologists went to federal
prison last year for implanting the devices and charging for them without medical justification.
A third doctor has agreed to do time in a plea bargain.
"There is a huge financial incentive to increase the number of these procedures," said Jamie Bennett,
a former assistant U.S. Attorney in Baltimore who handled stent investigations. "The cases we have
seen to date are just the tip of the iceberg."
Since Boden's Courage study, stenting procedures have declined by about 20 percent. Still, this
July, a panel of experts convened by the American Medical Association and the Joint Commission, a
hospital accreditor, named elective stenting as one of five overused treatments that too often "provide
zero or negligible benefit to patients, potentially exposing them to the risk of harm."
Better Choices
Doctors are using fewer stents and choosing more-appropriate patients than they were a few years
ago, according to John Harold, president of the American College of Cardiology, the specialty's main
professional group. Harold said that "real-world clinical practice" and research indicates Brown
probably overestimated how many people with coronary artery disease could be handled initially only
with drug-based treatment.
He said there are examples of inappropriate use and the ACC is taking steps to "address and correct
the imbalance" with treatment guidelines and by urging more hospital oversight. Cardiologists who've
been accused of fraud or are serving prison time are "outliers" who don't represent the "overwhelming
majority."
Lawyers for John McLean, a Salisbury, Maryland, cardiologist convicted of billing for unwarranted
stenting, argued in a federal appeal last year that inappropriate usage is widespread and their client
was prosecuted for behavior that's the industry norm.
Lost Appeal
They cited a 2011 study in the Journal of the American Medical Association that found only half
of elective stent procedures nationally were appropriate under usage guidelines written by societies
of heart specialists. The study found 12 percent were inappropriate, and 38 percent fell into the
uncertain category of the guidelines.
"The study demonstrated clearly that a large number of stable patients receive coronary artery
stents that are later found to be inappropriate or questionable," the appeal argued. "The same was
true of the patients in Dr. McLean's practice." McLean's appeal was denied in April. He is serving
an eight-year sentence.
Elective-stent patients typically see rapid quality-of-life improvements, including in their ability
to work and be active, according to Ted Bass, president of the Society for Cardiovascular Angiography
and Interventions, whose members specialize in cardiac implants. The Courage trial found stents,
compared to medication and lifestyle changes, were better at relieving chest pain for as long as
two years after placement -- a benefit that ended by 36 months.
Profit Centers
First used in Europe in 1986, cardiac stents took off in the 2000s as cardiologists found them
to be more effective in heart attacks than angioplasty. In that earlier technology, a small balloon
is inflated to widen blood passages and then withdrawn. Stenting facilities, known as "cath labs,"
spread at hospitals and became profit centers.
Hospitals receive an average payment of about $25,000 per stent case from private insurers, according
to Healthcare Blue Book, a website that tracks reimbursements. The federal Medicare program pays
less. Doctors who implant stents earn a separate fee that averages about $1,000 and ranges from $500
to $2,850, according to Medicare and Blue Book data.
The procedure typically involves inserting the stent with a catheter through a small incision
in the groin area or wrist and snaking it through to heart vessels. It usually takes less than 45
minutes.
Kickbacks Alleged
Stony Brook's Brown, and Boden, who led the Courage study, argue that many elective patients should
be getting medical therapy before they risk stents. Only 44 percent try medication and lifestyle
changes before stenting, a 2011 study in the Journal of the American Medical Association found.
At least five hospitals have reached settlements with the Justice Department over allegations
that they paid illegal kickbacks to doctors for patient referrals to their cath labs. St. Joseph
Medical Center in Towson, Maryland, paid the government $22 million without admitting liability.
Prosecutors alleged the hospital paid kickbacks to a practice co-founded by Baltimore cardiologist
Mark Midei for stent referrals. His doctor's license was revoked in 2011 when the Maryland Board
of Physicians found he falsified records to justify unwarranted stents.
St. Joseph told 585 of its patients they may have received unnecessary stents. In May, 252 patients
reached a settlement with the hospital under confidential terms, according to Jay D. Miller, an attorney
for the plaintiffs.
Plea Agreement
The hospital settled the government's case "to avoid the expense and uncertainty of litigation,"
it said in a statement. Spokeswoman Julia Sutherland said the hospital declined to comment on any
patient lawsuits.
In an interview, Midei denied he stented without medical need. He took issue with experts who
deemed many of his stents needless, and said disagreement among cardiologists on cases is common.
Midei was not a party to the federal settlement. The government has said its investigation of the
case continues.
In June, Sandesh Patil, a cardiologist practicing at another St. Joseph hospital -- this one in
London, Kentucky -- agreed to plead guilty to charging Medicaid for a stent that wasn't medically
warranted under the program's rules. (Although both hospitals were once owned by the same parent,
the one in Maryland has been sold.)
Catheterization procedures multiplied at St. Joseph in London after Patil began practicing there
in 2000, when the hospital had a different name. In that year, the type of procedure used for stents
was done 210 times. They climbed to 929 by 2009, state data show.
Multiple Stents
Stenting income from Medicare alone was more than a sixth of the hospital's 2009 operating income,
based on data from American Hospital Directory, a research firm. When Patil left London in 2010,
catheterization procedures fell 34 percent from their 2009 high. Using the midpoint of the directory's
price range for such procedures, the decline would have cost the hospital about $15 million. David
McArthur, the hospital's spokesman, declined to comment on its revenues.
Rhonda McClure, one of Patil's patients, had her arteries catheterized 18 times by him and his
partners over four years, according to her deposition and other filings in a lawsuit she and 361
other patients have brought against Patil, St. Joseph and other doctors who practiced there. She
said she received eight cardiac stents. The defendants deny the negligence and fraud allegations
against them.
McClure's deposition says a cardiologist who reviewed her case after the stents told her that
scarring caused by "too many procedures" was her main problem.
Short Breath
McClure said she suffers from chest pain and shortness of breath, and has been told by her new
doctor that she may need more stents and surgery to keep her coronary arteries from closing. She
said she gets so tired she needs to sit and rest after walking down the stairs.
St. Joseph-London repaid Medicare $256,800 for unnecessary procedures and is cooperating with
federal prosecutors, McArthur said. He said Patil was never employed by St. Joseph and lost his privileges
to practice there in December 2010. Patil's attorney said his client had no comment.
Under his plea bargain, Patil agreed to serve 30 to 37 months in federal prison. He forfeited
his Kentucky medical license for five years. In 2012, he told a family court judge his monthly income
was $53,300.
"Thirty-seven months is nothing for all the injuries he done for money," McClure said.
Message Balancing
After the Courage trial shed doubt on stents' effectiveness for stable patients, stent-implanting
cardiologists felt unfairly attacked and organized a campaign to "better balance the messaging,"
said Bonnie Weiner, who was president of the Society for Cardiovascular Angiography and Interventions
at the time.
The society hired a public relations firm and paid it more than $300,000 a year to help publicize
the benefits of stents, according to the group's filings with the Internal Revenue Service. The firm
helped launch a consumer website for SCAI, SecondsCount.org, which has published several articles,
including one under the headline, "For many patients, open arteries are better than closed arteries."
SCAI collected $2.7 million in donations for "public education" between 2008 and 2011 from stent
makers Abbott Laboratories Inc., Boston Scientific Corp., Cordis Corp. and Medtronic Inc., its Web
site says. Manufacturers' sales of cardiac stents were about $5.5 billion globally last year, down
5 percent from 2011, according to the Health Research International consulting firm.
High Median
Medtronic spokesman Joseph McGrath said grants to SCAI for patient education are "unrestricted,"
and SCAI is solely responsible for how the funds are used. Spokesmen for Abbott, Boston Scientific
and Cordis declined to comment.
Interventional cardiologists, the specialty SCAI represents, earn a median income of $562,855
a year, as compared to $207,117 for family doctors, according to Medical Group Management Association,
which surveys physician practices. The interventionalists ranked 13th among 118 specialties tracked
by MGMA.
Michigan Death
Mehmood Patel, a Lafayette, Louisiana, cardiologist who went to prison last year on 51 counts
of charging for needless stents, made over $16 million in one three-year span, evidence in the case
showed. Prosecutors said he was driven by the desire to be the busiest cardiologist in town.
He unsuccessfully argued that he used his best medical judgment in every case and lost an appeal.
Patel is serving a 10-year sentence in a federal penitentiary.
Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures
in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation
to Mehmood Patel).
The suit alleged Patel implanted needless stents in at least two patients, including one that
led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac
blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want
interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the
government's attention.
"It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she
didn't need, which killed her."
False Claims
Kovach said that when she told the chief operating officer of the hospital where Patel worked
about the death, the executive, Karen Chaprnka, diverted the conversation. Reached recently by e-mail
through a hospital spokesman, Chaprnka said she "disagreed with the allegations made by Dr. Kovach."
"He's their cash cow," said Kovach, now co-director of a clinic that treats congenital heart disease
at the Detroit Medical Center. "They're not about to turn him in."
Patel and the hospital, Allegiance Health, agreed to pay the U.S. a total of $4 million to settle
the federal charges. Kovach was awarded $760,000 as a whistle-blower under the U.S. False Claims
Act. Allegiance disagreed with the allegations and settled the claims to avoid "lengthy litigation,"
it said in a statement.
Patel continues to practice at the hospital and must improve record-keeping to substantiate cardiology
procedures, Allegiance said. In the settlement, Patel agreed to hire a consultant to oversee treatment
of his patients and an auditing firm to monitor billings. He didn't return phone messages.
Cleveland Raid
In Ohio, Simecek, the worker at the Ford dealership, grew suspicious after his sixth stent from
cardiologist Harry Persaud at the Cleveland Clinic's Fairview Hospital in 2011. Simecek said he went
for a second opinion and was told he didn't need any of the stents. Now he said he has to take blood
thinners the rest of his life.
"With the littlest cut, the blood starts running," said Simecek. "What if I am in an auto accident?"
Persaud is under criminal investigation for health care fraud, mail fraud and money laundering, according
to federal court filings. Last October, Federal Bureau of Investigation agents raided his office
and removed financial records and patient files for procedures at three Cleveland-area hospitals.
The government has seized $343,634 from his and his wife's bank accounts, alleging the funds represent
the proceeds of fraud related to a "significant number" of unnecessary stent procedures.
Multiple, Elongated
The Cleveland Clinic found "problems related to the use of stents in some patients" at Fairview
and reported them to the government, according to spokeswoman Eileen Sheil. She would not say how
many patients were affected. Persaud resigned from the hospital staff last year.
At least 64 of Persaud's patients at St. John Medical Center in suburban Westlake received letters
from the hospital saying they may have received an unnecessary stent between 2010 and 2012, according
to spokesman Patrick Garmone, who said Persaud no longer practices there.
Persaud denied wrongdoing in court filings and said his stent procedures were proper. Neil Freund,
his attorney in lawsuits filed by patients alleging unwarranted stents, said "it is our intent to
defend these cases." He had no comment on the federal investigation.
Final Order
In Texas, the state medical board's final order in DeMaio's case found that the cardiologist placed
"multiple, elongated, overlapping" stents in patients in areas of "insignificant or only moderate
disease." Peterson, the retired mailman, was identified only as Patient C in the staff complaint.
No patient was mentioned in the final order.
Peterson was thriving in his new career in the travel business, his wife Shirlee said. He had
a heart attack in 1997, which didn't crimp his love of travel and dance, she said. "He was an awesome
man who never met a stranger," she said.
After his death, Shirlee Peterson said a friend told her she had a cardiologist who refused to
do multiple stents.
"I do believe that Bruce was a guinea pig," she said. "That was the way it was done."
DeMaio said Peterson was extremely sick when he came to him. He said it was significant that the
board's final order didn't use the word "excessive" in describing his stent work. That included 31
stents stretching for 14 inches inside the arteries of Patient B in the staff complaint.
"Any patient of mine who received a full metal jacket" -- interventional cardiology's term for
such extensive work -- "would have been turned down by at least one, if not multiple surgeons," DeMaio
said. He said he doesn't use stents as much these days because standards have changed and he doesn't
see as many seriously ill patients.
That's what Dr. Dean Kereiakis told Angioplasty.Org when characterizing the results of the
long-awaited Dual Antiplatelet Therapy (DAPT) study, which were presented today at the annual
American Heart Association Scientific Sessions in Chicago.
Dr. Kereiakes is the co-principal investigator
for this five year study of 10,000 patients, which adds to the knowledge base of whether long-term
treatment with aspirin and a thienopyridine, such as Plavix, after stent implantation is
beneficial to patients.
Reviewed by a board-certified
physician. Updated We have all heard the claims that cardiologists are inserting too many
stents
in patients with
coronary artery disease (CAD) . And the fact is that this happens much more often than we would
like to think.
So what should you do if your doctor says you need a stent? Are you one of those people who actually
do need a stent - or should your doctor be talking to you about medical therapy instead?
If your doctor tells you that you need a stent, it is likely he or she will attempt to explain
why. But the issue can be quite complicated, and your doctor may not be entirely clear in his/her
explanation. And you may be too stunned by the news that you need a stent to concentrate completely
on what you are being told.
Fortunately, if your doctor says you need a stent, there are three simple questions you can ask
which will tell you what you really need to know. If you ask these three questions, you stand a much
better chance of getting a stent only if you really need one.
Question One: Am I Having A Heart Attack?
If you are in the early stages of an acute heart attack, the immediate insertion of a stent can
stop the damage to your heart muscle, and can help reduce your chances of suffering cardiac disability
or death. If the answer to this question is "yes," then a stent is a very good idea.
Unstable angina
, like an actual heart attack, is a form of
acute coronary
syndrome (ACS) - and therefore it should be considered a medical emergency. The early insertion
of a stent can stabilize the ruptured
plaque that
is producing the emergency, and can improve your outcome.
If the answer to this question is "yes," placing a stent is most likely the right thing to do.
No need to go on to Question Three.
Question Three: Isn't There Medical Therapy I Can Try First?
If you get to Question Three, it means that you are not having an acute heart attack or unstable
angina. In other words, it means you have stable CAD. So, at the very least, placing a stent is not
something that needs to be done right away. You have time to think about it, and to consider your
options.
It is the patients with stable CAD who, according to the best clinical evidence available, are
receiving far too many stents. In stable CAD, stents turn out to be very good at relieving
angina ,
but they do not prevent heart attacks or reduce the risk of cardiac death. So, the only really good
reason to insert stents in people with stable CAD is to relieve persistent angina when aggressive
treatment with medication fails to do so.
The Best Approach For Stable CAD
The best treatment for people with stable CAD is to take every step that is available to stabilize
plaques in the coronary arteries -- that is, to keep the plaques from rupturing.
(It is the rupture of a plaque that produces ACS in the first place).
If your angina persists despite this kind of aggressive medical therapy, then by all means a stent
is something that should be strongly considered. But keep in mind that a stent only treats one particular
plaque, and that most people with CAD have several plaques. Furthermore, while most of these plaques
are considered "insignificant" by traditional measures (since they are not producing much blockage
in the artery), it now appears that the majority of cases of ACS occur when one of these "insignificant"
plaques suddenly ruptures.
What this means is that, whether or not you end up getting a stent for your stable CAD, you still
will need aggressive medical therapy to prevent the rupture of one of those "other" plaques, the
"insignificant" ones, the ones for which too many cardiologists may express little or no interest.
Summary
If you are told you need a stent, you can quickly determine how badly you need one, if at all,
by asking three simple questions. These questions are so easy for your doctor to answer - generally
with a simple yes or no - that there will be no excuse for his/her failing to take them up with you.
But if it turns out that you have stable CAD, and therefore a stent is at least not an emergency,
you are owed a full discussion about all your treatment options before you are pressured
into a stent.
"... The Finance Committee reportedly found that Abbott Laboratories, which manufactures stents, had long been in the practice of rewarding Dr Midei financially for being a high-volume user of its stents. ..."
"... "Stenting in stable angina is open to debate in some circumstances as to whether it reduces mortality but every study done shows it is effective in relieving symptoms," he said. ..."
"... New England Journal of Medicine ..."
"... Journal of the American College of Cardiology ..."
"... There is also another interesting dynamic operating here. In the days when the cardiologists did "medical therapy" and the Cardiothoracic surgeons did bypass procedures, the cardiologists were the gatekeepers to the surgical therapy, referring on those who had failed medical therapy. The dynamics have now changed with interventional cardiology there is no gatekeeper to interventional therapy cardiologists self-refer for intervention procedures from which they derive considerable profit. It would be difficult to argue that this has had no influence on the stent rate. ..."
"... As an interventionist, I unfortunately know of at least one cardiologist who stents clearly non-significant disease a la Dr Midei. He doesn't "believe" in FFR or MIBI scans! It is very hard to prove though. ..."
UP TO one-third of coronary stents inserted in patients with stable coronary artery disease
(CAD) in Australia each year ― about 3500 stents - may be unnecessary, potentially harmful and
costing the nation millions of dollars, according to a leading cardiologist.
Professor Richard Harper, emeritus director of cardiology at MonashHeart, Monash Medical Centre
in Melbourne, said any experienced interventional cardiologist would admit that many coronary
lesions with 50‒70% stenosis were being stented in Australia without certain knowledge that the
particular lesion was causing ischaemia.
Medicare statistics show that, last year, there were 22 383 operations for insertion of a stent
or stents in Australia (20 780 in 2008 and 21 204 in 2007), for which Medicare paid $6.78 million
($6.24 million in 2008 and $6.2 million in 2007).
These payments do not include the cost of a coronary angiography, radiological services and
preparation, or aftercare.
The average cost of coronary angiography with stent insertion, including hospital stay, is
$18 300 of which Medicare pays $1647.
Professor Harper said about 50% or more of stents were inserted in stable CAD patients and
the remainder were in patients with acute heart attack, for which stenting was almost always warranted.
A rapid online publication of a detailed paper written by Professor Harper on the use of stents
in CAD patients has been published by the MJA
.
He was commenting after the issue of unnecessary stenting hit the headlines in the United States,
with the revelation that Baltimore cardiologist Dr Mark Midei may have implanted 585 stents that
were medically unnecessary from 2007 to 2009.
An article in theheart.org , the website for cardiovascular health professionals,
said a US Senate Finance Committee report called the Midei imbroglio "a clear example of potential
fraud, waste, and abuse".
(1)
The Finance Committee reportedly found that Abbott Laboratories, which manufactures stents,
had long been in the practice of rewarding Dr Midei financially for being a high-volume user of
its stents.
However, many US cardiologists believe Dr Midei is being treated unfairly.
The Cardiac Society of Australia and New Zealand (CSANZ)'s Interventional Council chair, Associate
Professor Andrew MacIsaac, said any fraud or criminal behaviour by a cardiologist, as was being
alleged in the US, was appalling and would be totally unacceptable.
However, he had never heard of it occurring in Australia and it was different from doctors
having a diversity of opinion over the appropriate indications for coronary stenting.
"Stenting in stable angina is open to debate in some circumstances as to whether it reduces
mortality but every study done shows it is effective in relieving symptoms," he said.
Professor Harper said the problem with what he considers to be unnecessary stents in Australia
"lies in our system of reimbursement for coronary procedures".
He said patients often had more than one coronary lesion and the only sure way to tell which
one was the cause of the myocardial ischaemia was by measuring fractional flow reserve (FFR) -
or the effect of the narrowing on blood flow - during coronary angiography.
However, FFR was not commonly undertaken in Australia because the flow wire was costly and
not adequately reimbursed in either the public or private system.
The procedure was also fiddly, took time and resulted in fewer stent insertions - a procedure
which attracted a much higher fee.
"Faced with a 50-70% coronary stenosis, it is easier and more remunerative for an interventional
cardiologist to stent the lesion rather than measure FFR - particularly when there is a two-thirds
likelihood that the result will show no need for the stent," Professor Harper said.
Medicare statistics show that, last year, only 385 procedures for FFR were carried out in Australia
(234 in 2008 and 131 in 2007).
Professor Harper said the health system should be restructured to make it more financially
viable to measure FFR.
He said a pivotal randomised study in the New England Journal of Medicine last year,
of 1000 patients with multi-vessel coronary artery disease, showed that routine measurement of
FFR in patients undergoing percutaneous coronary intervention with drug-eluting stents significantly
reduced the rate of death, non-fatal myocardial infarction and repeat revascularisation compared
with patients who had stents inserted on the basis of angiography alone.
(2)
The patients who underwent FFR had fewer stents implanted at a lower cost.
The results were replicated in a follow-up study at two years, which was reported in the
Journal of the American College of Cardiology .
(3)
Professor MacIsaac said CSANZ had been lobbying for more than 10 years for the establishment
of a national registry of coronary interventions to audit outcomes and quality assurance.
However, it was still waiting for federal and state funding.
"A database has essentially been prepared but there is no funding mechanism to implement the
collection or analysis of the data," he said.
"If we really want to be assured that everything is fine, that would be the way to go."
A Medicare spokeswoman said the unnecessary insertion of cardiac stents had not been identified
as a specific compliance issue.
"However, health professionals should be aware that when Medicare Australia has a concern that
items are being claimed without meeting the item requirements, an audit may be conducted," she
said.
Medicare Australia treated all allegations of non-compliance seriously and encouraged anyone
who suspected potential fraud or non-compliance under the Medicare program to call the Australian
Government Services Fraud Tip-off Line on 131 524.
There is also another interesting dynamic operating here. In the days when the cardiologists
did "medical therapy" and the Cardiothoracic surgeons did bypass procedures, the cardiologists
were the gatekeepers to the surgical therapy, referring on those who had failed medical therapy.
The dynamics have now changed with interventional cardiology there is no gatekeeper to interventional
therapy cardiologists self-refer for intervention procedures from which they derive considerable
profit. It would be difficult to argue that this has had no influence on the stent rate.
Very interesting and informative article with some good comments need more like this.
Highlights a long-standing major problem with Medicare failing to keep up with technology,
but would interventionalists change their habits if Medicare changed? In the public sector
the Medicare rebate usually doesn't matter; in private they'll charge (and should charge)
what they feel is the appropriate fee. What is needed is proper peer review and clinical
governance in both sectors.
Probably highlights the need for better funding of cognitive work compared to intervention.
As far as MIBI scans go, not all labs are equal. If I can, I get mine done in hospital
labs with regular through-put where they regularly correlate results with angiography.
Predictable response from the Medicare bureaucrat, but not understanding the issue
at all (nothing to do with fraud, and everything to do with delivering a better outcome
more cheaply).
Myocardial perfusion studies are well reimbursed and are an arm's length procedure. It is
also rumoured that stress echo, not an arm's length procedure, works.
As an interventionist, I unfortunately know of at least one cardiologist who stents
clearly non-significant disease a la Dr Midei. He doesn't "believe" in FFR or MIBI scans! It
is very hard to prove though.
The article makes some very important and quite radical points about diagnosis and assessment
of chest pain and atherosclerosis.
But they then assert that in patients with ischaemia, revascularisation improves outcomes,
and that patients with significant ischaemia should have invasive angiography.
This is unproven. All the randomised trials of stable angina show that revascularisation
may reduce short term angina but does not reduce mortality or myocardial infarction rates.
If they want to reduce the cost and wastage in modern cardiology just restrict PCI to those
patients in whom angina is limiting or in whom an adequate trial of medical therapy has failed
to control symptoms.
This will reduce the numbers of interventions by far more than 30%.
If and when FFR measurements are shown to reduce mortality or AMI then the conclusions of this
article will be evidence based. At the moment they are not.
Whilst many procedures are beneficial to patients, vast numbers of procedures are performed
on patients in whom no proven long-term benefit has been demonstrated.
Has there been a greater racket in the history of medicine?
The MJA article also states that stenting non-ischaemic lesions (ie with normal FFR) worsens
the prognosis. This is of concern.
The article also suggests abolishing the item number for MIBIs and using CT coronary angios
to diagnose CAD not sure that this is a viable option for patients with significant renal
failure or even in areas where CT coronary angio is relatively new; seems like an exclusively
teaching hospital perspective.
And this overuse does not cover the large number of patients having multiple stents and
ending up with a definitive operation some time and multiple infarcts later
John.
This is happening in australia now. Have 3 drug eluting stents fitted with no tests prior,same
niggles of exertional pain continued at start of exersise then dissapeared for duration of
1.5 hours bike ride after stents.niggles of chest pain lasted approx 4 months after stenting.
Never breathless/overweight/or smoked,very athletic. Father 100 years old no cardiac history.
Have had conformation of my angiogram confirmed that there were no restrictions by leading
USA medical institution, that needed intervention. Qld cardiologist also falsified his files,
where do I go now?.
Hundreds of thousands of Americans may undergo unnecessary
angioplasty
and stent procedures to open clogged
heart arteries each year,
a landmark study suggests.
Of the more than 1.2 million angioplasty procedures performed each year, at least 50% of them
are done on an elective basis in people with stable coronary artery disease, says Stephen Nissen,
MD, president of the American College of Cardiology (ACC) and head of cardiovascular medicine at
The Cleveland Clinic.
In people with coronary artery disease, plaque builds up in the arteries, making it harder for
blood to get through,
thereby depriving the heart muscle of oxygen. This can lead to chronic
chest pain that worsens during
exercise and to
heart
attacks .
During angioplasty, a balloon at the end of a long tube is threaded through an artery in the groin.
The doctor shimmies the probe up through the patient's leg and into the arteries of the heart, inflating
the tiny balloon at the spot where the vessel has narrowed.
To keep the vessel open, doctors usually add a stent to the end of the balloon catheter. These
metal, mesh-like tubes prop open
clogged
arteries to restore
blood flow.
Angioplasty Still Best for Some
The study's results do not apply to people who get stents because they are in the midst of a
heart attack
or whose chest pain suddenly gets worse, doctors stress. For them, angioplasty is a proven lifesaver.
Additionally, angioplasty is better at relieving the chest pain associated with
angina , says
researcher William Boden, MD, of Buffalo General Hospital/Kaleida Health in Buffalo, N.Y.
"For an individual patient, angioplasty may still be the best option," he tells WebMD. "But there
has been an implication that if you give patients drug therapy rather than angioplasty, you're giving
them less than optimal treatment.
"Now we know that if you opt for medicine, you are not putting patients at risk," Boden says.
The study, known as COURAGE, was released at the annual meeting of the American College of Cardiology
and simultaneously published online by The New England Journal of Medicine .
Stent Patients as Likely to Die, Have Heart Attack
The researchers studied 2,287 people with stable coronary artery disease who experienced chest
pain for about two years, with an average of 10 episodes per week. All had at least a 70% blockage
in one or more heart arteries.
Then, about half the participants also underwent angioplasty, usually with stents.
Over the next five years, 19% of those in both groups died or had a heart attack. Similar numbers
of people in both groups -- about 12% -- were hospitalized for heart problems.
However, there were some benefits to angioplasty. People who had the procedure were 40% less likely
to need another procedure to open up blocked heart arteries. And, particularly in the first two years,
they reported better quality of life and less frequent episodes of chest pain.
But over time, some of the differences started to dissipate. By five years later, 74% of people
who had angioplasty were angina-free vs. 72% of those who got drugs alone, a difference so small
it could be due to chance.
Results Stun Medical Community
Boden notes that COURAGE is "the first properly-sized study to answer the question of whether
angioplasty and stents reduce the risk of death and heart attacks in people with stable coronary
artery disease."
The results came as a shock to many in the cardiology community -- even to the researchers themselves.
"The study was designed with the hypothesis that the combination of angioplasty and optimal medical
therapy would be superior," Boden says. "But the results do not support its benefit in reducing heart
attacks and death when used as an initial management strategy."
So why would so many doctors recommend a costly procedure without strong evidence it works?
The average cost of having an angioplasty was $38,000 in 2003, according to the American Heart
Association.
Nissen thinks it's because "it seems so intuitively obvious: If you open up a block artery, you'll
fix the problem."
American Heart Association President Raymond J. Gibbons, MD, chief of cardiology at the Mayo Clinic,
adds that there's a financial incentive for doctors. "People get paid for how many procedures they
do," he tells WebMD.
But this study "clearly shows there is no advantage to PCI [percutaneous coronary intervention,
or angioplasty] as an initial strategy. It's unnecessary," Gibbons says. "Angioplasty should be reserved
for patients [who can't be helped] by medical therapy."
Adds Nissen, "This study will change a lot of thinking. The benefits of angioplasty in people
with stable chest pain is very modest, at most. It should be reserved for patients for intolerable
symptoms."
Results Questioned
But many doctors who perform angioplasties say the procedure's proven benefits in relieving angina,
or chest pain, is getting lost in the shuffle.
Donald Baim, MD, chief medical officer of Boston Scientific, a manufacturer of drug-eluting stents,
says, "COURAGE is not a catastrophic failure. [It shows that angioplasty plus stents] improves symptoms."
Marty Leon, MD, of Columbia University Medical Center, says, "There are so many deep flaws in
the way this study was executed and planned. It was rigged to fail," and it did. "This study should
not affect treatment patterns."
Boden says the criticism is unfounded, pointing out that the researchers purposely studied people
at medium to high risk of having a heart attack or dying -- "the very people you would expect to
benefit most from the procedure."
"... Last year, the DOJ joined two whistleblower lawsuits against Asad Qamar, who owned the Institute of Cardiovascular Excellence in Ocala, Florida. The lawsuits alleged that he regularly billed for unnecessary procedures and violated the Anti-Kickback Statute by waiving Medicare copayments. ..."
"... Months later, the Centers for Medicare & Medicaid Services banned Qamar from the Medicare program ..."
"... Qamar was Medicare's second-highest paid physician in 2012, earning $18.3 million. In 2013, he made $16 million, more than seven times the amount received by the next highest earning Florida cardiologist, according to data collected by ProPublica. ..."
"... Unnecessary cardiology procedures have been a focal point for government investigators over the last year, and some have questioned whether Medicare's fee-for-service model incentivizes unnecessary surgeries. ..."
, Washington, DC - One of the country's highest paid physicians agreed to a three-year exclusion
to settle claims that he billed Medicare for medically unnecessary cardiac procedures, according
to the Department of Justice.
Last year, the DOJ joined two whistleblower lawsuits against Asad Qamar, who owned the Institute
of Cardiovascular Excellence in Ocala, Florida. The lawsuits alleged that he regularly billed for
unnecessary procedures and violated the Anti-Kickback Statute by waiving Medicare copayments.
Months later, the Centers for Medicare & Medicaid Services banned Qamar from the Medicare
program , prompting support from a Super PAC of former patients who were "disgusted and distressed"
by the government's portrayal of Qamar.
In addition to a three-year exclusion from Medicare, Qamar will pay $2 million and forgo an additional
$5.3 million in suspended claims.
Qamar was Medicare's second-highest paid physician in 2012, earning $18.3 million. In 2013,
he made $16 million, more than seven times the amount received by the next highest earning Florida
cardiologist, according to data collected by ProPublica.
Unnecessary cardiology procedures have been a focal point for government investigators over
the last year, and some have questioned whether Medicare's fee-for-service model incentivizes unnecessary
surgeries.
Posted on
December 8, 2010 by
Maggie Mahar Over
the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist
at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei
implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't
need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007
to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.
The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured
the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted
30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott
sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings
for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast.
Although St. Joseph's has not admitted to any wrongdoing, last month it agreed to pay a $22 million
fine to settle charges that it paid illegal kickbacks to Dr. Midei's medical practice in exchange
for patient referrals. In other words, it seems that the hospital encouraged the doctor to implant
those tiny mesh tubes in his patients' arteries. Certainly, hospital executive knew that they were
making handsome profits on Midei's stent procedures. This is why they paid him those "bonuses" to
shepherd unwitting patients to their cath-lab where doctors can diagnose heart attacks, and quickly
open arteries. Midei was a rainmaker.
Clinical guidelines generally suggest that an artery be at least 70 percent blocked before a stent
is used to open it up, and St. Joseph's rules consider anything less than 50 percent blockage to
be "insignificant." But court documents allege that some of Midei's patients were told they had blockages
in the 90 percent range, while a subsequent review of their records shows blockages closer to 10
percent or less.
Medical Journals Have Been Telling Us This for Years
But what I find most disturbing is that the story about Dr. Midei is not new; nor is it
"news." As Dr. Nortin Hadler , author of Worried Sick , argues in his guest-post
below, medical research suggests that stents have been overused, nationwide, for years ,
exposing patients to needless risk and exorbitant expense.
In January of 2006, an article published in the journal Circulation observed that although
there has been a dramatic increase in artery-opening procedures in order to prevent heart attacks
over the last 10 to 15 years, the rate of heart attacks stayed relatively constant. The findings
came from two studies, one done in the U.S. and one done in Canada.
At the time Dr. Thomas Graboys, a professor of medicine at Harvard Medical School, told the
Center for Medical Consumers that stents "are virtually useless, in stopping the progress of
the disease itself." "The public is looking for a magic bullet," Graboys warned. "Go to a non-hospital-based
doctor in the community. A well-trained internist can take care of the lion's share of people with
coronary heart disease. The vast majority of people do well on medication-cholesterol-lowering
drugs, antihypertensives, low-dose aspirin ."
For an expert opinion on "the best" and most persuasive of the many studies that raise serious
questions about invasive heart procedures, see Dr. Hadler's post below.
Nevertheless, as the
Center for Medical Consumers reported in 2006 : "The number of people undergoing artery-opening
procedures continues to rise not only because they are huge money-makers , but they are also very
effective at relieving the severe chest pain of angina, which is a common symptom of heart disease."
Patients like the "quick fix" of the stent treatment for angina. Medication doesn't work as rapidly.
Writing about the Midei case over at Kevin M.D,.
Bob Wachter , Professor of Medicine and Chief of the Division of Hospital Medicine at the University
of California, San Francisco, comments on the patient response: "Most of his patients were probably
quite content many had chest pain and a stent undoubtedly seemed like an appropriately aggressive,
high-tech cure. 'He put two stents in almost immediately,' said one grateful patient. 'I felt relief.'
"Although this patient, 66-year-old Peggy Lambdin, later received a letter indicating that her
coronary artery was less than 50 percent blocked (clinically meaningless and not an indication for
stenting), she was unfazed," Wachter observes. "No one can ever tell me that I didn't need that stent,'
she told the Baltimore Sun. 'I feel like [Dr. Midei] saved my life.'
" Moreover, I'm guessing that Dr. Midei's complication rate was quite low ,"
Wacther continues, " as it usually is when one does procedures on healthy people
. He probably followed all the protocols mandated by accreditors and the relevant specialty societies.
(Oh yeah, except for the ones regarding professionalism.)
"The problem is this," he concludes, "as long as the cardiologist reading the cath is the one
who pulls the trigger on the intervention, we have a potential Fox/Henhouse problem."
"Gizmo Idolatry"
What may be most troubling about the Medei imbroglio is that it highlights how our infatuation
with high-tech medicine tempts us to ignore medical evidence. The popularity of stents is all part
of a mindset that Drs. Bruce Leff and Thomas E. Finucane have termed "
gizmo idolatry
."
Back in June of 2006, a few months before I began HealthBeat, I wrote a post about our use of
stents for The Health Care Blog. It was titled: "
Tech: Is Newer Better? It's a Coin Toss ." Below, an excerpt :
"Last week The Annals of Internal Medicine roiled the medical world by publishing a study suggesting
that the drug- coated stents produced by companies like Boston Scientific and J&J may not
be quite as miraculous as first advertised . (You will
find the abstract here
) Following a two-year study, researchers at the Cedars-Sinai Medical Center in Los Angeles are
now suggesting that the 'putative superiority' of drug-coated stents is founded on questionable premises.'
Or as The Wall Street Journal put it, the clinical trials of drug-coated stents (mostly funded
by manufacturers), may 'have exaggerated their real-life advantage.' [Dr. Midei was using a new generation
of drug-coated stents.]
"Stents, you may remember, are those tiny metal scaffolds that cardiologists use to prop arteries
open after they have been cleared of fatty deposits. Since they were approved in the early 1990s,
manufacturers have made a fortune peddling the devices which, they say, can prevent a future heart
attack while avoiding riskier and more invasive bypass surgery. Today, stents are used in
85% of all coronary interventions in the United States .
"Before turning to the new Cedars Sinai study, it should be said that THCB has long harbored
doubts as to whether these cunning devices represented the best solution for quite so many patients.
Back in 2003, THCB quoted a Stanford study which suggested that, over the long term, patients with
multi-vessel disease would achieve better outcomes, at a lower cost, if they opted for the bypass
operation. In 2005 THCB questioned the cost-effectiveness of the new, improved "drug-coated" stents
that are designed to prevent the growth of scar tissue inside the artery. . .
Yet "drug-coated stents have become wildly popular, thanks in part to what The Annals of Internal
Medicine describes as 'aggressive marketing' and the unbridled expectations of patients. Wall
Street likes them too. At $2300 a pop (vs. a mere $700 for the uncoated, bare-metal variety), the
newer stents are far more profitable. Despite the hoopla, nine months ago THCB was once again
forced to ask 'Are Stents A Waste of Money?' after reading about a study of 826 patients, published
in Lancet , which suggested that the drug-coated stents made by J&J and Boston Scientific
aren't cost-effective for all patients and should be restricted to those at highest risk for heart
attack.
"A second 2005 study, published in The New England Journal of Medicine , added to the uncertainty
about the widespread use of stents by reporting that patients suffering minor heart attacks
do equally well with drug therapy . 'In a study colliding with established practice,
recovery from small heart attacks went just as well when doctors gave cardiac drugs time
to work as when they favored quick, vessel-clearing procedures ," the NEJM reported.
"The surprising Dutch finding raises questions over how to handle the estimated 1.5 million Americans
annually who have small heart attacks the most common kind. Most previous studies support the aggressive,
surgical approach. . . . Meanwhile, just last fall, Dr. Eric Topol, chairman of the cardiology
department at the Cleveland Clinic, warned Consumer Reports : 'Unfortunately, the extensive
use of such stents is far ahead of the data that can be cited to support them .'
"But it's not just that manufacturers over-estimated the benefits; they underestimated the new
risk that the coated stent introduces. For after reviewing outcomes research, Cedars Sinai's clinicians
found that the drug-coated stents increase the danger that a blood clot will form inside
the stent months, or even years after the procedure. Such clots can be life-threatening
. . .
"The stent story illustrates a major problem in our money-driven health care system. When
a product is very profitable, it is promoted to the skies-and, in such cases manufacturers tend to
put the very best face on their clinical research . A startling study published last month
in the Journal of the American Medical Association comparing clinical trials funded by for-profit
entities to clinical trials funded by nonprofit entities underlines the point: it seems that that
the industry-funded trials were far more likely to report positive findings .
"Finally, most patients (and even many physicians) tend to assume that, when it comes to medical
technologies, 'newer' means 'better.' This is why, when asked to participate in a randomized clinical
trial, some patients refuse, fearing that they will 'miss out' on receiving what they assume is the
newer, better product. Yet the odds that the bleeding-edge therapy represents an improvement
over existing technology are only about 50/50. As Americans we tend to believe in what's new-as if
medical science progressed in a straight linear fashion, one breakthrough after another, from Madame
Curie to me . As a result, we pay more-and more-and more-as drug makers and device-makers
flood the market with 'new, improved' products."
In Money-Driven Medicine: The Real Reason Health Care Costs so Much , I quote Kaiser Permanente
CEO George Halverson who points out that few modern researchers are willing to risk betting their
own money on their newest products or procedures. In some cases, he reports, when health care plans
have been asked to cover a new, as yet unproven treatment, they have said: 'Try it. If it works,
we'll pick up the bill. If it fails, then it's your cost, not ours.'
" Researchers virtually never take the bet because they 'know that most research fails
,' says Halvorson. "So having their personal incomes tied to the actual success of their
unproven care isn't at all attractive. There is some irony in the fact that the same researchers
who enthusiastically extend hope to individual patients are, almost without exception, far too practical
about the actual value of their experimental care to risk their own income."
Monday, the Times ' story acknowledged that " Prosecutors, malpractice lawyers
and state medical boards are only now waking up to the issue . . .The Texas Medical Board
last month accused a widely known cardiologist in Austin of inserting unnecessary stents. In September,
federal prosecutors accused a cardiologist in Salisbury, Md., of performing unnecessary stent surgeries,
and last year a Louisiana doctor was sentenced to 10 years in prison for inserting unneeded stents.
. . "
The Times went on to quote Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland
Clinic: "What was going on in Baltimore is going on right now in every city in America." Nissen added
that he "routinely treats patients who have been given multiple unneeded stents. We're spending a
fortune as a country on procedures that people don't need."
I would love to see the Times expand on these comments by exploring the larger national problem.
Ideally, the nation's paper of record would launch an investigation by looking into the use of stents
in its own backyard-Manhattan.
Why the Delay in Acting on the Problem?
Why has it taken so long for state medical boards to "wake up?
I am afraid that many hospitals have resisted the news for one simple reason: procedures that
involve stents are extremely lucrative. In 2007
Business
Week told the story of how stents rescued New York's Mt. Sinai hospital:
"The 2,000-doctor hospital was struggling in March, 2003, when Dr. Kenneth L. Davis took over
as chief executive. During the previous six months, Sinai had lost $50 million, partly as the result
of tougher caps on Medicare reimbursement rates. . . . While trimming costs, Davis also decided to
build up practices in high-margin specialties. 'Interventional cardiology was one of myriad areas
where we were eager to facilitate growth,' Davis explains. Dr. Samin Sharma, Mt. Sinai's "King of
Stents," ran a cath lab which was central to this campaign, performing procedures that typically
brought in as much as $20,000 a piece for the hospital.
"Sharma convinced his bosses that to capitalize fully on the stent boom, Mount Sinai should turn
his cath lab into a 24/7 operation. At a cost of $400,000 a year, he figured, the hospital could
put enough doctors and nurses on call to do emergency angioplasties late at night and on weekends.
Soon the lab was averaging 15 off-hours patients a month. Interventional cardiology became
a key revenue source for Sinai. By the end of 2006 the hospital's total patient revenues had grown
41%, to $1.2 billion. Cardiology services, excluding surgeries such as heart bypass, contribute 15%
of that, most of which comes from Sharma's cath lab ."
This is one of many such stories. Two years ago, a physician at another prestigious Manhattan
hospital explained to me why his hospital didn't offer palliative care: "The COO would rather put
the money into expanding the cath lab; it's far more profitable."
Let me add that I don't think that most doctors who recommend procedures using stents are motivated
by greed. As Dr. Hadler points out in his guest post, there are many ways for physicians to rationalize
their use. Professional pride plays a role: doctors who implant stents firmly believe that they are
helping their patients.
Since 2007 Study, Use of Stents Has Dropped, but Many Remain Undaunted
Not everyone has ignored the research. The
Baltimore Sun notes that "after a landmark 2007 study in the New England Journal of
Medicine concluded that stents were often not beneficial," enthusiasm waned. "In 2009,
Medicare paid 'just' $3.5 billion for stent procedures nationwide, down from about $5 billion
a year before the 2007 study " was released.
According to the Sun : "The 2007 study didn't find that stents are worthless, just that
not implanting a stent can often be as good - and avoids the real risks of complications or even
death from the procedure. But hospitals can't bill $12,000 for deciding not to implant a
stent, even if that's the best thing for the patient ."
Some physicians remain clearly undeterred by the research.
For example,
the Sun reports , "Dr. Midei's [use of stents] increased, by his own estimate, 50 percent,
to about 1,200 a year."
As for Mt. Sinai's Stent star, Cardio Brief , a blog for cardiologists and other cardiovascular
health care professionals, heard from Dr. Sharma just last year, shortly after
the Brief reported that Columbia University cardiologist Jeffrey Moses had earned $2.5
million in 2006-7, vaulting him to 8th place in the Chronicle of Higher Education 's Hit Parade
of individuals receiving the "highest total compensation at private colleges, 2006- 2007." Apparently
Dr. Sharma was miffed . He got in touch with the blog to point out that "
he performs 1,500 complex coronary interventions each year, which apparently is an American
record ," Cardio Brief noted. "Sharma also wanted to let us know that the Chronicle
's list failed to include Sharma's own salary of $2.75 million which would have put him ahead
of Moses."
Health Care Reform Legislation Points to Solutions
Bob Wachter recalls that when the Midei scandal broke, a reporter asked him "Why didn't peer
review catch this?"
Peer review is improving Wachter says, but cases like Dr. Midei's don't trip any alarms. Patient
who think he saved their lives don't complain. Still, there are ways stop them.
"Obviously, the Mideis of the world could be caught by requiring that every cath undergo an independent
second reading," Wacther adds. His point is that the physician who diagnoses the need for stents
shouldn't be the one who also performs the procedure. "Some insurers in New Jersey now require such
readings before they authorize a stent, and at least one SoCal Kaiser hospital mandates that each
cath be presented at a conference before a treatment decision is rendered, analogous to what many
tumor boards do for cancers."
No doubt many of the New Jersey insurers' customers-and some physicians-object to the requirement.
But this is an example of how insurers can add value to health care, not by trying to make treatment
decisions themselves, but by calling for more collaboration. If a second doctor must sign off on
the reading, this could stop a serial stenter in his tracks. It's one thing to close your eyes when
a colleague is wheeling one patient after another into the cath lab, quite another to associate your
name with his activity.
Under health care reform, doctors are more likely to be looking over each others' shoulders. There
will be incentives to join Accountable Care Organizations where doctors or doctors and hospitals
work together, and all share in the financial rewards if they are able to avoid waste. Under the
Affordable Care Act (ACA) bonuses will encourage doctors to move away from fee-for-service, and toward
working on salary (as doctors already do at multi-specialty clinics such as Kaiser or the Mayo Clinic)
or accepting "capitated" payments.
In Massachusetts, Blue Cross/Blue Shield, which owns about 45 percent of the private insurance
market in the state, already has moved to a combination of capitation and bonuses for higher quality
care. BCBS pays contracting groups of doctors to provide all care, including inpatient services,
for its members. The payments are risk-adjusted for age, gender, and health status. Any savings the
physicians achieve remain with their group, unless they share the risk with a hospital; in the latter
case, part of the savings flow back to the hospital.
Physicians and hospitals also can
receive
bonuses of as much as 10 percent by doing well on nationally recognized process and outcomes
measures. The Massachusetts Blues program is the first major global capitation effort on the East
Coast in a decade. Capitation has remained more common the West, where HMO penetration remains greater.
The Centers for Medicare and Medicaid is determined to move away from "fee- for service" payment
because we know that inevitably, it leads to more procedures, yet earlier this year,
the Commonwealth Fund reported that "physicians and industry leaders [feel] that cost reductions
of 20 percent to 30 percent are achievable under well-constructed global payment models" which pay
doctors a lump sum to keep patients well. Meanwhile "patient care suffers in the fee-for-service
environment." Medicare will not force physicians to give up fee-for-service, but those who cling
to being paid "piece work" are less likely to be eligible for the bonuses that reward collaboration
and better outcomes.
Under the Affordable Care Act doctors who create a "medical home" also will be rewarded if they
are able to keep their patients healthy and out of the hospital, while avoiding invasive treatments.
For heart patients, medication, and diets like Bill Clinton's "plant diet" are likely to be favored.
In addition, the Medicare Payment Advisory Commission (MedPAC) has suggested that when Medicare
spots high volume combined with high profits margins, this is a place to look for overtreatment.
The Accountable Care Act allows the Secretary of HHS to lower fees for "overvalued medical services."
One would expect that she will take MedPAC's advice and that especially in light of the Senate Finance
Committee report, as well as legal action in a number of states, procedures involving stents would
come under scrutiny.
Finally, as
I reported earlier this year , a more proactive Food & Drug Administration has announced that
it plans to begin requiring drug makers and device makers to disclose details about their clinical
trials-providing detail on their failures as well as their successes. Greater transparency will make
it much harder for those who manufacture stents to paint a rosy picture of risks versus benefits-the
FDA aims to make sure that these companies are not hiding information about risks.
Reform Will Mean More Team Work
Wachter goes on to suggest that team work can also reduce medical errors-including overtreatment.
Many at the hospital must have known what Midei was doing, he suggests, but looked the other way.
" Cardiologists don't perform caths on desert islands they are assisted by cath techs and
nurses . In my experience, these folks become as adept at reading cath films as any physician.
If the allegations against Midei are true, it strains credibility to think that no one in the lab
knew that inconsequential lesions were being read as tight stenoses and treated with stents.
" And what about hospital administrators ?" he asks. "While it is possible that
no St. Joe's leader knew precisely what was happening, I'm guessing that some did but chose to look
the other way: the pressure to steer clear of the golden-egg-laying goose must have been intense.
Perhaps the fact that the hospital's CEO and two other senior executives resigned after the case
broke provides a clue as to who knew what when.
"Cases like this one are terribly troubling," he continues, "not just because they harm individual
patients but because they do violence to the trust that is so fundamental to the physician-patient
relationship.
" But these cases also force us to consider the kind of culture that could allow such
a fraud to take root and go on for years a culture that likely prized the hospitals' and
physicians' financial health over the clinical health of their patients. If the allegations are true,
the penalties should be severe, not only for Dr. Midei but also for leaders who knew or
should have known what was going on, yet remained silent ."
Under reform, "accountability" is likely to extend beyond the individual patient-doctor relationship.
Physicians and hospitals that work together-and are paid as a team-will become accountable for each
other.
Yes, but physicians rarely go to jail for malpractice.
Even in Redding, California, where a doctor performed hundreds of unnecessary bypasses and angioplasties,
he did not go to prison.
Part of the problem is that in these cases, the doctor may well have thought that he was helping
the patients.
The physician himself becomes part of a mass cultural delusion about the efficacy of certain procedures.
People are thanking and congratulating him patients, their relatives, the hospital, etc.
He may well believe he is saving lives.
Though of course there are extreme cases where a doctor is consciously over-treating, but I suspect
those are very rare.
Reply ↓
whilst I'm enthusiastic about CMS moving toward capitation, I'm not holding my breath. In the
meantime, simply releasing payment information would help the press and public target such excess,
as the WSJ piece on prostate care indicates.
Reply ↓
NG
Just to clarify
As long as a doctor has obtained a signed consent, they are pretty much immune from assault charges,
unless of course they engage in sexual or other illegal activity with a patient. As Maggie says,
doctors who engage in inappropriate care are guilty of malpractice, a violation of contract (civil)
law, not criminal law.
If it can be demonstrated that a doctor was willfully negligent or engaged in fraudulent behavior,
many, perhaps most, malpractice policies have clauses that obsolve the insurance company of responsibility,
potentially leaving the doctor responsible for the entire cost of settlement or judgements themselves.
In practice, this is rarely invoked except in cases involving falsifying records after the fact,
perjury, and other similar things, but in theory it could be in some cases. Court findings of
fraud or willful negligence also expose the doctor to potential punitive financial damages, in
addition to the usual compensatory damages. Malpractice insurance generally does not cover punitive
damages.
In addition, of course, doctors are subject to investigation and censure by their hospitals, potentially
leading to loss of privileges (the right to work in the hospital) or other lesser sanctions, and
by state medical boards, potentially leading to loss of license or other lesser sanctions.
Finally, if there is a finding that a doctor willfully or fraudulantly billed for false charges
to Medicare, Medicaid, or private insurance, the doctor would be liable for a judgement of insurance
or Medicare fraud. That can result in criminal charges and in permanent or temporary loss of the
right to bill Medicare for services.
Reply ↓
VA
You are correct-you if you make physical contact with your victim, that's battery.
But doctors can go to jail for malpracticetypically if they are found guilty of fraud and malpractice.
A doctor who knowingly performs unnecessary surgery or hospializes patients who don't need to
be hospitalized is bilking the insurer while harming the patient, and can go to jail.
Intent is very important.
Of course very, very, very few doctors ever intend to harm a patient. But some do set out to over-charge
insurers, Medicare or Medicaid, and sometimes the patient suffers the "collateral damage."
I'm not an attorney, so I don't know whether a prosectuor has
to prove intent, or whether there are cases where criminal negligence could put a doctor in jail.
Ordinarily, though doctors are not imprisoned for malprctice because society acknowledges that
we all are human and even the very best doctors make mistakes.
Reply ↓
Maggie,
I have a different take on this.
First, my own experience goes like this. I had quintuple bypass surgery in 1999. I was told that
I probably had a small heart attack sometime in the past and never realized it as there was some
minor heart damage. I was put on maximum medical therapy after the surgery and have been on it
ever since. I take a beta blocker, an ACE inhibitor, a statin, an anti-spasmodic drug and a blood
thinner plus baby aspirin. After six years, an angiogram following new complaints of chest pain
found one artery that was 85% blocked and a stent was inserted on the spot which took only an
incremental 15 minutes or so beyond the time for the angiogram by itself. While I occasionally
have some chest pain from time to time, it's minor and the medical regimen continues and will
continue indefinitely.
I was glad to get the stent at the time of the angiogram rather than have to come back for a separate
procedure. If a second doctor had to sign off to confirm the need for one or more stents, it would
delay treatment and add to the patient's anxiety. If the first and second doctor each worked for
the hospital with their compensation tied, at least in part, to the hospital's revenue and profit,
I'm skeptical how many times the first interventional cardiologist would be overruled.
Instead, when payers, including commercial payers as well as Medicare and Medicaid notice that
a particular doctor and/or hospital is performing an unusually large number of procedures of any
type, timely unannounced post-procedure audits should be performed by experts hired and paid for
by the payers. If clearly unnecessary procedures are being done, especially when claiming that
a blockage is much greater than the film shows it to be, the consequences for the doctor should
be swift and severe including prosecution for fraud and, possibly, loss of his medical license.
If hospital compliance departments want to perform their own audits as well, more power to them.
With regard to the studies that claim to show that there is no benefit from stents regarding either
life expectancy or preventing future heart attacks or strokes, they don't speak to the quality
of life implications of reduced chest discomfort. Chest discomfort, especially if it occurs at
rest and not during or shortly after eating is not only stressful, it can be perceived as life
threatening. By contrast, pain from, say, arthritis, is both annoying and can negatively affect
quality of life, but it's not life threatening. That's a huge difference to those of us who live
with heart disease.
Finally, the new reform driven approach to pay hospitals modest bonuses if they meet certain quality
standards is not likely to be as effective as you think or imply. Hospitals that don't do procedures
don't get paid. For capitation or bundled payments to work, they would need probably to be assured
of total revenue equal or at least close to what they are generating today. For most hospitals,
60% of their costs are fixed and 40% are variable. It's not that easy for them to reduce costs
in the short term.
As an aside, I recently met with the CEO, who is also a physician (OBGYN), of a large hospital
system in the NYC metropolitan area and the CFO of a well known hospital system in Pennsylvania.
Both said that they could not make money if they had to take Medicare rates from all comers even
if there were no uncompensated care.
Reply ↓
Barry
Your story is a good example of why anecdotal results don't mean much.
It is true that people with angina often get faster relief from stents than medical treatment,
but it is also true that medical treatment is usually successful at providing relief from angina
after a short interval, an interval that can usually be bridged successfully with use of morphine
and nitrates. On the other side of the coin, stent patients have much higher incidence of problems
related to stent failure, re-stenosis, and delayed stent complications, plus face the risk of
acute complications, including death, during the procedure.
In fact, in most stent patients the stent most likely is responsible for the pain effects for
only a fairly short time, at which point the maximal medical therapy they are almost always on
as well takes over and carries most if not all of the weight.
Studies still do suggest that stenting is the preferred treatment in either acute heart attacks
or in unstable angina, but the studies are very convincing, as shown elsewhere on this and the
related thread, in showing that there is no real advantage and most likely a slight disadvantage
to managing both standard angina and non-symptomatic coronary artery disease with stents instead
of medical therapy alone.
Reply ↓
Barry
]
The research shows that
stent procedures offer relief from the pain of angina for a whilebut not forever.
It's fast, but a band-aid fix.
Drugs and a change of diet
can help the patient for a much longer period of time.
And as Pat S. points out in his comment, pain-relieving drugs can help patients until the other
medications kick in.
As for whether hospitals can make money on Medicare-or lowered Medicare payments sse the Medicare
Payment Advisory Commission report which I have referenced in the past showing that
most hospitals do turn a profit on most Meidcare patients.
As for hospital CEOs at overpaid hospitals in NYC and PIttsburgh who tell you they couldn't surive
on Medicare paymtents? (I'm pretty sure I know the hospitals you are referring to) What did you
think these CEO's would say?
As for Medicare paying hospitals less: this will begin quite soon. Medicare will be penalizing
hospitalis with excessive readmissions, and, each year, they will be cutting annual increases
to all hospitals by 1%.
Medicare wants to put hospitals under some fianncial pressure because MedPAC reserach shows
that when hospitals are under financial pressure, they learn to become more efficientand, in
fact, beginning making a profit on those Medicare reimbursements.
As Pat S. points out, in his comment, anecdotes (or stories you hear from people with an ane
to grind) are one thing; MedPAC's well-documented analysis is another.
These CEOs are making 7-figure salaries as a reward for running a hospital as a revenue center
(as opposed to a patient-care center).Of course they will say that the government isn't paying
hospitals enough.
Pat S.
Yestand hank you.
But in your last paragraph I think you mean "but the studies are NOT very effective" ???
If so, let me know, and I can go in and make the fix.
Reply ↓
Pat
Do you have any data on the percentage of stent placements that go into patients who are either
asymptomatic or have stable angina? I don't understand why and under what circumstances asymptomatic
patients would ever be sent to the cath lab in the first place. Conversely, I also wonder how
many patients who receive stents would have been better off for the longer term with a CABG.
Maggie
The PA hospital system is based in Philadelphia, not Pittsburgh. The CFO said their current margin
on their Medicare business overall ranges from 0 to -10%. They make decent money on the surgical
procedures but the medical admissions, as a group, are more problematic from a financial standpoint.
He also said that in the two years prior to this year, their costs per adjusted admission grew
3.5% with the comparable number for this year at 2.0%. Meanwhile, Medicaid pays them less than
70% of their costs with more payment reductions coming due to state fiscal pressures. If Medicare
payments rise only 1% or so while their costs continue to go up at 2%, it's a formula for continued
cost shifting to commercial insurers.
The main area where all hospitals have the potential to get better is in reducing 30 day readmission
rates and they are all working on that. ACO's certainly have the potential to do a better job
with care coordination, especially if decent electronic records are in place and used. The trend
toward more hospital employed physicians makes it easier to consolidate vendors and standardize
operating room protocols. At the same time, they could lead to even greater concentration of market
power which could result in healthcare costs even greater than they would have been under fee
for service even with global payments, bundled payments for surgical procedures or partial capitation.
The powerful hospitals will vigorously resist value based insurance design though BCBS of Massachusetts
is moving ahead with the introduction of a tiered in network insurance product on January 1, 2011.
While I strongly support that approach, I suspect that, in the end, we may well wind up with an
all payer system but Medicare and, especially, Medicaid will have to pay more than they do now.
That's a heavy lift in the current fiscal environment.
Reply ↓
As you know, a profit margin turns on the cost of operations.
MedPAC has found that the cost of operations at a great many hospitals is much, much higher
than it needs to be. This is because they are terribly inefficient.
Just one example: they have three or four ORs that are all very busy during the morning and
more or less empty in the afternoon.
This is because many surgeons prefer to operate in the morning, and if these surgeons bring in
business, hospital administrators do their best to please them.
These hospitals need only two ORs.
As for hospitals having greater market power as physicians and hospitals consolidate, the
government pays more and more hospital bills, "the makket" is not going to determine prices. Government
(taxpayers) already pays more than 50% of all health care bills in the U.S.
Going forward, govt's share will grow (as more people age into Medicare, and as as Medicaid
and SCHIP expand).
Note what happened this year when the Secretary of HHHS negotiated with Medicare Advantage insurers
on prices: next year, premiums will be 1% lower than they were this year, and Sebelius insisted
that they slash co-pays for extremely expensive drugs for cancer, MS, etc.
In other words, government is beginning to regulate prices. (Medicare Advantage insures will
be pushing back, refusing to overpay drugmakers, hospitals, etc.)
The Affordable Care ACt also cuts increases in payment to hospitals and nursing homes by 1%
a yearevery year. This provision is designed to put pressure on hospitals to become more efficient.
As MedPAC research show, when hospitals are under some financial pressure, they find a way
to cut waste in what it costs them to deliver care.
Reply ↓
Barry
Pat didn't say that "asymptomiatic patients" undergo stent procedures.
He said that patients suffering from anginawho have never had heart attacks- undergo these
procedures.
This is true.
And, research shown that while angioplasty with stents offers them quick relief from pain,
over the long term, their angins often comes back.
Medication and change of diet, on the other hand, is much more likley to lead to long-term
relief from angina.
More imporantly, when patients undergo angioplasty with stents, long-term repeated reserach
shows that their chances of suffering a heart attackor dying from a haert attack are NOT REDUCED..
Reply ↓
Barry
Non-symptomatic patients end up in cath lab because of results of other tests - ecg, stress ecg,
nuclear cardiology, lab tests, and these days especially coronary artery CT. These tests are advocated
as screening tests and are obtained for things like clearance to begin exercise programs, "executive"
physicals, family history or other risk factors, or just plain general prinicples. When they have
positive findings, the logical next step is to send the patient to cath. Part of this is pure
overkill, and part of it is due to some physicians' desire to locate patients with the so-called
"widowmaker" lesion - significant stenosis in the left main coronary artery - before they suffer
severe or life threatening events.
The result goes: screening suggested for one reason or another > abnormal results in screeing
> cath > abnormal cath findings > stenting. It is a good example of the problem of accidentally
creating disease by the doctor boxing themselves in with testing that was not needed in the first
place.
I have no idea of what the percentages of people who are non-symptomatic who end up getting stents,
but simple angina is the most common cause of heart cath and stenting in many centers.
I personally once had a stress ecg - clear back when I was in my late 40′s - as a screening
test at the urging of my doctor despite being asymptomatic at the time. Fortunately, it was negative
and everything ended there.
Reply ↓
Maggie
Actually, I did say that asymptomatic patients undergo cath and stenting, under the circumstances
that I outlined in my answer to Barry. The problem is that some, probably many or most, cardiologists
believe that once they discover what they consider to be a significant stenosis they more or less
HAVE to treat it to prevent it from causing the patient problems down the road.
As to the sentence: it may be awkward because of the parenthetical phrase, but what it says,
minus the aside, is:
"the studies are very convincing in showing that there is NO real advantage and most likely a
slight disadvantage to managing both standard angina and non-symptomatic coronary artery disease
with stents instead of medical therapy alone."
(caps added to "no" for empnasis.)
Reply ↓
Pat
Thanks for the explanation of how non-symptomatic patients wind up in a cath lab. It makes perfect
sense. In my own case in 2005, there were some symptoms and a stress test showed a significant
adverse change from my prior stress test a year or so earlier.
I understand that stent placement is a lucrative procedure for both the hospital and the interventional
cardiologist. I wonder, though, what role defensive medicine plays in the equation as compared
to how decisions about how to treat screening test findings are determined in other countries.
I could see where formula based protocols might be developed here that would call for a stent
if the percent blockage is above X depending on where it is maybe a lower threshold for the
Left Main or, perhaps, the LAD as compared to one of the distal branches. Even if the interventional
cardiologist knows that the patient has stable angina or is non-symptomatic, if the percent blockage
is above the threshold, and he doesn't put a stent in, what if the patient has a heart attack
in the next week / month / year? The path of least resistance in our litigious culture is to insert
the stent. Oh, and by the way, it pays well too. If the docs in other countries perceive, correctly,
that, as a practical matter, they are unlikely to ever be sued, even if the screening results
are positive, the patient may not be sent to the cath lab if he/she is non-symptomatic or has
stable angina. My sense is that defensive medicine may be an important part of the equation that
determines interventional cardiologists' practice patterns in the U.S. even though its effect
cannot be specifically determined or quantified.
Reply ↓
"This is pretty much what happened in one notorious case,that of Shasta Regional Medical Center
in the small town ofRedding, California. There, two rogue cardiologists, Chae Hyun Moon and Fidel
Realyvasquez Jr., headed a team that performed extraordinary volumes of unnecessary and recklessly
dangerous heart operations. In the end, both would lose their licenses, and each would pay a $1.4
million fine in lieu of federal criminal prosecution. Yet for years before, their building reputations
as top-notch cardiologists brought in patients from all over Northern California. In gratitude,
the hospital pampered them with department chairmanships and perks. Dr. Moon even enjoyed occasional
use of the hopital's emergency helicopter to fly to golf tournaments.
Our Lady of Lourdes Regional Medical Center in Lafayette, Louisiana, provides another example
of how high-volume rogue surgeons can escape scrutiny for years, either because hospital administrators
don't know, or profit from pretending not to know, how dangerous they are. At Lourdes, there were
rumors for years that one of its surgeons, a Dr. Mehmood Patel, was performing vast amounts of
unnecessary heart operations. Yet it wasn't until one of Patel's fellow doctors at last secretly
sued him in federal court under a special whistleblower law that the hospital revoked his admitting
privileges. The hospital subsequently agreed to pay a fine of $3.8 million but still denies it
had any way of knowing about the safety or effectiveness of Dr. Patel's care.
As the number of specialists in a community grows, many people cut out visits to their primary
care physicians altogether. Instead, they skip from one specialist to another according to what
body part gives them reason to complain that day, all the while gathering more and more bottles
for the medicine cabinet." Phillip Longman "Best Care Anywhere"
Reply ↓
run 75441-
Yes, the Redding story eptiomizes what has been happening.
I interviewed some of the victims of Redding when I wrote Money-Driven Medicne. Very sad stories.
And I do blame the hospitals. While looking at overtreatment, Dartmouth researchers realized that
Redding was doing an extraordinary number of bypasses and angioplasties. Dartmouth helped expose
the problem.
Dartmouth is on the ohter side of the country. Administrators at the California hospital should
have realizled that something unusual was going on.
Reply ↓
Barry
This is the usual complicated stew of motives for performing tests and procedures that are not
scientifically warranted. The main issue, in truth, is probably that the doctors believes that
they are doing the right thing, based on their grasp of the science and their personal feelings
about what they are doing, possibly influenced by personally not having kept up on the science
and by the continued insistence of academic doctors with career stakes and of reps from supply,
equipment, and drug companies that the evidence against the procedures are flawed, incomplete,
or don't apply to a brilliant person like themselves who gets far better results than the people
at institutions where the research is done .
It is very very hard for doctors to admit to themselves that something they have been doing
for a while is now demonstrated to be of little value or even potentially harmful. The rest of
the complicated motives behind this, ranging from the desire of their hospitals to keep expensive
equipment paying for itself to personal prestige to the financial rewards to the feeling that
if they don't do something they might be sued all enter into the mix, but the first is the main
thing.
The interesting thing is that the article in the Times suggests that the tide has turned
and that doctors are actually at greater risk of litigation from DOING the procedure than from
NOT DOING it. This is relatively unusual in medical circles, although there have been some
spectacular cases of litigation for performing a procedure that is useless or causes harm. The
most spectacular was the case of retrolental fibroplasia causing blindness in infants who had
been given too high of levels of oxygen in intensive care nurseries, usually because of prematurity.
A small group of unfortunate pediatricians who had been somewhat behind the curve on the issue
ended up being sued by the children when they reached adulthood, 18 to 21 years later. In many
cases, the malpractice insurance that was in force for the incidents had been acquired two decades
earlier and had cash limits that were way too low for the settlements and judgements that were
being given, leaving the pediatricians, many of whom had already retired, to pay 7 figure awards
out of their own pockets. That lesson influenced a lot of doctors from my generation, who saw
all this happen early in our careers, but lessons that don't quite fit with personal ego and ambition
have a tendency to be forgotten after a while, especially by younger people who did not see the
events first hand.
Reply ↓
Pat
Thanks for the very thorough and nuanced explanation. It makes a lot of sense as usual. I think
it's encouraging that doctors may be starting to perceive greater litigation risk from doing this
procedure as opposed to not doing it. In the meantime, with modern data analytics, I think
both public and private payers could more aggressively audit some of these cases to confirm medical
necessity, especially when they notice unusually large numbers of procedures being performed by
a given institution or a specific physician or group.
Reply ↓
I have been researching, investigating, speaking & writing on the ugly reality of physician misbehavior
for more than a decade. I've seen it from the inside and out.
What any cursory investigation reveals is truly jaw-dropping:
NO other profession injures & kills more citizens unnecessarily;
No segment of professionals escape more appropriate discipline upon being found guilty
2,500+ doctors are found responsible of Felony-level crimes each year another 5,500 convicted
of "lesser" bad behavior.
Health Care almost never reports its own miscreants to authorities, as they are mandated
by law to do.
The Nat'l Practitioner Data Bank holds files on a whopping 1/4 million physicians just
since 1985. A shocking number of them fall into the categories of "Dangerous" or "Questionable."
And that 250,000 is considered an extremely low number, by those who understand the scope of
the misbehavior.
As a society, we are getting exactly what we tolerate which as of this writing, includes
skyrocketing health care costs, and almost exactly 500 innocent deaths . . . per day.
We are being enormously group-stupid in not bringing the roof down on the bad boys of medicine.
Thanks for the commentI am afraid you are entirely right.
Why don't doctors police themselves and blow the whistle on bad doctors?
I've read that the "hazing" experience of med school causes doctors to bond with
each other: "anyone who has gone through this deserves to be a doctor."
That hazingwhich includes being humiliated by people who are supposed to be
training you makes doctors extremely sensitive to criticism.
These things may be true of manythough not necessarily most doctors.
A more practical reason is that doctors are concerned about being sued if they try to
blow the whistle on other doctors. (We need better laws protecting whistle-blowers).
Finallyand I am afraid this is a major reason a great many hospital CEO's protect their
"rainmakers" and this includes doctors who bring in revenues by doing too many surgeries (even
when
they are very tired), too many unnecessary and expensive tests, etc. Often, if they're moving
too fast and
doing too much, they make mistakes. If a colleague tries to bring this to the attention of the
administration,
he may find himself in trouble. The politics inside hospitals can be ugly.
I wonder if you might want to write a guest post about this?
Click on "Contact Maggie" on the blog's home page.
"... An internal review by Tennessee-based Hospital Corporation of America found unnecessary heart procedures being performed at several facilities, according to The New York Times. ..."
"... A 2011 study in the Journal of the American Medical Association found that only half of 144,000 nonemergency heart catheterizations - typically the use of tiny balloons and stents to clear blocked arteries - were appropriate; 38 percent were "uncertain" and 12 percent were "inappropriate." ..."
"... "It's presented in the media as if it's an aberrancy, when actually it's the rule," said Dr. David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School of Medicine of the unnecessary heart procedures. "The medical system is addicted to the revenues that it generates." ..."
"... Comparisons to common practice among doctors and hospitals may not be the best barometer of proper patient care. Studies show that doctors often do not adhere to best practices when they treat patients who have plaque buildup in their coronary arteries but whose condition is stable. ..."
"... About 600,000 procedures are performed every year to clear coronary artery blockages, according to the American Heart Association. The procedure involves snaking a catheter through the patient's arteries and clearing the blockage with a tiny balloon and a small wire cage - the stent - that holds the artery open. ..."
"... But studies show that medicine alone is as effective in patients with stable heart disease and that many procedures to clear blockages are unnecessary. Brown published a review of eight studies and found "there's absolutely no evidence" for substituting stents for medical therapy in patients with stable heart disease, he said. ..."
"... Editor's Note: ProPublica is working on a project to document cases of harm to patients. You can share your story by filling out our Patient Harm Questionnaire , or by joining our ProPublica Patient Harm Community on Facebook . ..."
by Marshall Allen
As Hospital Corporation of America comes under scrutiny, experts say unnecessary heart procedures
are common, costing taxpayers, driving insurance premiums and putting patients at risk.
An internal review by Tennessee-based Hospital Corporation of America found unnecessary heart
procedures being performed at several facilities, according to The New York Times.
New accusations that one of the nation's largest hospital chains performed more than a thousand
unnecessary heart procedures grabbed headlines this week, but the practice is far from unique in
U.S. health care.
A
2011 study in the Journal of the American Medical Association found that only half of 144,000
nonemergency heart catheterizations - typically the use of tiny balloons and stents to clear blocked
arteries - were appropriate; 38 percent were "uncertain" and 12 percent were "inappropriate."
"It's presented in the media as if it's an aberrancy, when actually it's the rule," said Dr.
David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School
of Medicine of the unnecessary heart procedures. "The medical system is addicted to the revenues
that it generates."
The New York Times
reported this week that the U.S. attorney's office in Miami is investigating allegations that
patients underwent unnecessary heart treatments at facilities owned by Tennessee-based Hospital Corporation
of America, a 163-hospital chain.
According to the Times, an internal HCA review found unnecessary procedures being performed at
several facilities, including more than 1,200 at Lawnwood Regional Medical Center & Heart Institute,
in Fort Pierce, Fla.
HCA did not return a call for comment, but said in a
statement posted on its website that there's wide disagreement among physicians about which procedures
are medically necessary and its use of stents was within the range of those at other hospitals.
Comparisons to common practice among doctors and hospitals may not be the best barometer of
proper patient care.
Studies show that doctors often do not adhere to best practices when they treat patients who
have plaque buildup in their coronary arteries but whose condition is stable.
About 600,000 procedures are performed every year to clear coronary artery blockages, according
to the American Heart Association. The procedure involves snaking a catheter through the patient's
arteries and clearing the blockage
with a tiny balloon and a small wire cage - the stent - that holds the artery open.
But
studies show that medicine alone is as effective in patients with stable heart disease and that
many procedures to clear blockages are unnecessary. Brown
published a review of eight studies and found "there's absolutely no evidence" for substituting
stents for medical therapy in patients with stable heart disease, he said.
The American Heart Association
recommends putting patients with stable heart disease on blood thinning medication before they
try a stent,
said the authors of a May 2011 study in the Journal of the American Medical Association. Yet
it happens in fewer than half of the cases where doctors use stents,
the study found .
There is some debate about the scope of the problem.
Dr. William Zoghbi, president of the American College of Cardiology, says there are "pockets"
around the country where unnecessary procedures are more prevalent. The college offers seminars and
guidelines on appropriate use for doctors, he said, and keeps a national registry so they can compare
their practices to others. Zoghbi said the educational efforts are showing signs of success.
Unnecessary stenting persists in part because doctors are not explaining the medication-alone
option to patients, said Dr. Michael Barry, president of the Informed Medical Decisions Foundation,
which has created a
guide of treatment choices for patients with stable heart disease .
Barry was part of a team of researchers that surveyed 472 Medicare patients with stable heart
disease about their interactions with doctors who performed nonemergency stent procedures on them.
A key finding : Only 6 percent of the patients said their doctor offered medication as an alternative
to a stent.
Correction: This post originally said that the Archives of Internal Medicine
found that only half of 144,000 nonemergency heart catheterizations were appropriate. It was actually
the Journal of the American Medical Association.
I'm in healthcare and can tell you that there's an enormous amount of unnecessary procedures performed
for the $$$. Also a lot of billing for procedures never performed, and even in some cases for patients
never even seen. Some of the worst fraud and abuse is in cardiology, and gastroenterology. Ted
Very fine article. It is not just about "stents". Virtually all aspects of medicine from colonoscopies
to mammography, to PSA's to what we pay for medications is part of the huge issue of "more is better"
practice of US Medicine Inc. Warren Liebman
I see that your survey is about patients that suffered harm through the insertion is stents. I had
day surgery for a procedure unrelated to my heart. I had heart failure in the recovery room and was
sent by ambulance to the nearby heart center where I had three stents inserted the next day.
My cardiologist thought the stents were the best alternative. I deferred to his opinion as I was
unqualified to make the decision.
I was on Plavix for three years and now just blood pressure and cholesterol drugs. I am very pleased
with the outcome.
Carefully read the HCA online document that alleges that the number of cardiac caths and stent procedures
has decreased per year.
Missing from the document is the number of HCA cath labs and HCA cardiologists doing the procedures.
As we know, HCA downsized so if it has fewer hospitals and or fewer cardiologists then there may
be an increase in the number of procedures done per remaining hospital or remaining cardiologist.
Greg
Given the setup, this is the inevitable result. With insurance in the way, doctors jump through hoops
to get paid and money is invisible to the patient. Put those together, and the doctor has strong
incentive (even if we completely ignore pressure from the pharmaceutical and other supply companies)
to give everybody the most expensive health care possible, whether or not it's the best.
As Warren points out, stents are wonderful tools. But sledgehammers are also wonderful tools,
and I wouldn't want to use such a tool to clean a dirty window. When you have the right tool for
the right job, there's not much better.
And since, in this country, we confuse "health care" with "health insurance"-two completely unrelated
things except through their placement in the dictionary-we drive to make it worse, every time.
And note, the organization in the middle always benefits. And they sell the idea to doctors that
the problem with health care is fraudulent malpractice claims (i.e., blame the patient), while selling
the idea to patients that we need protection from the big, bad doctor bills.
It's one of the best scams running, really. You keep the parties blaming each other AND play on
the fear and implied threat that "it'd be a shame if something happened to your health," while raking
in profits from a biased system.
The placement of a stent in a coronary artery that has no blockage (as described in the NY Times)
is fraud. It also exposes the person receiving the stent to life-threatening complications at the
time of the procedure and for years afterward. This is a criminal act that should be prosecuted aggressively.
Innocent people deserve protection. Salvador
I myself have had 6 procedures done, and they have been done because of actual blockage. My cardiologist
that I have now is a very good Doctor; who use other ways of preventive care for someone like me,
before doing any kind of senseless procedure. He communicates with me in every aspect of the disease
that I have. As far I am concerned here in Austin Tx. I have had 2 cardiologist and have been wonderful,
and I see no fraud in any of the cases that I have been with. what ever goes on in those parts of
the country its because they have Dr. who don't care about their patients; only about how to rip
off the federal government. Jason Buc
So what are the guidelines for who ought to be stented vs those that ought to be treated with pharmacology?
Is there ever a proper non-emergent stent? I am familiar with guidelines for who gets cathed emergently
vs those that ought to receive fibrinolytics in the presence of mi. Salvador
I don't know any guidelines, I am merely stating incidents that has happened to me. Believe me when
I say that at the time of my procedures I felt I was on my dying bed massive MI and it took a lot
out of me. I am still struggling but not as bad as I was then, and I am also under a major meds regimen,
including blood thinner Effient. I have tried many other thinners that have failed me and appears
that this one is doing its job (Effient). Sharon
This is just the beginning of this reporting I hope ProPublica because you are hitting on THE most
important driver of the ever increasing costs of healthcare. There is very little health in healthcare
but there are huge profits.
And who pays when things go wrong? It's not the manufacturers or the doctors because you know
frivolous lawsuits. The patients' in this country, if they were informed consumers would want more
legitimate lawsuits that would weed out faulty products and procedures. Instead what we get are lawsuits
that vilify a doctor when he doesn't use an expensive scan or treat with an expensive drug. Those
lawsuits are allowed to proceed, step right up we'll help you sue your doctor. But when a product
like gadolinium based contrasting agents is maiming and killing millions and GE is the manufacturer
with the least stable product, the injuries go uncompensated. In these situations we have to pick
up these costs through higher premiums, our largest employers pay and so do health insurance companies
and the government. No matter what you think about health insurance companies and how evil they are
they still shouldn't have to pay for GE's faulty products or other faulty products. Those costs should
be borne by the ones that caused them. Great work ProPublica. I'm be watching and waiting for more
reporting.
While many unnecessary procedures are performed, some are actually related to the fact that patients
consider one approach as 'doing something', and the medical approach as being passive and less thorough.
A physician who does not perform a procedure has nothing to lose by recommending it. Any complications
are the result of the operator. But if a procedure is not recommended and an event occurs, such as
a heart attack, a physician may be blamed by the patient for 'not doing enough'. The fact that medical
therapies may indeed be better than procedures is not strongly embedded in the culture of patients.
And there is an aura of higher technology to procedures compared with medications.
This is an attitude that needs to change, both on the part of physicians and patients.
Perhaps everything that is being discussed here may make sense to some but not all. I'm sure that
people are not ignorant; when they are being treated by a good Dr. or a very bad Dr.: that is why
its always best top go for first, second, and even third diagnoses. As the old cliche goes we are
only human, and we all make mistakes, must not be taken as advise when it comes down anybodies health.
I my self am against lawsuits of any kind, as this is very degrading on both parts. Plus it goes
contrary to what I believe and what I have been taught through the word of God. One thing I will
say in the six procedures that I have had; I would rather do it all over again instead of having
open heart surgery. The basic fact is, that we all have the cure within ourselves if we know how
to do what is right, admittance, acceptance, and avoidance.
"... Medical provider knowingly submits false medical bills by billing for services not rendered, billing for wrong procedure codes or billing for procedures of a medical necessity when procedures may have been elective or cosmetic in nature and not covered by health insurance. ..."
Inflated Billing - Inflated billing by any medical facility, doctor, chiropractor,
laboratory, etc.
Healthcare
Billing Fraud - Medical provider knowingly submits false medical bills
by billing for services not rendered, billing for wrong procedure codes or billing for procedures
of a medical necessity when procedures may have been elective or cosmetic in nature and not covered
by health insurance.
"... Blood clots can occasionally form in an inserted stent, which can then lead to the artery narrowing once again. In some cases, the blood vessel can become completely blocked a condition called in-stent thrombosis. ..."
"... Most patients that undergo stenting are prescribed blood thinners in the wake of the procedure to ensure such events don't occur. ..."
"... Cardiac stents are big business for hospitals and their staff, with the average private insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery, surgeons can restore blood flow that has been compromised in heart attack patients, or give help to patients at risk for future heart attack. But when misused or overused in patients, cardiac stents can prove fatal, as they did for former postal service worker Bruce Peterson. ..."
"... Peterson developed several blood clots and blockages due to his weakened heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson. ..."
"... Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on" because "the interventional cardiology industry has a cash flow comparable to the GDP of many countries" and doesn't want to sacrifice the revenue, he said. ..."
About a third of all cardiac stents implanted in patients are unnecessary, says cardiologist
David Brown of Stony Brook University School of Medicine. That amounts to more than 200,000 stents a
year, and controversy surrounding this practice has spurred nationwide litigation and a federal
investigation into several cases involving illegal kickbacks and allegations of cardiac stent
malpractice.
For the most part, stenting procedures are relatively low in risk and moderately safe. However,
as with any surgical procedure even a minimally invasive one there is a risk of developing
complications.
Blood clots can occasionally form in an inserted stent, which can then lead to the artery
narrowing once again. In some cases, the blood vessel can become completely blocked a condition
called in-stent thrombosis.
Most patients that undergo stenting are prescribed blood thinners in the wake of the
procedure to ensure such events don't occur.
Additionally, manipulating arteries with a stent or any other sort of medical procedure can lead
to the walls of the blood vessel becoming injured or damaged. The innermost layer of coronary
arteries, known as the endothelium, is particularly susceptible to this sort of damage; the result
can be the formation of scar tissue in the area of the stent, and this too can lead to the artery
re-narrowing in a process known as restenosis. Treating Restenosis can involve an additional
stenting procedure, though in severe cases where a stented artery recloses it may be necessary to
have a patient undergo a coronary artery bypass to remedy the condition.
Overuse of cardiac stents leads to patient deaths
Cardiac stents are big business for hospitals and their staff, with the average private
insurance reimbursement for a procedure totaling $25,000. By placing a stent inside an artery,
surgeons can restore blood flow that has been compromised in heart attack patients, or give help to
patients at risk for future heart attack. But when misused or overused in patients, cardiac stents
can prove fatal, as they did for former postal service worker Bruce Peterson.
After suffering chest pain, Peterson paid a visit to cardiologist Dr. Samuel DeMaio, who inserted
21 stents in his patient's chest over a period of eight months, including five mesh tubes in a
single artery.
Peterson developed several blood clots and blockages due to his weakened
heart, which ultimately caused his untimely demise, argues his widow Shirlee Peterson.
She later sued DeMaio for cardiac stent malpractice an increasingly common charge in a Dr.
Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology & Interventional Cardiology & Internal
Medicine Healthgrades.comqaDr. Darshan P. Godkar, MD - Cedar Knolls, NJ - Cardiology &
Interventional Cardiology & Internal Medicine Healthgrades.com
Nortin Hadler, a UNC Chapel Hill professor of medicine told Bloomberg News, "Stenting belongs
to one of the bleakest chapters in the history of Western medicine. Cardiologists "are marching on"
because "the interventional cardiology industry has a cash flow comparable to the GDP of many
countries" and doesn't want to sacrifice the revenue, he said.
Cardiac stent problems cost $2.4 billion a year
The U.S. health care system spends an estimated $2.4 billion a year caring for patients that
received unnecessary cardiac stents, says Dr. Sanjay Kaul, of Cedars-Sinai Medical Center. Patients
face a much greater risk for complications like coronary scar tissue, blood clots and uncontrolled
bleeding from anticoagulant medications all of which can be life-threatening. Jim Simecek
told Bloomberg that he is on blood-thinning medicine for the rest of his life to prevent clots in
the cardiac stents he received from a Cleveland doctor who is currently the subject of a federal
probe.
Sixty-four year old Monica Crabtree's cardiac stent problems caused a torn artery, which resulted
in an infection and her death, according to her husband. He also pursued legal action after it was
determined by another cardiologist that Monica's stent was completely needless. The surviving spouse
recovered $240,000 in a malpractice settlement brought against the surgeon.
FDA reports hundreds of deaths attributed to cardiac stents
Some 773 patient deaths linked with cardiac stents were logged with the FDA last year, according
to Bloomberg. Though this figure has jumped more than 70 percent since 2008, with recent media
coverage on cardiac stent overuse and ongoing federal investigations, cardiologists may be using
fewer stents and only on suitable patients.
John Harold, president of the American College of Cardiology said the doctors who have been
charged with cardiac stent malpractice or fraud are essentially "outliers" in their community, and
that these surgeons fail to represent the "overwhelming majority."
"... Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation to Mehmood Patel). ..."
"... The suit alleged Patel implanted needless stents in at least two patients, including one that led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in her file said she didn't want interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the government's attention. ..."
"... "It was appalling," Kovach said in an interview. "Patel coerced her into getting a stent she didn't need, which killed her." ..."
"... "He's their cash cow," said Kovach, now co-director of a clinic that treats congenital heart disease at the Detroit Medical Center. "They're not about to turn him in." ..."
"... Patel continues to practice at the hospital and must improve record-keeping to substantiate cardiology procedures, Allegiance said. In the settlement, Patel agreed to hire a consultant to oversee treatment of his patients and an auditing firm to monitor billings. He didn't return phone messages. ..."
"... "I do believe that Bruce was a guinea pig," she said. "That was the way it was done." ..."
When Bruce Peterson left the U.S. Postal Service after 24 years delivering mail, he started a
travel agency. It was his dream career, his wife Shirlee said.
Then he went to see cardiologist Samuel DeMaio for chest pain. DeMaio put 21 coronary stents in
Peterson's chest over eight months, and in one procedure tore a blood vessel and placed five of
the metal-mesh tubes in a single artery, the Texas Medical Board staff said in a complaint.
Unneeded stents weakened Peterson's heart and exposed him to complications including clots,
blockages "and ultimately his death," the complaint said.
DeMaio paid $10,000 and agreed to two years' oversight to settle the complaint over Peterson and
other patients in 2011. He said his treatment didn't contribute to Peterson's death.
"We've learned a lot since Bruce died," Shirlee Peterson said. "Too many stents
can kill you."
Peterson's case is part of the expanding impact of U.S.
medicine's binge on cardiac stents -- implants used to prop open the arteries
of 7 million Americans in the last decade at a cost of more than $110 billion.
When stents are used to restore blood flow in heart attack patients, few
dispute they are beneficial. These and other acute cases account for about half
of the 700,000 stent procedures in the U.S. annually.
Among the other half -- elective-surgery patients in stable condition --
overuse, death, injury and fraud have accompanied the devices' use as a go-to
treatment, according to thousands of pages of court documents and regulatory
filings, interviews with 37 cardiologists and 33 heart patients or their
survivors, and more than a dozen medical studies.
'Marching On'
These sources point to stent practices that underscore the waste and patient
vulnerability in a U.S. health care system that rewards doctors based on volume
of procedures rather than quality of care. Cardiologists get paid less than
$250 to talk to patients about stents' risks and alternative measures, and an
average of four times that fee for putting in a stent.
"Stenting belongs to one of the bleakest chapters in the history of Western
medicine," said Nortin Hadler, a professor of medicine at the University of
North Carolina at Chapel Hill. Cardiologists "are marching on" because "the
interventional cardiology industry has a cash flow comparable to the GDP of
many countries" and doesn't want to lose it, he said.
Stenting abuse is by no means the norm, but neither is it a rarity. Federal
cases have extended from regional medical centers in Louisiana, Kentucky and
Georgia to a top-ranked metropolitan hospital system in Ohio.
Asset Seizure
A doctor practicing at a hospital owned by the Cleveland Clinic, rated the
premier heart center in the country by U.S. News and World Report, had his
assets seized by federal agents in a stent investigation, according to federal
court filings in April. The Clinic has not been accused of wrongdoing, and says
it's cooperating with the investigation.
Two out of three elective stents, or more than 200,000 procedures a year,
are unnecessary, according to David Brown, a cardiologist at Stony Brook
University School of Medicine in New York. That works out to about a third of
all stents.
Brown said his estimate is based on eight clinical trials of 7,000 patients
in the last decade, which he analyzed in the Archives of Internal Medicine last
year. Two cardiology researchers who have studied the use of stents say the
number could be as low as about half Brown's estimate, and one said it is
probably larger.
Costs, Risks
Even the low end of these estimates translates into more than a million
Americans in the past decade with implants in their coronary arteries they
didn't need, said William Boden, chief of medicine at a Veterans Administration
hospital in Albany, New York. Boden was the principal investigator of a 2007
study known as Courage that found stents added no benefit over medicines,
exercise and dietary changes in stable patients.
Unnecessary stents cost the U.S. health care system $2.4 billion a year,
according to Sanjay Kaul, a cardiologist and researcher at Cedars-Sinai Medical
Center in Los Angeles. Patients who received them are living with risks
including blood clots, bleeding from anti-clotting medicine and blockages from
coronary scar tissue, any of which can be fatal, Kaul said.
Monica Crabtree died at age 64 after one of her arteries was torn in a stent
procedure that led to infection, according to her widower, Gary Crabtree. He
received at least $240,000 from a 2011 settlement of his lawsuit against her
doctor, after a second cardiologist reviewed the case and told him the stent
wasn't needed. Crabtree choked up speaking about his late wife and showed
pictures of their 47 years together.
Worried Shaving
"It wasn't just a simple mistake," said the retired auto worker in Largo,
Florida. "If the stent was something she really needed, I could have handled
it. But it was a total loss of life that didn't need to happen."
Jim Simecek, of Medina, Ohio, said he worries every morning that a nick from
shaving could bleed out of control. Simecek, who works at a Ford dealership,
said he has to take blood-thinning medicine for life to ward off clots in the
six stents he received from a Cleveland-area cardiologist who's under federal
investigation for his stent work.
"It's as if your heart was open and somebody was sticking a knife in," said
Rhonda McClure, 54, referring to eight stents she received from a Kentucky
cardiologist who agreed in June to plead guilty to a federal Medicaid-fraud
charge for falsifying records used to justify a stent he placed.
Patient Letters
Cardiac stents were linked to at least 773 deaths in incident reports to the
U.S. Food and Drug Administration last year, according to a review by Bloomberg
News. That was 71 percent higher than the number found in the FDA's public
files for 2008. The 4,135 non-fatal stent injuries reported to the FDA last
year -- including perforated arteries, blood clots and other incidents -- were
33 percent higher than 2008 levels.
The FDA declined to comment on whether the reports were a cause for concern.
It said adverse-event reports tied to medical devices have increased overall
due to agency efforts. It also said the data can contain incomplete and
unverified accounts from reporting parties.
More than 1,500 patients have gotten letters from hospitals since 2010
alerting them that their stents may have been unnecessary. In Philadelphia, the
University of Pennsylvania Health System sent 700 such notices in April.
Stenting Decline
At least 11 hospitals have settled federal allegations of charging for
needless stenting and other misdeeds in the catheterization labs where the
procedures are performed. Federal probes of stenting practices continue in at
least five states. In Louisiana and Maryland, cardiologists went to federal
prison last year for implanting the devices and charging for them without
medical justification. A third doctor has agreed to do time in a plea bargain.
"There is a huge financial incentive to increase the number of these
procedures," said Jamie Bennett, a former assistant U.S. Attorney in Baltimore
who handled stent investigations. "The cases we have seen to date are just the
tip of the iceberg."
Since Boden's Courage study, stenting procedures have declined by about 20
percent. Still, this July, a panel of experts convened by the American Medical
Association and the Joint Commission, a hospital accreditor, named elective
stenting as one of five overused treatments that too often "provide zero or
negligible benefit to patients, potentially exposing them to the risk of harm."
Better Choices
Doctors are using fewer stents and choosing more-appropriate patients than
they were a few years ago, according to John Harold, president of the American
College of Cardiology, the specialty's main professional group. Harold said
that "real-world clinical practice" and research indicates Brown probably
overestimated how many people with coronary artery disease could be handled
initially only with drug-based treatment.
He said there are examples of inappropriate use and the ACC is taking steps
to "address and correct the imbalance" with treatment guidelines and by urging
more hospital oversight. Cardiologists who've been accused of fraud or are
serving prison time are "outliers" who don't represent the "overwhelming
majority."
Lawyers for John McLean, a Salisbury, Maryland, cardiologist convicted of
billing for unwarranted stenting, argued in a federal appeal last year that
inappropriate usage is widespread and their client was prosecuted for behavior
that's the industry norm.
Lost Appeal
They cited a 2011 study in the Journal of the American Medical Association
that found only half of elective stent procedures nationally were appropriate
under usage guidelines written by societies of heart specialists. The study
found 12 percent were inappropriate, and 38 percent fell into the uncertain
category of the guidelines.
"The study demonstrated clearly that a large number of stable patients
receive coronary artery stents that are later found to be inappropriate or
questionable," the appeal argued. "The same was true of the patients in Dr.
McLean's practice." McLean's appeal was denied in April. He is serving an
eight-year sentence.
Elective-stent patients typically see rapid quality-of-life improvements,
including in their ability to work and be active, according to Ted Bass,
president of the Society for Cardiovascular Angiography and Interventions,
whose members specialize in cardiac implants. The Courage trial found stents,
compared to medication and lifestyle changes, were better at relieving chest
pain for as long as two years after placement -- a benefit that ended by 36
months.
Profit Centers
First used in Europe in 1986, cardiac stents took off in the 2000s as
cardiologists found them to be more effective in heart attacks than
angioplasty. In that earlier technology, a small balloon is inflated to widen
blood passages and then withdrawn. Stenting facilities, known as "cath labs,"
spread at hospitals and became profit centers.
Hospitals receive an average payment of about $25,000 per stent case from
private insurers, according to Healthcare Blue Book, a website that tracks
reimbursements. The federal Medicare program pays less. Doctors who implant
stents earn a separate fee that averages about $1,000 and ranges from $500 to
$2,850, according to Medicare and Blue Book data.
The procedure typically involves inserting the stent with a catheter through
a small incision in the groin area or wrist and snaking it through to heart
vessels. It usually takes less than 45 minutes.
Kickbacks Alleged
Stony Brook's Brown, and Boden, who led the Courage study, argue that many
elective patients should be getting medical therapy before they risk stents.
Only 44 percent try medication and lifestyle changes before stenting, a 2011
study in the Journal of the American Medical Association found.
At least five hospitals have reached settlements with the Justice Department
over allegations that they paid illegal kickbacks to doctors for patient
referrals to their cath labs. St. Joseph Medical Center in Towson, Maryland,
paid the government $22 million without admitting liability.
Prosecutors alleged the hospital paid kickbacks to a practice co-founded by
Baltimore cardiologist Mark Midei for stent referrals. His doctor's license was
revoked in 2011 when the Maryland Board of Physicians found he falsified
records to justify unwarranted stents.
St. Joseph told 585 of its patients they may have received unnecessary
stents. In May, 252 patients reached a settlement with the hospital under
confidential terms, according to Jay D. Miller, an attorney for the plaintiffs.
Plea Agreement
The hospital settled the government's case "to avoid the expense and
uncertainty of litigation," it said in a statement. Spokeswoman Julia
Sutherland said the hospital declined to comment on any patient lawsuits.
In an interview, Midei denied he stented without medical need. He took issue
with experts who deemed many of his stents needless, and said disagreement
among cardiologists on cases is common. Midei was not a party to the federal
settlement. The government has said its investigation of the case continues.
In June, Sandesh Patil, a cardiologist practicing at another St. Joseph
hospital -- this one in London, Kentucky -- agreed to plead guilty to charging
Medicaid for a stent that wasn't medically warranted under the program's rules.
(Although both hospitals were once owned by the same parent, the one in
Maryland has been sold.)
Catheterization procedures multiplied at St. Joseph in London after Patil
began practicing there in 2000, when the hospital had a different name. In that
year, the type of procedure used for stents was done 210 times. They climbed to
929 by 2009, state data show.
Multiple Stents
Stenting income from Medicare alone was more than a sixth of the hospital's
2009 operating income, based on data from American Hospital Directory, a
research firm. When Patil left London in 2010, catheterization procedures fell
34 percent from their 2009 high. Using the midpoint of the directory's price
range for such procedures, the decline would have cost the hospital about $15
million. David McArthur, the hospital's spokesman, declined to comment on its
revenues.
Rhonda McClure, one of Patil's patients, had her arteries catheterized 18
times by him and his partners over four years, according to her deposition and
other filings in a lawsuit she and 361 other patients have brought against
Patil, St. Joseph and other doctors who practiced there. She said she received
eight cardiac stents. The defendants deny the negligence and fraud allegations
against them.
McClure's deposition says a cardiologist who reviewed her case after the
stents told her that scarring caused by "too many procedures" was her main
problem.
Short Breath
McClure said she suffers from chest pain and shortness of breath, and has
been told by her new doctor that she may need more stents and surgery to keep
her coronary arteries from closing. She said she gets so tired she needs to sit
and rest after walking down the stairs.
St. Joseph-London repaid Medicare $256,800 for unnecessary procedures and is
cooperating with federal prosecutors, McArthur said. He said Patil was never
employed by St. Joseph and lost his privileges to practice there in December
2010. Patil's attorney said his client had no comment.
Under his plea bargain, Patil agreed to serve 30 to 37 months in federal
prison. He forfeited his Kentucky medical license for five years. In 2012, he
told a family court judge his monthly income was $53,300.
"Thirty-seven months is nothing for all the injuries he done for money,"
McClure said.
Message Balancing
After the Courage trial shed doubt on stents' effectiveness for stable
patients, stent-implanting cardiologists felt unfairly attacked and organized a
campaign to "better balance the messaging," said Bonnie Weiner, who was
president of the Society for Cardiovascular Angiography and Interventions at
the time.
The society hired a public relations firm and paid it more than $300,000 a
year to help publicize the benefits of stents, according to the group's filings
with the Internal Revenue Service. The firm helped launch a consumer website
for SCAI, SecondsCount.org, which has published several articles, including one
under the headline, "For many patients, open arteries are better than closed
arteries."
SCAI collected $2.7 million in donations for "public education" between 2008
and 2011 from stent makers Abbott Laboratories Inc., Boston Scientific Corp.,
Cordis Corp. and Medtronic Inc., its Web site says. Manufacturers' sales of
cardiac stents were about $5.5 billion globally last year, down 5 percent from
2011, according to the Health Research International consulting firm.
High Median
Medtronic spokesman Joseph McGrath said grants to SCAI for patient education
are "unrestricted," and SCAI is solely responsible for how the funds are used.
Spokesmen for Abbott, Boston Scientific and Cordis declined to comment.
Interventional cardiologists, the specialty SCAI represents, earn a median
income of $562,855 a year, as compared to $207,117 for family doctors,
according to Medical Group Management Association, which surveys physician
practices. The interventionalists ranked 13th among 118 specialties tracked by
MGMA.
Michigan Death
Mehmood Patel, a Lafayette, Louisiana, cardiologist who went to prison last
year on 51 counts of charging for needless stents, made over $16 million in one
three-year span, evidence in the case showed. Prosecutors said he was driven by
the desire to be the busiest cardiologist in town.
He unsuccessfully argued that he used his best medical judgment in every
case and lost an appeal. Patel is serving a 10-year sentence in a federal
penitentiary.
Jashu Patel, an interventionalist in Jackson, Michigan, billed $2.7
million for procedures in 2007, according to a U.S. Justice Department case
against him settled in July. (He is no relation to Mehmood Patel).
The suit alleged Patel implanted needless stents in at least two
patients, including one that led to a blood clot that killed an unnamed woman
who had reported no symptoms of reduced cardiac blood supply. A stress test
showed normal blood flow, and notes in her file said she didn't want
interventions, said Julie Kovach, a cardiologist who worked with Patel and
brought the case to the government's attention.
"It was appalling," Kovach said in an interview. "Patel coerced her into
getting a stent she didn't need, which killed her."
False Claims
Kovach said that when she told the chief operating officer of the hospital
where Patel worked about the death, the executive, Karen Chaprnka, diverted the
conversation. Reached recently by e-mail through a hospital spokesman, Chaprnka
said she "disagreed with the allegations made by Dr. Kovach."
"He's their cash cow," said Kovach, now co-director of a clinic that
treats congenital heart disease at the Detroit Medical Center. "They're not
about to turn him in."
Patel and the hospital, Allegiance Health, agreed to pay the U.S. a total of
$4 million to settle the federal charges. Kovach was awarded $760,000 as a
whistle-blower under the U.S. False Claims Act. Allegiance disagreed with the
allegations and settled the claims to avoid "lengthy litigation," it said in a
statement.
Patel continues to practice at the hospital and must improve
record-keeping to substantiate cardiology procedures, Allegiance said. In the
settlement, Patel agreed to hire a consultant to oversee treatment of his
patients and an auditing firm to monitor billings. He didn't return phone
messages.
Cleveland Raid
In Ohio, Simecek, the worker at the Ford dealership, grew suspicious after
his sixth stent from cardiologist Harry Persaud at the Cleveland Clinic's
Fairview Hospital in 2011. Simecek said he went for a second opinion and was
told he didn't need any of the stents. Now he said he has to take blood
thinners the rest of his life.
"With the littlest cut, the blood starts running," said Simecek. "What if I
am in an auto accident?"
Persaud is under criminal investigation for health care fraud, mail fraud and
money laundering, according to federal court filings. Last October, Federal
Bureau of Investigation agents raided his office and removed financial records
and patient files for procedures at three Cleveland-area hospitals. The
government has seized $343,634 from his and his wife's bank accounts, alleging
the funds represent the proceeds of fraud related to a "significant number" of
unnecessary stent procedures.
Multiple, Elongated
The Cleveland Clinic found "problems related to the use of stents in some
patients" at Fairview and reported them to the government, according to
spokeswoman Eileen Sheil. She would not say how many patients were affected.
Persaud resigned from the hospital staff last year.
At least 64 of Persaud's patients at St. John Medical Center in suburban
Westlake received letters from the hospital saying they may have received an
unnecessary stent between 2010 and 2012, according to spokesman Patrick Garmone,
who said Persaud no longer practices there.
Persaud denied wrongdoing in court filings and said his stent procedures
were proper. Neil Freund, his attorney in lawsuits filed by patients alleging
unwarranted stents, said "it is our intent to defend these cases." He had no
comment on the federal investigation.
Final Order
In Texas, the state medical board's final order in DeMaio's case found that
the cardiologist placed "multiple, elongated, overlapping" stents in patients
in areas of "insignificant or only moderate disease." Peterson, the retired
mailman, was identified only as Patient C in the staff complaint. No patient
was mentioned in the final order.
Peterson was thriving in his new career in the travel business, his wife
Shirlee said. He had a heart attack in 1997, which didn't crimp his love of
travel and dance, she said. "He was an awesome man who never met a stranger,"
she said.
After his death, Shirlee Peterson said a friend told her she had a
cardiologist who refused to do multiple stents.
"I do believe that Bruce was a guinea pig," she said. "That was the way
it was done."
DeMaio said Peterson was extremely sick when he came to him. He said it was
significant that the board's final order didn't use the word "excessive" in
describing his stent work. That included 31 stents stretching for 14 inches
inside the arteries of Patient B in the staff complaint.
"Any patient of mine who received a full metal jacket" -- interventional
cardiology's term for such extensive work -- "would have been turned down by at
least one, if not multiple surgeons," DeMaio said. He said he doesn't use
stents as much these days because standards have changed and he doesn't see as
many seriously ill patients.
Heart stents are small wire-mesh tubes which are used to keep previously clogged
arteries open. Following heart bypass surgery and angioplasty, the stents are
left in the artery to prevent it from re-closing. Stents gained widespread use in
the medical community during the 1990s. Original designs were bare metal devices
inserted into the arteries.
Since 2003, newer types of heart stents containing a
medication coating have dominated the stent market. The
Johnson and Johnson Cypher heart stent
was introduced in 2003 and the
Boston Scientific Taxus heart stent
was introduced in 2004. These medicated
stents have been linked to an increased risk of serious blood clots which could
occur years after the stent is implanted.
Medicated
stent lawsuits
are being reviewed by the lawyers at Saiontz & Kirk, P.A. for
individuals who have suffered:
The lawyers at Saiontz & Kirk are investigating potential heart stent
lawsuits for individuals throughout the United States who have experienced
problems.
Drug eluting stents were designed to prevent the formation of scar tissue
inside of the cardiac arteries which could be caused by bare-metal stents. The
drug-coating is intended to reduce inflammation at the site of the stent which
could lead to tissue growth. The intended benefit of the drug coating is that it
reduces the risk of new blockages forming by this scar tissue. However, recent
studies have shown the drug coating could actually increase the risk of more
serious and deadly blood clots.
The drug coating prevents heart cells from creating a biological lining around
the metal of the stent. This leaves the metal exposed, which acts as a clot
magnet for months and even years after the stent is implanted. When these blood
clots form, it leads to a major heart attack or death approximately 70% of the
time.
As a result of the increased risk of heart stent blood clots, experts have
recommended that patients take a blood thinning medication for significantly
longer than what the manufacturers have been recommending. Currently the warning
label for the Cypher heart stent recommends only three months of blood thinner and
the Taxus heart stent recommends only six months. The increased risk of late
stent thrombosis may require individuals to take a blood thinner for years, or
even the rest of their lives. However, the necessity for continued use of
anti-clotting drugs could carry additional risks. For example,
Plavix side effects
could include severe gastrointestinal bleeding, ulcers,
heart attacks and strokes.
Since the heart stent problems have become more widely known, there has been a
change in philosophy regarding the use of stents in heart patients. Many experts
are indicating that drug coated stents have been used in many situations where
bare-metal stents or long-term drug therapy would be a safer alternative. Only
20% of the drug eluting stents implanted each year are for patients meeting the
profile for which they were approved by the FDA.
MEDICATED STENT LAWSUITS
It has been estimated that over 2,000 deaths each year could have been caused
by drug coated heart stent problems. Although cardiologists previously expressed
concerns about the safety of drug coated stents, the manufacturers have attempted
to minimize the risks. They have previously taken the position that there is no
difference in the risk of clotting between medicated stents and older bare metal.
However, recent studies have established that this information is incorrect.
The medicated heart stent lawyers at Saiontz & Kirk, P.A. are reviewing
potential lawsuits for individuals who have received a drug coated stent.. If
you, a friend or family member have received a cardiac stent and suffered blood
clots, heart attack or death, you may be entitled to compensation. There are no
fees or expenses unless a recovery is obtained.
"... Though the Elyria doctors say they are doing a good job and caring well for their patients, some experts say doctors with financial incentives to prescribe costly treatments cannot be completely unbiased when assessing how to treat a patient. "It's sort of like, you go to a barber and ask if you need a haircut," says Dr. David D. Waters, chief of cardiology at San Francisco General Hospital. "He's likely to say you do." ..."
Aug 21, 2006 | NewsTarget
(NewsTarget) Recent statistics show that a medical clinic in Elyria,
Ohio prescribes profitable angioplasties for heart patients nearly four
times as often as the rest of the country, which has raised questions
among experts as to why the Elyria cardiologists recommend the procedure
so often.
Almost all of the angioplasties at the Elyria hospital are performed
by a group of cardiologists at the North Ohio Heart Center. The group's
leader, Dr. John W. Schaeffer, says his group treats cardiac patients
"very aggressively," and says his
doctors simply
detect disease more often than doctors in the rest of the country and
are quicker to intervene.
However, outside experts say they are concerned that the Elyria
doctors represent a larger trend in U.S. medicine, in which doctors make
medical decisions based more on financial incentives than what is best
and safest for the patient.
For example, Medicare pays the Elyria
hospital $11,000
per angioplasty that uses a drug-coated stent, which earns the
cardiologist
roughly an extra $800. The Elyria doctors performed 3,400 angioplasties
in 2004, which is three times the rate of the procedure in Cleveland,
just 30 miles away. Dr. Eric Topol, a nationally recognized cardiologist
at the Cleveland Clinic, says the Elyria hospital's high rate of
angioplasties lacks "a good explanation," and says Elyria does not seem
to have different risk factors than the rest of Ohio, which has much
lower angioplasty rates.
"It's clear that when doctors and
surgeons are
financially rewarded for treating patients with certain profitable
procedures, many will find a myriad of ways, either consciously or
unconsciously, to come up with a diagnosis that benefits their personal
bank accounts," said Mike Adams, a consumer health advocate and critic
of unnecessary
surgical
procedures.
"This particular practice in Ohio seems to be an
angioplasty factory rather than anything resembling genuine health
care."
Other healthcare systems have adopted a way of paying doctors that
effectively removes financial incentives for prescribing profitable
treatments.
Kaiser Permanente says its Ohio patients are less likely to
undergo the kinds of cardiac procedures performed at the Elyria hospital
because its cardiologists work on a salary basis rather than being paid by the
procedure.
Though the Elyria doctors say they are doing a good job and caring
well for their patients, some experts say doctors with financial
incentives to prescribe costly treatments cannot be completely unbiased
when assessing how to treat a patient. "It's sort of like, you go to a
barber and ask if you need a haircut," says Dr. David D. Waters, chief
of cardiology at San Francisco General Hospital. "He's likely to say you
do."
"... But stents haven't been shown to reduce the risk of heart attacks in patients without symptoms, says James Beckerman, a cardiologist at the Providence Heart and Vascular Institute in Portland, Ore. Stents also don't help these patients live longer. And Nissen notes that stents themselves can become clogged up, causing greater problems. ..."
"... Bush spokesman Ford said Tuesday that, while Bush didn't experience those symptoms, "the stent was necessary. His annual physical includes a stress test. EKG changes during the stress test yesterday prompted a CT angiogram, which confirmed a blockage that required opening." ..."
"... Nissen said he's concerned about "overtesting" and overtreating people like Bush when they have no symptoms. ..."
"... "He did a 100-kilometer bike ride," says Nissen, a feat that would be impossible for someone on the verge of a heart attack. "How can a stent make him better?" ..."
"... People without symptoms also don't need annual stress tests, in which patients walk on a treadmill while doctors perform a test called an EKG, or electrocardiogram, Nissen says. ..."
Patients typically will take blood thinners, such as aspirin and clopidogrel, which help prevent
further clots, McPherson says. Doctors will also test Bush's cholesterol to see if he needs to take
statins, which help reduce cholesterol and which, like clopidogrel and low-dose aspirin, would be
taken for the rest of his life.
At 67, Bush is at an age that puts him at higher risk of a heart attack, McPherson says.
Yet Bush, an avid jogger and bicyclist, is exceptionally fit for a man of any age. Since leaving
office, Bush has hosted 100-kilometer bicycle rides for wounded troops, the most recent in May near
Waco.
But even a healthy lifestyle won't prevent all heart disease, McPherson says. And while the stent
indicates that Bush has an increased risk of heart attack, managing his risk factors, such as his
cholesterol and blood pressure, will help keep him healthy.
The Cleveland Clinic's Steven Nissen questions whether Bush will really benefit from a stent.
Doctors typically place stents only in patients who are having heart attacks or significant symptoms,
such as chest pain, says Nissen, chairman of cardiovascular medicine at the Cleveland Clinic. Stents
can help keep blood flowing and reduce the risk of a heart attack in these patients.
But stents haven't been shown to reduce the risk of heart attacks in patients without symptoms,
says James Beckerman, a cardiologist at the Providence Heart and Vascular Institute in Portland,
Ore. Stents also don't help these patients live longer. And Nissen notes that stents themselves can
become clogged up, causing greater problems.
Bush spokesman Ford said Tuesday that, while Bush didn't experience those symptoms, "the stent
was necessary. His annual physical includes a stress test. EKG changes during the stress test yesterday
prompted a CT angiogram, which confirmed a blockage that required opening."
A significant number of patients end up with stents after a routine physical, McPherson says.
That's because some patients who experience occasional chest pain or shortness of breath may not
tell anyone about their symptoms until a doctor asks.
Nissen said he's concerned about "overtesting" and overtreating people like Bush when they
have no symptoms.
"He did a 100-kilometer bike ride," says Nissen, a feat that would be impossible for someone
on the verge of a heart attack. "How can a stent make him better?"
People without symptoms also don't need annual stress tests, in which patients walk on a treadmill
while doctors perform a test called an EKG, or electrocardiogram, Nissen says.
Bush likely "got the classical thing that happens to VIP patients, when they get so-called executive
physicals and they get a lot of tests that aren't indicated. This is American medicine at its worst."
While it's possible to have a major artery blockage without symptoms, Nissen says that screening
everyone with stress tests would end up doing more harm than good. That's because these screenings
can lead to risky medical procedures that don't offer any proven benefit.
Still, McPherson notes that experts agree it makes sense to test certain professionals, such as
school bus drivers and airline pilots, because a sudden heart attack on the job could cost many lives.
One motivation for insurance fraud is a desire for financial gain. Public healthcare programs
such as
Medicare and Medicaid are
especially conducive to fraudulent activities, as they are often run on a
fee-for-service
structure.[20]
Notable quotes:
"... Recent studies show that medicine and angioplasty with stenting have equal benefits. Angioplasty with stenting does not help you live longer, but it can reduce angina or other symptoms of coronary artery disease. ..."
"... Angioplasty with stenting, however, can be a life-saving procedure if you are having a heart attack ..."
A few days ago I answered the same question about Coronary Artery Bypass Graft (CABG) surgery.
The indications are essentially the same.
Stents are used to open blockages in a tubule structure. They are most commonly known for their
use in the coronary arteries but may be used in other areas as well. In the arteries they are
used to spread the artery open where a blockage or narrowing has occurred. Some patients are
served well by stents but others require CABG. The decision is normally made by the cardiologist.
Stenting or CABG is determined by the number of blockages, the severity and their location(s).
Normally, you go in for a catheterization.
If blockages are found and stents are needed, it will
normally be done at that time. If CABG is required, they will complete the catheterization then
arrangements will be made to perform the CABG.
To see the question on CABG and my and others answers click this link:
There are a ton of other information sources. If you would like more just contact me by going to
my profile. There you can click on "Email Terry S" or click the link below.
The main purpose of a stent is to counteract significant decreases in vessel or duct diameter by
acutely propping open the conduit by a mechanical scaffold or stent. Stents are often used to
alleviate diminished blood flow to organs and extremities beyond an obstruction in order to
maintain an adequate delivery of oxygenated blood. Although the most common use of stents is in
coronary arteries, they are widely used in other natural body conduits, such as central and
peripheral arteries and veins, bile ducts, esophagus, colon, trachea or large bronchi, ureters,
and urethra.(Wikipedia)
Most of the time, stents are used to treat conditions that result when arteries become narrow
or blocked. The devices are also used to unblock and keep open other tube-shaped structures in
the body, including the ureters (the tubes that drain urine from the kidneys to the bladder) and
bronchi (the small windpipes in the lungs).
Stents are commonly used to treat coronary heart disease (CHD). If you have coronary artery
disease that does not cause symptoms, you can be treated with either medicine or angioplasty with
stenting.
Recent studies show that medicine and angioplasty with stenting have equal benefits.
Angioplasty with stenting does not help you live longer, but it can reduce angina or other
symptoms of coronary artery disease.
Angioplasty with stenting, however, can be a life-saving procedure if you are having a heart
attack
Other reasons to use stents include:
* Keeping open a blocked or damage ureter * Treatment of aneurysms, including thoracic aortic aneurysms
* Unblocking a large artery, such as the carotid artery (carotid endarterectomy) * To keep bile flowing in blocked bile ducts (biliary stricture)
* Helping you breathe if you have a blockage in the airways
Dr Frank
Stents are inserted routinely now at angioplasty to improve the chances of keeping the vessel
open. They would be used for any lesion where the vessel is wide enough to take them. Since the
routine use of better anti platelet drugs, clopidogrel, the risk that the stent itself will clot
has been reduced dramatically.
Source(s): GP for more years than I care to remember Dr Frank · 9 years ago
"... A Westlake cardiologist was convicted of performing unnecessary catheterizations, tests, stent insertions and causing unnecessary coronary artery bypass surgeries as part of a scheme to overbill Medicare and other insurers by $7.2 million, law enforcement officials said. ..."
A Westlake cardiologist was convicted of performing unnecessary catheterizations,
tests, stent insertions and causing unnecessary coronary artery bypass surgeries as part of a scheme
to overbill Medicare and other insurers by $7.2 million, law enforcement officials said.
Dr. Harold Persaud, 56, was convicted of one count of health care fraud, 13 counts of making false
statements and one count of engaging in monetary transactions in property derived from criminal activity.
He was acquitted on one count of making a false statement.
"The evidence presented at this trial was troubling," said U.S. Attorney Steven M. Dettelbach. "Inflating
Medicare billings alone would be bad enough. Falsifying cardiac care records, making an unnecessary
referral for open heart surgery and performing needless and sometimes invasive heart tests and procedures
is inconsistent with not only federal law but a doctor's basic duty to his patients."
"This doctor violated the sacred trust between doctor and patient by ordering unnecessary tests,
procedures and surgeries to line his pockets," said Stephen D. Anthony, Special Agent in Charge of
the FBI's Cleveland Office. "He ripped off taxpayers and put patients' lives at risk."
"Medical providers have a duty and obligation to provide only those services that are medically necessary
and are in the best interests of the patients under their care," said Lamont Pugh III, Special Agent
in Charge, U.S. Department of Health & Human Services, Office of Inspector General Chicago Region.
"This conduct shows a disregard for patient needs in exchange for financial gain at taxpayer expense.
The OIG will continue to work with our law enforcement and prosecutorial partners to identify fraudulent
health care schemes and hold individuals accountable for their actions."
Persaud had a private medical practice at 29099 Health Campus Drive in Westlake and had hospital
privileges at Fairview Hospital, St. John's Medical Center and Southwest General Hospital, according
to court documents and trial testimony.
Persaud devised a scheme to defraud and obtain money from Medicare and other insurers. The scheme
took place between Feb. 16, 2006, through June 28, 2012. According to according to court documents
and trial testimony, his activities in furtherance of the scheme included:
Persaud selected the billing code for each customer submitted to Medicare and private insurers, and
used codes that reflected a service that was more costly than that which was actually performed;
Persaud performed nuclear stress tests on patients that were not medically necessary;
He knowingly recorded false results of patients' nuclear stress tests to justify cardiac catheterization
procedures that were not medically necessary;
Persaud performed cardiac catheterizations on patients at the hospitals and falsely recorded the
existence and extent of lesions (blockage) observed during the procedures;
He recorded false symptoms in patient records to justify testing and procedures on patients;
Persaud inserted cardiac stents in patients who did not have 70 percent or more blockage in the vessel
that he stented and who did not have symptoms of blockage;
He placed a stent in a stenosed artery that already had a functioning bypass, thus providing no medical
benefit and increasing the risk of harm to the patient;
He improperly referred patients for coronary artery bypass surgery when there was no medical necessity
for such surgery, which benefitted Persaud by increasing the amount of follow-up testing he could
perform and bill to Medicare and private insurers;
Persaud performed medically unnecessary stent procedures, aortograms, renal angiograms and other
procedures and tests.
As a result of this scheme, Persaud overbilled and caused the overbilling of Medicare and private
insurers in the amount of approximately $7.2 million, of which Medicare and the private insurers
paid approximately $1.5 million, according to the indictment.
This case is being prosecuted by Assistant U.S. Attorneys Michael L. Collyer and Chelsea Rice following
an investigation by the Federal Bureau of Investigation and the U.S. Department of Health and Human
Services Office of Inspector General
Heart stents are small wire-mesh tubes which are used to keep previously clogged
arteries open. Following heart bypass surgery and angioplasty, the stents are
left in the artery to prevent it from re-closing. Stents gained widespread use in
the medical community during the 1990s. Original designs were bare metal devices
inserted into the arteries.
Since 2003, newer types of heart stents containing a
medication coating have dominated the stent market. The
Johnson and Johnson Cypher heart stent
was introduced in 2003 and the
Boston Scientific Taxus heart stent
was introduced in 2004. These medicated
stents have been linked to an increased risk of serious blood clots which could
occur years after the stent is implanted.
Medicated
stent lawsuits
are being reviewed by the lawyers at Saiontz & Kirk, P.A. for
individuals who have suffered:
The lawyers at Saiontz & Kirk are investigating potential heart stent
lawsuits for individuals throughout the United States who have experienced
problems.
Drug eluting stents were designed to prevent the formation of scar tissue
inside of the cardiac arteries which could be caused by bare-metal stents. The
drug-coating is intended to reduce inflammation at the site of the stent which
could lead to tissue growth. The intended benefit of the drug coating is that it
reduces the risk of new blockages forming by this scar tissue. However, recent
studies have shown the drug coating could actually increase the risk of more
serious and deadly blood clots.
The drug coating prevents heart cells from creating a biological lining around
the metal of the stent. This leaves the metal exposed, which acts as a clot
magnet for months and even years after the stent is implanted. When these blood
clots form, it leads to a major heart attack or death approximately 70% of the
time.
As a result of the increased risk of heart stent blood clots, experts have
recommended that patients take a blood thinning medication for significantly
longer than what the manufacturers have been recommending. Currently the warning
label for the Cypher heart stent recommends only three months of blood thinner and
the Taxus heart stent recommends only six months. The increased risk of late
stent thrombosis may require individuals to take a blood thinner for years, or
even the rest of their lives. However, the necessity for continued use of
anti-clotting drugs could carry additional risks. For example,
Plavix side effects
could include severe gastrointestinal bleeding, ulcers,
heart attacks and strokes.
Since the heart stent problems have become more widely known, there has been a
change in philosophy regarding the use of stents in heart patients. Many experts
are indicating that drug coated stents have been used in many situations where
bare-metal stents or long-term drug therapy would be a safer alternative. Only
20% of the drug eluting stents implanted each year are for patients meeting the
profile for which they were approved by the FDA.
MEDICATED STENT LAWSUITS
It has been estimated that over 2,000 deaths each year could have been caused
by drug coated heart stent problems. Although cardiologists previously expressed
concerns about the safety of drug coated stents, the manufacturers have attempted
to minimize the risks. They have previously taken the position that there is no
difference in the risk of clotting between medicated stents and older bare metal.
However, recent studies have established that this information is incorrect.
The medicated heart stent lawyers at Saiontz & Kirk, P.A. are reviewing
potential lawsuits for individuals who have received a drug coated stent.. If
you, a friend or family member have received a cardiac stent and suffered blood
clots, heart attack or death, you may be entitled to compensation. There are no
fees or expenses unless a recovery is obtained.
"... Angioplasty is performed in more than 600,000 patients a year roughly half of them Medicare patients often as an alternative to bypass surgery. ..."
"... A study published in the Journal of the American Medical Association in 2011 pegged the cost to the health care system at an estimated $12 billion a year. ..."
"... The procedure also has risks. About 5 percent of people suffer complications including bleeding, blood clots, infection, heart rhythm disturbances and even death from heart attack. ..."
"... When doctors install drug-coated stents, as most now do, patients must take aspirin and certain anti-clotting medications for a year to guard against life-threatening clots. ..."
"... But the need to rein in unnecessary procedures is still considered so pressing that the American College of Cardiology in 2012 published "appropriateness" criteria to guide physicians' judgment. ..."
"... Monroe ranks near the top of hospital referral regions with the highest level of "potentially avoidable hospital costs," according to the Commonwealth Fund Scorecard on Local Health System Performance. ..."
"... The question is: Are they doing things that need to be done? Or are they widget makers, putting in widgets because that's what the system incents them to do?" ..."
"... In 2012 alone, Paulus received $305,967 from Medicare for 923 catheterizations and angioplasties. His work accounted for more than 15 percent of all of the procedures performed in the region and made him the sixth-busiest cardiac catheterization specialist in the nation. Federal investigators were so struck by the hospital's high catheterization rates that they launched a probe of its catheterization laboratory. ..."
"... Last spring, the hospital agreed to pay the government $41 million to settle allegations that, between 2006 and 2011, the hospital submitted millions of dollars' worth of "false claims" to Medicare and Medicaid for performing angioplasties and implanting stents in "numerous" patients who did not need them, according to an FBI press release. ..."
"... "The decision to do the procedure is made by the person who would benefit from the procedure," says Dr. David O. Williams, a cardiologist at Brigham and Women's Hospital in Boston. ..."
Dr. Gregory Sampognaro is one of the busiest interventional cardiologists in the
United States, clearing out clogged coronary arteries in hundreds of patients
every year. Sampognaro ranked 17th in the U.S. in 2012 in the number of these
procedures, according to a U.S. News & World Report analysis of Medicare data.
What makes these numbers noteworthy is that Sampognaro works not in a medical
mecca like New York or Chicago but in Monroe, Louisiana, a fading
Mississippi-delta agricultural community of 54,000 in one of the poorest
congressional districts in the U.S.
Sampognaro is one of dozens of cardiologists in communities outside major metro
areas who are performing catheterization procedures such as
diagnostic angiograms and artery-clearing angioplasties
at higher rates than
doctors working at big city hospitals that serve as major cardiac referral
centers, the U.S. News analysis found.
While no one has accused Sampognaro of doing anything wrong, experts who have
reviewed the U.S. News data say it raises a critical question, not just for
patients seeking coronary care in Monroe but for those in other parts of the
country: How many of these catheterization procedures are medically advisable and
how many put patients at unnecessary risk and add billions of dollars to the
nation's medical bill?
"You have to wonder what's going on," says Harvard physician and historian Dr.
David Jones, author of "Broken Hearts: The Tangled History of Cardiac Care." "Are
these doctors going to get bigger paychecks at the end of the month for doing more
of these procedures? That may be an uncomfortable question to ask, but it's
something patients should wonder about."
By his own account, Sampognaro does most of the procedures in Monroe.
"I already know that I'm one of the busiest cardiologists in the country," he
says. "The reason is geography. I practice in an extremely underserved area. There
are only four interventional cardiologists in northeast Louisiana. I'm one of
four. In Shreveport, there's probably 30. Want to know why? No one wants to live
in Monroe, except people who are from here. Now, if I was in some big city I
wouldn't have those numbers because there are interventional cardiologists on
every corner."
Dwight Vines, Monroe's economic development officer, says it's "generally known"
in Monroe that if you go see Sampognaro, he's likely to send you to the hospital
for a procedure. "He sent me over." Vines says. "He does a lot of this."
Until recently, U.S. doctors and their practice patterns were protected from
scrutiny by a legal ruling that shielded Medicare data from public release. A U.S.
District Judge lifted the ruling in 2014, making it possible for U.S. News and
other organizations to
examine Medicare data
that reveal how doctors practice medicine, how much
money they make and how they compare to their peers.
Angioplasties and related procedures are some of the most common and controversial
in medicine.
A study
published in the Journal of the American Medical Association in 2011 pegged the
cost to the health care system at an estimated $12 billion a year.
Interventional cardiologists like Sampognaro insert a small tube called a catheter
into a blood vessel in the patient's groin or wrist, and guide it to the coronary
arteries. There they obtain diagnostic images and remove blockages. Expandable
devices called stents are then inserted to prop open the blocked artery.
Angioplasty's benefits are unquestioned for patients in the grip of a heart
attack. Clearing a clogged artery and restoring the heart's blood supply can save
a patient's life. In the two-thirds of patients who are not having heart attacks,
however, angioplasty's benefits are far less clear. Angioplasty can relieve chest
pain from chronic angina, but it cannot prevent heart attacks or prolong survival.
Patients with unstable angina reap more symptom relief from angioplasty than from
drug treatment. In chronic, stable heart-disease patients, studies show, drug
treatment may work just as well angioplasty .
The procedure also has risks. About 5 percent of people suffer complications
including bleeding, blood clots, infection, heart rhythm disturbances and even
death from heart attack.
When doctors install drug-coated stents, as most now do,
patients must take aspirin and certain anti-clotting medications for a year to
guard against life-threatening clots.
"This is a very controversial arena. Any number of people don't want this exposed.
Nobody wants to kill the goose that lays the golden egg," says William Boden,
chief of medicine at the Albany Stratton VA Medical Center in Albany, New York.
Boden was lead author of a study, published in 2007 in the New England Journal of
Medicine, showing for the first time that optimal drug treatment worked as
effectively as angioplasty and stenting in stable heart - disease patients.
A
flurry of subsequent studies have since confirmed the finding and underpin the
push to eliminate unnecessary procedures.
Experts have zeroed in on reducing the number of catheterizations as a way to slow
rising health care costs. The total has declined dramatically since Boden's study,
called Courage, appeared.
But the need to rein in unnecessary procedures is still
considered so pressing that the American College of Cardiology in 2012 published
"appropriateness" criteria to guide physicians' judgment.
Applying these standards
nationwide could cut the number of catheterization procedures significantly,
research shows. One study of more than 140,000 procedures, for instance, found
that nearly 12 percent were unnecessary and 38 percent were questionable.
The trouble is that it is difficult for anyone other than the cardiologist-or
someone else with access to the patient's confidential medical record-to determine
whether an interventional procedure is appropriate or not.
The Medicare claims data used in the U.S. News analysis lack the critical
information needed to make that determination.
But claims data can "flag hospitals
that would potentially have a lot of cases that would then need to be investigated
in more detail," says Edward Hannan, a professor of epidemiology at the State
University of New York at Albany who pioneered efforts to evaluate the
appropriateness of angioplasty procedures in New York State.
U.S. Attorney Kerry Harvey, who handles Medicare, Medicaid and other cases in
eastern Kentucky, says federal investigators use data-analysis techniques similar
to those used by U.S. News to
identify doctors and
hospitals
that merit a close look by medical experts.
The experts compare the doctor's notes and billing records with images of the
patients' arteries. "We retain cardiologists," he says. "We look for people with
great skills and no bias. You have these experts look at the films and compare
what they see with what they see in the medical record. We steer a wide berth
around medical judgment. If it's close we're going to give [physicians] the
benefit of the doubt." Sampognaro performs many of his procedures at a same-day surgery center called P&S
Surgical Hospital that he co-owns with 49 other physicians and a local
full-service hospital.
In 2012, Medicare paid Sampognaro $1.1 million, of which $276,601 was for 729
angiographies and angioplasties. Services to patients covered by commercial
Medicare HMOs or to patients under age 65 are not included, nor are copayments
from Medicare patients.
The average cath-lab physician performed 99 procedures in
2012. Sampognaro asserts that the number of patients suffering from heart disease
in the Mississippi Delta drives demand for his services. "We're also in the center
of the most unhealthy part of the country," Sampognaro says. "People eat bad,
they're overweight, the congressional district in this area is one of the poorest
in the country. Everybody has coronary artery disease."
Monroe's unhealthy population may partly explain why Medicare's cost per enrollee
there is 35 percent higher than the national average. But the parish's health
status isn't the only explanation.
Monroe ranks near the top of hospital referral
regions with the highest level of "potentially avoidable hospital costs,"
according to the Commonwealth Fund Scorecard on Local Health System Performance.
U.S. News did a second analysis to examine whether population patterns influenced
the number of procedures performed by cardiologists outside of urban areas. This
analysis broke down cardiac catheterization statistics by hospital referral
regions, which are geographic areas surrounding medical centers that serve as
regional health care hubs. Rather than focusing on raw numbers of procedures, the
second analysis calculated the procedure rate per 1,000 Medicare beneficiaries,
which puts all of the analyzed areas on the same footing, regardless of
population.
For every 1,000 beneficiaries in the region served by Monroe's hospitals , 59 went
through cardiac catheterization lab procedures in 2012. That was double the
national average and far higher than in cities that are home to major medical
centers. In San Francisco, for example, the rate was 13 per 1,000 Medicare
enrollees. The analysis resulted in similar findings for many other rural areas.
U.S. News conducted a final analysis that adjusted the regional rates to account
for the incidence of heart attack in each region in 2012. That analysis showed
heart attack rates explained little of the regional variation in cardiac
catheterization. Many of the rural communities with unusually high rates,
including Monroe, remained outliers even after adjusting for the heart attack
rate.
Dr. Christopher White, chief of interventional cardiology at the Ochsner Clinic
Foundation in New Orleans, taught Sampognaro in the late 1990s during a
cardiovascular disease fellowship. He says the U.S. News findings underscore the
importance of making sure physicians are not exposing patients to unnecessary
procedures.
"Making seven figures isn't unusual for an interventional cardiologist," White
says. "These guys work hard. They're putting in their 12- or 13-hour days.
The
question is: Are they doing things that need to be done? Or are they widget
makers, putting in widgets because that's what the system incents them to do?"
The U.S. News analysis flagged cardiologists in other communities as well. Judging
from their catheterization rates, doctors in the Huntington, West Virginia, region
were also among the busiest cardiologists in the United States. More than 91 of
every 1,000 Medicare enrollees in the region underwent procedures in 2012-a rate
nearly triple the national average. The probability that the high rates were due
to random variation was less than one in 1,000.
The doctor who submitted the largest bill for cardiac cath lab procedures in the
region in 2012 was Dr. Richard Paulus, a prominent cardiologist at King's
Daughters Medical Center in Ashland, Kentucky, an Ohio River community of 21,000,
just west of Huntington, where the hospital has eclipsed the steel industry as the
town's biggest employer. Paulus, who retired from the hospital in July 2014, is so
closely identified with King's Daughters that the heart pavilion there carries his
name.
In 2012 alone, Paulus received $305,967 from Medicare for 923 catheterizations and
angioplasties. His work accounted for more than 15 percent of all of the
procedures performed in the region and made him the sixth-busiest cardiac
catheterization specialist in the nation.
Federal investigators were so struck by the hospital's high catheterization rates
that they launched a probe of its catheterization laboratory.
Last spring, the
hospital agreed to pay the government $41 million to settle allegations that,
between 2006 and 2011, the hospital submitted millions of dollars' worth of "false
claims" to Medicare and Medicaid for performing angioplasties and implanting
stents in "numerous" patients who did not need them, according to an FBI press
release.
The settlement terms allowed the hospital to deny wrongdoing in the case. Paulus has not been charged. His lawyer, Robert Bennett, acknowledges that Paulus
is under investigation, but asserts that his client "adamantly denies wrongdoing
in this case."
Terre Haute, Indiana, ranked just after Huntington as the second-busiest region in
the country for cardiac catheterization. For every 1,000 Medicare enrollees in the
area, doctors performed 83 procedures. The Alexandria, Louisiana, region ranked
third, with a rate of 73 per 1,000. Physicians there billed for 3,355 cath lab
procedures. By contrast, in Las Vegas, a region that is home to a more than three
times the number of Medicare beneficiaries, physicians billed the federal health
plan for only 3,368 procedures.
"In a world where everything made sense, it would be the big cities that have
high-volume angioplasty centers," says Dr. Spencer King of Emory Healthcare in
Atlanta, an angioplasty pioneer who reviewed the U.S. News data.
A factor that may contribute to the high rates of angioplasties is that some
interventional cardiologists administer the stress tests and imaging studies that
determine whether a procedure is warranted.
For aggressive cardiologists, that approach has two potential benefits it boosts
their income and gives them control over interpreting the tests. One way to
eliminate the conflict of interest, experts say, would be to shift responsibility
for giving the green light from the interventional cardiologist who performs the
procedure to the doctor who referred the patient in the first place. In most
hospitals, that's not the way it works.
"The decision to do the procedure is made by the person who would benefit from the
procedure," says Dr. David O. Williams, a cardiologist at Brigham and Women's
Hospital in Boston.
High volumes alone don't necessarily translate into unnecessary procedures. In
some cases, interventional cardiologists may perform large numbers of procedures
because they serve many doctors who refer patients for specialized testing and
treatment, says Dr. Gregory Dehmer, chief of cardiology at Scott & White
Healthcare in Dallas.
U.S. Attorney Harvey, who handled the Paulus case, agrees. "Just because you have
a provider who's a statistical outlier, that doesn't mean the provider has done
anything wrong," he says. " It simply raises questions. Sometimes there are
completely legitimate explanation why the data is what it is."
Even doctors who aren't swayed by financial considerations still wrestle daily
with the challenging question of whom to treat. The ACC's National Cardiovascular
Data Registry, which gathers clinical data on heart disease cases nationwide, has
moved to address the issue by encouraging cardiologists to monitor their own
practice patterns. Registry participation is voluntary, but the 1,600 member
hospitals supply data on 95 percent of the nation's angioplasties. Doctors can
explore their own procedure volumes, complications and outcomes against those of
other doctors, available as benchmarked averages. They seldom do, says ACC
cardiologist Dr. Ralph Brindis.
"Only a small percentage of physicians have gotten the message and bother to look
at their data," which have been available for about 18 months, Brindis says. The
registry is prohibited by its member hospitals from making detailed physician
performance data public, he adds.
Steve Sternberg is a senior writer for U.S. News and a data journalist
covering health care performance, health policy, clinical medicine and public
health. You can follow him on Twitter (
@stevensternberg
),
connect with him
on
LinkedIn
or email him at
[email protected].
The Last but not LeastTechnology is dominated by
two types of people: those who understand what they do not manage and those who manage what they do not understand ~Archibald Putt.
Ph.D
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