Despite COURAGE, unnecessary caths still rule the day...

[tibor75]

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Shocking!

Interventional cardiologists still raking in the money

WSJ argues COURAGE is a missed opportunity for comparative effectiveness savings
FEBRUARY 12, 2010 | Reed Miller
New York, NY - The failure of the cardiology community to rein in stenting rates following the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial is an example of a missed opportunity for the US healthcare system to capitalize on the sort of comparative effectiveness research that is set to get $1.1 billion in funding under the healthcare insurance reform bills now before Congress, according to an article in the February 11, 2010 Wall Street Journal [1].

As reported by heartwire, results of the 2287-patient COURAGE trial, published in the New England Journal of Medicine in 2007, showed that coronary stenting with optimal medical therapy is no better at preventing future coronary events than optimal medical therapy alone in patients with stable coronary disease.

In the article, WSJ reporter Keith J Winstein suggests that the COURAGE results have failed to change clinical practice as much as the results suggest they should because the economic incentives for interventionalists and insurance companies favor stenting over medical therapy.

The article quotes Dr Sanjay Kaul (Cedars-Sinai Heart Institute, Los Angeles, CA), who estimates that by not stenting the patients COURAGE showed do not benefit from stents, the US healthcare system could save $5 billion of the $15 billion a year it spends on stent procedures.

As reported in heartwire, Medicare data show that, contrary to professional guidelines, most patients getting a stent do not have a stress test to prove they urgently need the stent. The Journal quotes theheart.org editor-in-chief Dr Eric Topol (Scripps Translational Science Institute, La Jolla, CA) as stating, "It's certainly remarkable that nothing has been done to put some checks and balances" into stenting practices in light of COURAGE. "I have a very strong disagreement with cardiologists who see no reason to do the stress test."

The WSJ states that interventional cardiologists have an incentive to implant stents because they receive $900 per procedure, while the only revenue they get from prescribing drugs is about $100 for an office visit.

The article points out that neither Medicare nor private insurers have changed their coverage policies in light of COURAGE. "There's no incentive on the part of the insurance company to do that," Dr George Diamond (Cedars-Sinai Medical Center, Los Angeles, CA) says in the article. "[It] would cause an uproar on the part of the physicians saying insurance companies were attempting to interpose themselves on the medical process."

However, according to the article, Blue Cross/Blue Shield plans in western and northeastern New York State recently began requiring stress tests prior to stenting to verify a stent is necessary to preserve coronary flow, and the plans will soon require that patients try drug therapy for three months before elective stenting for chronic chest pain.

http://www.theheart.org/article/1047209.do

 

[dreamfox]

how about all those people who are angina free? how about that 30% crossover rate?

 

[tibor75]

how about all those people who are angina free? how about that 30% crossover rate?

So?

That means 7/10 didn't need any procedures. That's pretty good.

Should be remembered the next time an interventionalist stupidly tells a patient "That LAD was hanging by a thread! I just saved your life!" (I've seen this several times)

 

[Myostatin]

I'm not an interventionalist, but....

1) Sure, what we need right now is added government/insurance involvement in medical decision making.... we don't have enough of that already.
2) Who's referring all these people for cath in the first place? the vast majority of patients referred for cath aren't self-referred by interventionalists.
If stress tests are so useful, then why all these referrals from noninterventionalists?
3) I don't think most cardiologists were suprised by the COURAGE trial.
4) What % of stent implants on a yearly basis are for UA/NSTEMI/STEMI and what % for stable angina? I don't know the answer to this
5) Stress tests are often wrong, most of the decision making is pretest probability anyway.

Given a choice between 1) cath to define anatomy, then being put on nitrates and betablockers with the hope for symptomatic improvement and then being brought back for another procedure if it doesn't work 2) cath->cabg->increased stroke risk->immediate improvement in symptoms or 3) cath->DES->immediate improvement in symptoms but possibility of repeat revasc

I'll chose 3.

 

[tibor75]

1) Sure, what we need right now is added government/insurance involvement in medical decision making.... we don't have enough of that already.

Uh, please tell me how the government is involved in medical decision making?? I've been a doctorb for 10 years and the government has never told me what I could and could not do with a patient. Private insurers do this all the time, a fact lost on the clueless people who cry about health reform.

2) Who's referring all these people for cath in the first place? the vast majority of patients referred for cath aren't self-referred by interventionalists.
If stress tests are so useful, then why all these referrals from noninterventionalists?

More caths equal more money for the entire group. That's the biggest sham with cardiology. It doesn't matter who is doing the case. The non-inventionalist reading the stress test is in the same group as the inverventionalist. They are biased to read abnormal studies. More abnormal studies, more caths, more money for the group.

 

[Myostatin]

Granted insurance company meddling is more direct than the government, but clearly there are attempts from CMS to influence our practices by changes in reimbursement structure.... i.e. 40% cut for nuclear this year, increases in PCP visit reimbursement. And, as you've pointed out, money controls all.

If we're now implicating noninvasive cardiologists as overreading tests -> more cath referrals, then its not just ICC that's supposedly innapropriately "raking in the money" as the article suggests, is it?

There's the potential for abuse all across the board. I don't think the courage trial results are all that surprising, and I don't think most ICCs were putting in stents thinking there was a dramatic mortality benefit.

 

[rmbsstock]

out

 

[Scaredshizzles]

My dad died because of his heart problems. Anyways, his cardiologist (A) implanted a stent for him around six months before he died. When we talked to cardiologist( A)'s partner in practice Cardiologist (B) (after they split the practice), he stated that there was no reason what so ever to put a stent for for my dad, it does not help his heart at all. I felt like crap since I convinced my dad to put the stent thinking that it MIGHT HELP as Cardiologist (A) told me, and I just wanted some hope to hang on to.
I took dad's files and I hand carried them to a friend cardiologist (C). His answer was the same as (B), there was no reason at all for the stent. He said the only reason that he can think about is that Cardiologist (A) is building a new house, and he needs the money.
I told my dad I want to report his cardiologist for what he did. Dad refused he said he loves his Cardiologist, he has been with him doing his best for a long time, and maybe this time was a mistake 🙁 . I do not believe so

I have no reason to think cardiologist A acted wrongly here. Neither cardiologist B or C had a relationship with the patient. There is no one right decision for all patients, as much as evidence based medicine tries to shove it down our throats. It is certainly possible cardiologist A was trying to put another story on his house, but tehre is a lot of thinking that goes on in medicine, and no one would ever have the time to record every thought and observation in a chart. So cardiologist B and C really have no right to comment; certainly nothing grossly negligent was done, even if it didn't help your dad. Maybe cardiologist B can comment because he has observed A in the past as his partner, but then again he may have an axe to grind.

 

[dragonfly99]

I agree with scaredshizzles.
There is no evidence of malpractice or even greed in the story above.
There are more reasons to put in stents than just to improve mortality. Sometimes stents are put in to decrease angina/chest pain episodes.
I don't agree that we are probably overusing stents overall...but I know A LOT of interventional cardiologists (all academic, I'll admit) and I've NEVER seen someone put a stent in out of greed. They make the decision based on the patient's overall clinical status, including symptoms, medical history, the current labs and imaging studies, etc.

Coronary disease is a very serious disease and we can't keep every patient with coronary disease and heart failure alive indefinitely, and that includes with the best medical therapy and/or with stents. I have a lot of patients who have had heart attacks and still are 20-40 pounds overweight, they eat too much salt and they don't exercise at all. Some still smoke cigarettes. We are just doctors - not God. And sometimes when people get to a certain point medically, they are going to die and there isn't always something we can do to prevent that. I think sometimes in the U.S. patients get more procedures because the patient and family want that, and physicians feel cornered and that we have to "do something". If the patient in the example above didn't get the stent, and then died, perhaps the patient's family would be feeling that not enough was done for the patient. All clinical decision making is individual and has to take into account individual patient's medical history, etc.

 

[dragonfly99]

I agree with scaredshizzles.
There is no evidence of malpractice or even greed in the story above.
There are more reasons to put in stents than just to improve mortality. Sometimes stents are put in to decrease angina/chest pain episodes.
I don't agree that we are probably overusing stents overall...but I know A LOT of interventional cardiologists (all academic, I'll admit) and I've NEVER seen someone put a stent in out of greed. They make the decision based on the patient's overall clinical status, including symptoms, medical history, the current labs and imaging studies, etc. ]

oops, I meant that I don't disagree we are overusing stents.

I think that overreading stress tests is more a function of fear of liabity versus wanting to send more people for cath. A lot of noninvasive stress testing is done to try to AVOID cathing people.

 

[tibor75]

There are more reasons to put in stents than just to improve mortality.

Actually stents are RARELY implanted to improve mortality. The only time they have been shown to improve mortality is in STEMIs, and the benefit over lytics is not THAT great. In NSTEMI they have mortality benefit in high risk cases.

In almost every case - nope.

The bottom line is the reason stents are so popular is that they make more money for the hospital, practice, and cardiologist.