Map of life expectancy at birth from Global Education Project.

Wednesday, May 11, 2011

Time for a percutaneous cerebral intervention?

I've written before about this scandal of cardiologists doing revascularization procedures -- usually that means basically reaming out a coronary artery and implanting a metal stent to help keep it open -- inappropriately. What is really strange about this, but maybe not so much after all, is that many cardiologists, most of the general public, and even health care journalists, believe that these procedures prevent heart attacks and extend life. They absolutely do not. Nortin Hadler has written about this frequently and he always attracts a barrage of outrage from physicians who claim he's wrong. The same thing has happened to me when I've commented on blogs, and gotten into e-mail wars.

But there is no doubt about this. As William B. Borden and a multitude write in their report in today's JAMA (you are scum and may only read the abstract) "[A] meta-analysis of 11 trials concluded that there was no benefit of PCI in preventing myocardial infection or death in patients with stable CAD [coronary artery disease]." Yes, if you've just had a heart attack, it's called for, otherwise the only benefit may be symptomatic relief of angina. And there are costs and risks.

So, the right thing to do is first to try so-called "Optimum Medical Therapy" (OMT) -- basically give people statins and beta blockers and aspirin and see how they do. If they don't have symptoms they can't live with, Bob's your uncle.

So Borden and friends find, based on a large database of information about PCI procedures, that less than half of them were getting OMT before they got the PCI. They are mystified why this keeps happening when it's so well-known that it's the wrong thing to do.

Well it's no mystery to me. That's what interventional cardiologists do. It's what they get paid to do. So they do it.

This is why, while it's nice to do comparative effectiveness research -- which is how we know that you ought to try OMT before even thinking about PCI -- it isn't enough. We need a method to get pointy headed bureaucrats to come between you and your doctor. Why? Because your doctor isn't in business for his or her health, and apparently not for yours either. If you want to pay for a PCI out of your own pocket, even if it isn't in your own best interest, nobody ought to stop you I suppose.

But why should I pay for it, from my taxes and my own insurance premiums? What exactly is supposed to be "libertarian" about that? And that's what we're talking about here Dr. Paul -- forcing everybody to pay for inappropriate medical procedures. Insurance companies and Medicare should make a rule -- we won't pay for PCI for people with stable CAD unless you document either that you tried OMT first, or it was counter-indicated; and that the patient complains of angina and understands that the procedure is for symptomatic relief only. If that isn't in the record, you don't get paid.

Unfortunately, that seems to be what it's going to take. Either that or injecting responsibility into their brains.

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