Why Are Stents Still Used If They Don’t Work?

santoelia/shutterstock

Over and over, studies have shown that doctors tend to make different clinical decisions for patients based on how much they will get paid personally.

In 2007, we learned from the COURAGE trial that angioplasty and stents don’t reduce the risk of death or heart attack, but patients didn’t seem to get the memo. Only 1 percent realize there was no mortality or heart attack benefit. Perhaps because most cardiologists failed to happen to mention that little fact. One can imagine that if patients actually understood all they were getting was symptomatic relief that they’d be less likely to go under the knife. But then, ten years later, the ORBITA trial was published, showing even the promise of symptom relief was an illusion.

The implications are profound and far-reaching. First and foremost, the results showed unequivocally that there are no benefits to angioplasty and stents for stable heart disease. Basically, patients would be risking harm for no benefit whatsoever; so, it’s hard to imagine a scenario where a fully-informed patient would choose an invasive procedure for nothing. Remember the stent consent form? Now, it looks like this.

So, is the ORBITA trial the last nail in the coffin for stents in non-emergency situations? An editorial in the journal Cardiovascular Revascularization Medicine disagreed, pointing to the broad angina relief that occurred in both arms. In other words, “stents helped” (even if the fake operation without stents helped just as much. So hey, if I give a patient a stent and they are benefiting from the “placebo effect,” who am I to interfere with that benefit of this quote-unquote “therapy”? Well then, why not do fake surgeries? Stent placement can go for like $40,000. It’d be cheaper to just fake the whole thing. The reason we shouldn’t keep electively stenting people is because there’s a body count. During stent placement, 2 percent of patients develop bleeding or blood vessel damage, and another 1 percent die or have a heart attack or a stroke. And then, because you are having something stuck in your chest, 3 percent of patients have a bleeding event from the blood thinners you have to be on, or the blood thinners don’t work, and the stent clots off and causes a heart attack.

Why are they still done when we don’t just have no evidence of benefit, but in many cases explicit evidence of no benefit? One of the sources of resistance may be all the financial gain. These procedures make a lot of money for hospitals. Don’t expect them to be promoting lifestyle changes anytime soon, nor will physicians quickly abandon a practice that seems to make sense and supports their income. Is it that simple? Is it that famous Upton Sinclair quote on how “[i]t is difficult to get a man to understand something when his salary depends upon his not understanding it?” Think that’s just cynicism? Let’s ask doctors themselves.

Thousands of physicians were surveyed, and 70 percent believed that physicians provide unnecessary procedures when they profit from them. That’s what doctors themselves believe. And the data bears this out. Doctors have been shown to make different clinical decisions for patients based on how much they get paid. For example, when choosing which chemotherapy to treat breast cancer, increasing a physician’s margin by 10 percent can yield up to a 177 percent increase in the likelihood of choosing one drug over another.

That may be why Caesarean sections are more likely to be performed by for-profit hospitals compared to non-profit hospitals. Operating on commission. Pay surgeons per procedure and you can increase surgery rates 78 percent. Could that explain why we do 101 percent more angioplasties than any other rich country? A study on physician financial incentives and treatment choices in heart attack management found that they do indeed respond to payments, and the response is quite large. Unconditionally, plans that pay physicians more for more invasive treatments seem to result in more invasive treatments. So, it may actually be quite common for patients to receive different treatments based on whether the doctor is getting paid per procedure.

One of my heroes, Dr. Caldwell Esselstyn—who always tries to see the best in people—even he had to break down and admit that compensation may be playing a role, after evidence surfaced that doctors are running up millions doing unnecessary stent implants: doctors like Mark Midei, who inserted 30 in a single day. That could be like a million dollars’ worth of billing. As a token of their gratitude, a sales representative from the stent company spent $2,000 to buy him a whole, slow-smoked pig, peach cobbler, and all the fixins.

We’re the only developed country where health care is delivered like this, explained the chief of cardiovascular medicine at the Cleveland Clinic. “The economic incentives are just too strong.”

Republished from NutritionFacts.org

Sources Cited

• Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-16.
• Whittle J, Fyfe R, Iles RD, Wildfong J. Patients are overoptimistic about PCI. BMJ. 2014;348:g5613.
• Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How cardiologists present the benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis. JAMA Intern Med. 2014;174(10):1614-21.
• Kawasuji M. Clinical evidence versus patients’ perception of coronary revascularization. Surg Today. 2013;43(4):347-52.
• Al-Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391(10115):31-40.
• Brown DL, Redberg RF. Last nail in the coffin for PCI in stable angina? Lancet. 2018;391(10115):3-4.
• Warriner DR, O'Sullivan JW. Has too much cardiology been sent into the appropriateness ORBITA? BMJ Evid Based Med. 2018;23(2):48-9.
• Krumholz HM. Informed consent to promote patient-centered care. JAMA. 2010;303(12):1190-1.
• King SB 3rd. The ORBITA Trial: What Does It Mean for Practice?. Cardiovasc Revasc Med. 2018;19(4):397-8.
• Kolata G. ‘Unbelievable’: heart stents fail to ease chest pain. The New York Times. November 2, 2017.
• Esselstyn CB. A plant-based diet and coronary artery disease: a mandate for effective therapy. J Geriatr Cardiol. 2017;14(5):317-20.
• Rothberg MB. PCI for stable angina: A missed opportunity for shared decision-making. Cleve Clin J Med. 2018;85(2):105-21.
• Brown DL, Redberg RF. Continuing Use of Prophylactic Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease Despite Evidence of No Benefit: Déjà Vu All Over Again. JAMA Intern Med. 2016;176(5):597-8.
• Rothberg MB. Coronary artery disease as clogged pipes: a misconceptual model. Circ Cardiovasc Qual Outcomes. 2013;6(1):129-32.
• Dyer O. The challenge of doing less. BMJ. 2013;347:f5904.
• Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970.
• Shen J, Andersen R, Brook R, Kominski G, Albert PS, Wenger N. The effects of payment method on clinical decision-making: physician responses to clinical scenarios. Med Care. 2004;42(3):297-302.
• Epstein AJ, Johnson SJ. Physician response to financial incentives when choosing drugs to treat breast cancer. Int J Health Care Finance Econ. 2012;12(4):285-302.
• Hoxha I, Syrogiannouli L, Luta X, et al. Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis. BMJ Open. 2017;7(2):e013670.
• Shafrin J. Operating on commission: analyzing how physician financial incentives affect surgery rates. Health Econ. 2010;19(5):562-80.
• Coey D. Physicians’ Financial Incentives and Treatment Choices in Heart Attack Management. Quant Econ J. 2015;6(3):703-48.
• Esselstyn CB Jr. Defining an Overdue Requiem for Palliative Cardiovascular Medicine. Am J Lifestyle Med. 2016;10(5):313-7.
• Devi S. US physicians urge end to unnecessary stent operations. Lancet. 2011;378(9792):651-2.
• Harris G. Doctor faces suits over cardiac stents. The New York Times. December 5, 2010.