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Had an angioplasty? Maybe it wasn't needed
Most elective angioplasties, including those in Wisconsin, are done without checking to see whether they are needed by doing a non-invasive stress test, an analysis has found.
As a result, the study suggests, some angioplasties are done on patients for whom the risk outweighs the benefit, leading to costly, inappropriate invasive procedures.
"We have a system that pays doctors equally for inappropriate procedures as appropriate procedures," said senior author Rita Redberg, a professor of medicine at the University of California, San Francisco.
The study is published Wednesday in the Journal of the American Medical Association.
The research is based on an analysis of 23,887 Medicare cases and 1,630 commercial insurance cases. It is the latest indication that elective angioplasty, which has increased by 300 percent over the last decade, has been overused.
It also shows huge variations in the practice of medicine around the country and even within states such as Wisconsin, said Raymond Gibbons, a cardiologist and professor of medicine at the Mayo Clinic in Rochester, Minn.
"What the patients in Wisconsin should worry about is, which physician you go to makes a difference," Gibbons said. "If everybody thinks they are providing good care, why is there such a difference between doctors? The differences in the rate of stress testing within Wisconsin should be of concern to the public."
Gibbons said the health care system in America rewards doctors for doing procedures, not for practicing evidence-based medicine.
The study also shows that many patients are undergoing unneeded procedures, exposing them to unnecessary risks, said Timothy Gardner, president of the American Heart Association and a heart surgeon in Wilmington, Del.
"This study should cause all of us . . . to make sure we are only subjecting patients to procedures who will benefit," Gardner said. The study found that 45 percent of Medicare patients got a stress test within 90 days before elective angioplasty. In a separate group of private insurance patients, only 34 percent got a stress within one year of undergoing angioplasty.
The study is the latest in a string of developments suggesting that elective angioplasty in patients with stable heart disease has limited benefit and has been overused.
Last year, researchers found that common heart drugs performed as well in preventing heart attacks and deaths in people with stable heart disease as the more invasive and expensive angioplasty and stenting, suggesting that many of the hundreds of thousands of such procedures done each year might be unnecessary.
In August, the same group of researchers found that drugs worked nearly as well as stenting, plus drugs, in relieving chest pain in patients with stable heart disease. The study found that those who got stents and drugs had only a small additional benefit in pain relief that disappeared within two to three years, compared with those who got drugs alone.
Those studies looked only at people with stable coronary disease. In the United States, that is a group of several hundred thousand people who make up about one-third of all people who undergo angioplasty and stenting each year.
Doctors noted that in situations such as when a person is having a heart attack or suffering from acute coronary disease, angioplasty and stents can be lifesavers.
David Beiser, a cardiologist with Appleton Cardiology Associates, said that in the vast majority of cases, doctors in his group perform stress tests. The group treats heart patients at two Appleton area hospitals - Appleton Medical Center and Theda Clark Medical Center.
"It has to be more than 30 percent," he said, adding, "it's just good medicine."
Fredric Hildebrand, a cardiologist with Affinity Health System, which treats patients at St. Elizabeth hospital in Appleton, said the hospital performs stress tests in 44 percent of cases, the same as the national average.
The average charge for an angioplasty in 2004 was $44,110, according to the American Heart Association. Angioplasty involves threading a catheter through an artery in the groin up to the heart, opening a blockage with a balloon and placing a stent. An angiogram, which is done in the same way, determines how much an artery is blocked. It is done before placing a stent.
Medicare pays $10,000 to $15,000 for each angioplasty, which has accounted for at least 10 percent of the increase in Medicare spending since the mid-1990s, the study said.
Stress tests, which generally cost several hundred dollars, normally are done while walking on a treadmill or pedaling a stationary bike. They are a non-invasive way to detect reduced blood flow to the heart.
Professional guidelines used by cardiologists say non-invasive testing should be done before elective angioplasty.
However, interpretations differ on how to apply the guidelines, doctors said, and in some cases, stress testing is not needed.
For instance, in about 10 percent of cases, a stress test will not detect a potentially dangerous lack of blood flow to the heart, said Matthew Wolff, chief of cardiovascular medicine at the University of Wisconsin Hospital and Clinics in Madison.
"You are going to be missing people with severe disease," Wolff said.
Wolff acknowledged that some people who are subjected to angioplasty should not be, but the new study "doesn't provide us with a strategy to prevent the problem."
Redberg, co-author of the study, said the solution is to change the payment system so it rewards doctors who follow guidelines and perform a stress test to determine if angioplasty is needed.
But Anthony DeFranco, a cardiologist who practices at Aurora St. Luke's Medical Center in Milwaukee, said stress testing is not a viable option in all cases. At most, it is needed in 65 percent of cases, he said.
He said some patients, especially older ones, are not able to undergo exercise stress testing. When those patients are experiencing severe chest pain, going straight to an angiogram is a better option, he said.
"We might improve slightly, but it's not terribly off what the real number should be," he said.
In a statement, the Society for Cardiovascular Angiography and Interventions said the study only looked back 90 days to see if a stress test had been done. The organization said most patients who undergo angioplasty have had a stress test showing a problem long before they undergo the procedure.
It also said the study failed to account for the fact that most patients with stable heart disease undergo angioplasty because their medications no longer are working.
___
© 2008, Milwaukee Journal Sentinel.
Visit JSOnline, the Journal Sentinel's World Wide Web site, at http://www.jsonline.com/
Distributed by McClatchy-Tribune Information Services.
The study is published Wednesday in the Journal of the American Medical Association.
The research is based on an analysis of 23,887 Medicare cases and 1,630 commercial insurance cases. It is the latest indication that elective angioplasty, which has increased by 300 percent over the last decade, has been overused.
It also shows huge variations in the practice of medicine around the country and even within states such as Wisconsin, said Raymond Gibbons, a cardiologist and professor of medicine at the Mayo Clinic in Rochester, Minn.
"What the patients in Wisconsin should worry about is, which physician you go to makes a difference," Gibbons said. "If everybody thinks they are providing good care, why is there such a difference between doctors? The differences in the rate of stress testing within Wisconsin should be of concern to the public."
Gibbons said the health care system in America rewards doctors for doing procedures, not for practicing evidence-based medicine.
The study also shows that many patients are undergoing unneeded procedures, exposing them to unnecessary risks, said Timothy Gardner, president of the American Heart Association and a heart surgeon in Wilmington, Del.
"This study should cause all of us . . . to make sure we are only subjecting patients to procedures who will benefit," Gardner said. The study found that 45 percent of Medicare patients got a stress test within 90 days before elective angioplasty. In a separate group of private insurance patients, only 34 percent got a stress within one year of undergoing angioplasty.
The study is the latest in a string of developments suggesting that elective angioplasty in patients with stable heart disease has limited benefit and has been overused.
Last year, researchers found that common heart drugs performed as well in preventing heart attacks and deaths in people with stable heart disease as the more invasive and expensive angioplasty and stenting, suggesting that many of the hundreds of thousands of such procedures done each year might be unnecessary.
In August, the same group of researchers found that drugs worked nearly as well as stenting, plus drugs, in relieving chest pain in patients with stable heart disease. The study found that those who got stents and drugs had only a small additional benefit in pain relief that disappeared within two to three years, compared with those who got drugs alone.
Those studies looked only at people with stable coronary disease. In the United States, that is a group of several hundred thousand people who make up about one-third of all people who undergo angioplasty and stenting each year.
Doctors noted that in situations such as when a person is having a heart attack or suffering from acute coronary disease, angioplasty and stents can be lifesavers.
David Beiser, a cardiologist with Appleton Cardiology Associates, said that in the vast majority of cases, doctors in his group perform stress tests. The group treats heart patients at two Appleton area hospitals - Appleton Medical Center and Theda Clark Medical Center.
"It has to be more than 30 percent," he said, adding, "it's just good medicine."
Fredric Hildebrand, a cardiologist with Affinity Health System, which treats patients at St. Elizabeth hospital in Appleton, said the hospital performs stress tests in 44 percent of cases, the same as the national average.
The average charge for an angioplasty in 2004 was $44,110, according to the American Heart Association. Angioplasty involves threading a catheter through an artery in the groin up to the heart, opening a blockage with a balloon and placing a stent. An angiogram, which is done in the same way, determines how much an artery is blocked. It is done before placing a stent.
Medicare pays $10,000 to $15,000 for each angioplasty, which has accounted for at least 10 percent of the increase in Medicare spending since the mid-1990s, the study said.
Stress tests, which generally cost several hundred dollars, normally are done while walking on a treadmill or pedaling a stationary bike. They are a non-invasive way to detect reduced blood flow to the heart.
However, interpretations differ on how to apply the guidelines, doctors said, and in some cases, stress testing is not needed.
For instance, in about 10 percent of cases, a stress test will not detect a potentially dangerous lack of blood flow to the heart, said Matthew Wolff, chief of cardiovascular medicine at the University of Wisconsin Hospital and Clinics in Madison.
"You are going to be missing people with severe disease," Wolff said.
Wolff acknowledged that some people who are subjected to angioplasty should not be, but the new study "doesn't provide us with a strategy to prevent the problem."
Redberg, co-author of the study, said the solution is to change the payment system so it rewards doctors who follow guidelines and perform a stress test to determine if angioplasty is needed.
But Anthony DeFranco, a cardiologist who practices at Aurora St. Luke's Medical Center in Milwaukee, said stress testing is not a viable option in all cases. At most, it is needed in 65 percent of cases, he said.
He said some patients, especially older ones, are not able to undergo exercise stress testing. When those patients are experiencing severe chest pain, going straight to an angiogram is a better option, he said.
"We might improve slightly, but it's not terribly off what the real number should be," he said.
In a statement, the Society for Cardiovascular Angiography and Interventions said the study only looked back 90 days to see if a stress test had been done. The organization said most patients who undergo angioplasty have had a stress test showing a problem long before they undergo the procedure.
It also said the study failed to account for the fact that most patients with stable heart disease undergo angioplasty because their medications no longer are working.
___
© 2008, Milwaukee Journal Sentinel.
Visit JSOnline, the Journal Sentinel's World Wide Web site, at http://www.jsonline.com/
Distributed by McClatchy-Tribune Information Services.
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