Avoiding avoidable cardiac care

by Carolyn Thomas  ♥  @HeartSisters

I’ve written here previously about the difference between people who are health-seekers as opposed to those who tend to be disease-seekers.  I  would lump myself into the former category;  what I’m looking for is quality medical care that’s appropriate and available when I need it. But as a heart attack survivor, I also want to avoid health care that is not 100% absolutely necessary, whether that’s a drug or a clinical procedure or a diagnostic test.

Drugs, procedures and tests that are not necessary make up what doctors call “avoidable care”. It’s a growing issue that the medical profession has been aware of for decades. But many physicians appear oddly unreceptive to hearing or talking about avoidable care, apparently even among their doctor buddies.   

During a recent interview, noted cardiologist Dr. Bernard Lown recalled a lecture that he delivered in New York City 30 years ago to 600 other doctors (including a “good sprinkling” of heart specialists, he pointed out). Dr. Lown, whose International Physicians for the Prevention of Nuclear War won the 1985 Nobel Peace Prize, asked how many of the doctors in the room who ordered coronary bypass surgery had actually told their patients that this procedure would not prolong their lives.

He reported that not one of the doctors raised a hand.

One motive for unnecessary bypass surgeries was profit, Lown explained. But another key component, he said, was cultural.

“It’s the way we train people in medical school and the way we indoctrinate them in hospitals. It’s the way you want to do something that is decisive.

“When you’re a young person, you cannot tolerate uncertainty, and when you get older you learn that you have to live by it.

“The bypass or the stent are definite answers to a problem; you have it done and it’s over, it’s ended.

“But that ain’t so. A patient still has coronary disease, still has risk factors, and the lifestyle that brought the patient to the doctor in the first place will bring that patient to the doctor a second and third time.”

Emerging research continues to confirm a shocking reality that Dr. Lown claims doctors recognized decades ago: widespread, expensive procedures exist that show no benefit for the patient.

Consider that almost half a million coronary stent angioplasties are performed each year on stable patients. But a study(1) reported recently in the Archives of Internal Medicine shows that for patients with stable coronary artery disease, standard recommended medical therapies such as taking aspirin, beta-blockers, ACE-inhibitors, and statin medications do not reduce death rate, chest pain, and the risk of future cardiac events any better when combined with stent angioplasty.

This was one of the first studies to look at the outcomes of patients who received modern angioplasties. In short, the study found that adding an invasive, expensive procedure to prescribed therapy regimens has no apparent benefit.

According to this study, up to 76 percent of stable patients could avoid angioplasties.

“Research has also shown that lifestyle changes can help regress coronary disease, but there is a dearth of major research on whether doctors encourage lifestyle changes—and, importantly, whether patients follow through with their doctors’ lifestyle recommendations for reducing heart disease.”

Another study(2) reported in the Journal of the American College of Cardiology this year suggests that two-thirds of the justifications for stent angioplasties in non-emergency patients were either “uncertain” or “inappropriate“.

The rate of those cardiac procedures has increased 300% over the last decade. About 65% of balloon angioplasties are currently performed as elective procedures on non-emergency patients who have only partial coronary artery lesions.  Some hospitals have in fact become angioplasty factories, as described by Consumer Reports Health.

The way doctors are paid may be one reason why avoidable procedures like these persist. Extra time spent talking to a patient, as Lown and other medical professionals claim, can help identify the root cause of an ailment. But that pays far less than performing a procedure.

Under the typical fee-for-service system, doctors get paid for action, not attention.

As a result of this system, young doctors have less financial reason to even consider primary care as a career choice – the first line of defense against avoidable procedures – and turn instead to specialty areas where they can earn, on average, an extra $3.5 million over the course of a career, according to Dr. Allan H. Goroll, professor of medicine at Harvard Medical School.

There exists in some circles what we call scienciness, the illusion that a sophisticated new procedure or technology should be used simply because it exists. Take that clogged coronary artery as an example. For a patient actually having a serious heart attack (as I experienced in 2008), re-opening a blocked artery is critically important. For everybody else, maybe not so much. . .

As the Daily Beast interview adds, physicians like Dr. Bernard Lown may be gaining a more prominent voice in the national conversation, citing recent media coverage of both the Choosing Wisely Campaign and last month’s Avoiding Avoidable Care conference in Cambridge, Massachusetts that probed important questions like:

• How much of the $2.7 trillion we spend on health care every year is wasted on unnecessary services? (hint: some estimates range from 10 to 30%)
• Is precise knowledge about the scope and drivers of unnecessary care important?
• How big a part does defensive medicine play?
• How much is outright fraud or patient demand?
• What is the scope of harm caused by unnecessary care?

And finally:

“These programs indicate there is an appetite among health professionals to move away from expensive, unnecessary procedures – and the driver for that appetite comes down to dollars and cents.”

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(1) Stergiopoulos K, Brown DL. “Initial coronary stent implantation with medical therapy vs medical therapy alone for stable coronary artery disease: Meta-analysis of randomized controlled trials.” Arch Intern Med. 2012;172(4):312-319.  doi:10.1001/archinternmed. 2011.1484.

(2) Edward Hannan. “Appropriateness of Coronary Revascularization for Patients Without Acute Coronary Syndromes.” Journal of the American College of Cardiology, 2012; 59:1870-1876, doi:10.1016/j.jacc.2012.01.050

See also:

Why Aren’t More Doctors Like Dr. Bernard Lown?

Why You’ll Listen to Me – But Not to Your Doctor

Did You Really Need That Coronary Stent?

Squishing, Burning and Implanting Your Heart Troubles Away

Say What? Do Patients Really Hear What Doctors Tell Them?

Doctors On The Take: How to Read the Fine Print in Cardiac Research Study Results

What Prevents Heart Disease “Better Than Any Drug”?

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