HCA Probe Spotlights Cardiologists' 'Irresistible Temptation'

Cheryl Clark, August 30, 2012

Physicians specializing in cardiology coined the term "oculostenotic reflex" over a decade ago. But the phrase has been popping up this month in conversations about accusations that thousands of patients underwent inappropriate heart procedures at HCA hospitals in Florida and in three other states, the subject of a federal probe.

Writing in the journal Circulation in 1995, Eric Topol, MD, and Steven Nissen, MD, described this phenomenon as "an irresistible temptation among some invasive cardiologists to perform angioplasty on any significant residual stenosis after thrombolysis"—that is, after clot-busting medications have been used.

I paraphrase: the interventionalists see a vessel narrowing and are overcome with an urge to fix it, even if the patient won't benefit from the procedure, and some say, could be harmed in the process.

Nissen and Topol wrote that while professional organizations don't support this practice, "the ritual of reflex angioplasty is exercised thousands of times each year."

Last July, Paul Chan, MD, and colleagues updated information on oculostenotic reflex, although they did not call it that. They wrote in the Journal of the American Medical Associationthat inappropriate angioplasty still goes on, a lot. From their review of the American College of Cardiology's registry of percutaneous coronary interventions at 1,091 hospitals, they discovered that 11.6%, or 16,838, of 144,737 non-acute patients underwent a PCI that did not meet necessity criteria during a 15-month period ending Sept. 30, 2010.

But perhaps just as worrisome is that another 38%, or 54,988, non-acute patients had a procedure for which the appropriateness could not be determined. Many of those procedures surely were inappropriate too.

Hospital cost to Medicare is $10,000 per PCI, plus $3,000 per stent
For patients presenting with acute symptoms, the percentage undergoing inappropriate PCI was only 1.4%. But still, across both categories that's a lot of unnecessary or inappropriate PCI procedures, about 600,000 of which are done a year in the U.S., reportedly at a hospital cost to Medicare of $10,000 each, plus $3,000 per stent, plus whatever the physician might charge.

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