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HCA Probe Spotlights Cardiologists' 'Irresistible Temptation'

 |  By cclark@healthleadersmedia.com  
   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.

If practice standards were followed for stable patients, especially findings realized from the March 2007 COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), patients would be informed that medical therapy is just as good as angioplasty or stent to relieve their angina, and that a PCI will not reduce their risk of heart attacks or death.

I asked Chan this week why so many cardiologists are doing procedures that aren't based on necessity criteria, especially in light of COURAGE and the recent federal probe of thousands of procedures in Florida and three other states.

"While there's about 20 or 25 indications for when a PCI is inappropriate, the major driver as to why a procedure would be labeled inappropriate is that a patient didn't have symptoms to begin with," he says. "They were asymptomatic. They never had chest pain or anything that would be considered similar to angina, and for whatever reason they wound up getting a heart catheterization."

He adds, "more than half of the patients who were inappropriate didn't have symptoms at all."

What is going on?

The urge to screen for heart disease
Chan, who practices at the Saint Luke's Mid America Heart and Vascular Institute in Kansas City, MO, replies that today "there's a greater emphasis on prevention within the cardiovascular community, kind of what is mimicked in mammography and colon cancer screening. We're trying to prevent heart disease from happening to begin with."

And many of these inappropriate procedures are being done, he says, "by well-intentioned physicians, not realizing they were not going to benefit these patients."

Many of the procedures, Chan thinks, occur when patients turn 50 or 60 and realize they should have a physical exam. "And the doctor says, oh, you're now 60. We should get a stress test to see if you're at risk," even though that age alone would not pass criteria muster.

To make matters worse, some of the patients in the registry study who had PCI procedures that were labeled inappropriate "were not only asymptomatic, but they had normal stress tests too, which makes it even more of a head scratcher why they were getting them to begin with."

Chan and his research team were unable to dig deeper because the ACC's registry cases are de-identified.

Researchers are trying to find out more, Chan says. For starters, a paper in the works, perhaps to be released next March, will look at regional variation for these procedures, and may even highlight specific hospitals with higher rates of PCI that are inappropriate.

Another research project unfolding soon will tell whether cardiologists are performing "inappropriate" procedures in fewer patients, because perhaps more doctors are getting the message.

"Everybody is talking about this"
"We're still running the analyses, so we don't know the definitive answer, but the likelihood is that there probably has been improvement, and the proportion of inappropriate procedures has decreased," Chan says. "Probably because, as a lot of hospitals that I've spoken to have said, everybody is talking about this."

Participating hospitals "are getting a line-item list of every patient labeled inappropriate, and they're encouraged to compare that with the national average, and with their prior quarter for that hospital, and then go back to the patient records...to understand why that patient underwent the procedure to begin with," he says.

Strong suspicions exist among cardiologists I've spoken with that regional comparisons will reveal dramatic variation.

Elliott Fisher, MD, co-principal investigator of the Dartmouth Atlas, known for highlighting regional variation in expensive hospital procedures, believes the problem of inappropriate cardiovascular procedures would almost disappear if hospitals set up decision tools for patients before they have their procedures.

Fisher says the burden is on hospitals that perform angioplasty to show "that they are using validated decision aids and methods for shared decision making. In the absence of those, some patients are receiving surgery who would not have chosen it. And that is wrong patient surgery, a problem as serious as wrong-side surgery," he says.

Too many physicians have 'oculostenotic reflex'
Unfortunately, Fisher says, "too many physicians have 'oculostenotic reflex.' They see a blockage and say, 'Gosh, I can fix that. Because fixing the blockage must be good for the patient. It can't hurt them.' "

Even though it might.

Chan agrees that tools for informed decision making are rarely offered to patients prior to cardiovascular procedures.

"Often times, in the case of angioplasty, the discussion is very short before the procedure, and it's really just a list, often in legalese of what the complication rates and risks may be," Chan says. "[Cardiologists] don't even elicit patient preference as to how patients would want to manage their angina if they were found to have significant blockages during the catheterization."

Chan realizes that realignment of payment models will remove financial incentives to perform unnecessary procedures, but that is years away for most healthcare systems.

"We live in a quick-fix society," Chan says. "I'm also a trained pediatrician, and I often see families who want an antibiotic for their child's cold, even knowing it wasn't likely to benefit, because they think having something in hand is better than just waiting for the cold to get better.

"In many ways, I think we need to realign both physicians and patients into understanding what the limits and options for treatment are. And what they would prefer."

Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, says that today around the country, cardiologists "are being much more careful about appropriateness, recognizing that the field is under scrutiny. And I think that's a good thing, that people who pay for these procedures are saying we have to do a better job of documenting appropriateness.

He adds, "Every place that does these procedures needs to have in place safeguards to make sure they're being done on the right patients."

I'm hoping that details from HCA, as well as Chan's ongoing research, can be unveiled soon to help us understand why so many patients might be getting care they didn't need, and wouldn't have wanted if they knew it wouldn't do any good.

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