Three new studies show that too many patients with stable angina are still persuaded by cardiologists to undergo unnecessary elective angiography with subsequent percutaneous coronary intervention.
It's been more than three years since Paul Chan, MD, and colleagues shook the cardiosphere with their finding that 11.6% of non-acute stent procedures cardiologists performed in more than 1,000 U.S. hospitals were "inappropriate" and another 38% were of "uncertain" appropriateness, making about half of them questionable.
This was a big study, culled from the American College of Cardiology's National Cardiovascular Data Registry, which looked at more than 140,000 non-acute procedures performed during a 15-month period ending Sept. 30, 2010.
Inside Cardiology's PCI Problem
What with all the talk about efficiency, and resource stewardship, and bending the cost curve, you'd think things would have changed by now.
Yet a troika of studies published in Monday's JAMA Internal Medicine indicate the same-old, same-old patterns, as recently as 2012 and 2013. They show that an awful lot of patients with stable angina are still persuaded to undergo unnecessary elective angiography, with subsequent percutaneous coronary intervention.
Somehow patients are getting the message—sometimes from their doctors or from somewhere else—that plugging in a few stents will prevent heart attack and death, despite no evidence that is so.
There also may be insufficient information about severe risks, such as perforations—necessitating a rush to bypass surgery—and lesser risks such dye reactions, kidney toxicity, and radiation exposure. Then there is the cost, estimated at about $14,000 per procedure nationally, plus medication costs, a share of which patients have to absorb.
Cardiologists 'Sleep Pretty Well At Night'
I asked R. Adams Dudley, MD, associate director of research at UCSF's Institute for Health Policy Studies, who co-authored "Fighting the Oculostenotic Reflex," an invited opinion piece, in the same issue, why this is so.
Why do so many cardiologists persist in pushing unnecessary, potentially harmful care, with patients who remain clueless. Frankly, it seems at least disingenuous.
"Cardiologists don't think they're doing anything bad," Dudley explains. "They sleep pretty well at night. And they leave the hospital every night feeling like they helped a lot of people.
"They believe they are following the community standard of care, which doesn't mean evidence-based standard of care. It means the way we do things 'around here.' "
The patients, he says, "think they're getting the procedure to save their life. That they're about to die. And the doctor is a hero for saving them."
Dudley is keenly aware of the plethora of unnecessary cardiology procedures because, as a researcher focused on quality, appropriateness, and efficiency of care, he and his team organized "focus groups" to examine cardiologists motivations a few years back, and he has kept up on the topic.
"Despite acknowledging data showing that PCI offers no reduction in the risk of death or myocardial infarction in patients with stable coronary artery disease, cardiologists generally believed PCI would benefit such patients," their 2007 JAMA Internal Medicine paper said.
Alleviating patient anxiety, fear of being sued, and their own unsupported belief that the procedures would help factored into their rationale.
Cardiologists Revising Appropriateness Criteria
I also asked Charles Chambers, MD, president of the Society for Cardiovascular Angiography and Interventions (SCAI) what he thought of the three studies and Dudley's editorial.
He was reassuring, saying the cardiology community has taken a number of steps to reduce inappropriate angiography and stenting. Appropriate Use Criteria (called AUCs) were updated in 2012 and are undergoing another [review] this fall. There now are apps and calculators, which interventionalists can use while the patient is being catheterized, to help determine "whether or not to go ahead" with a stent.
Chambers says that many of the current journal edition's studies took place before many of these improvement strategies efforts got off the ground.
Nevertheless, journal authors must have felt there was value to the topic to publish three pieces in one issue.
According to one of the papers, stable coronary artery disease patients are still agreeing to these procedures even when presented a detailed explanation that heart attacks are not caused by plaque buildup completely clogging an artery, but by plaque elsewhere that ruptures and causes a clot around the rupture. "However, despite the more detailed explanation, 30.6% continued to believe that PCI would prevent an MI."
One of the most creative of the papers comes from Tufts University, Baystate Medical Center, and the Mayo Clinic. Michael Rothberg, MD, and colleagues culled actual transcripts from conversations between participating cardiologists and patients about their need for angiography and PCI, noting communication patterns that urged some patients to agree to the procedure even though there was no evidence they'd benefit from it.
Overstating the Benefits
The problem, the study suggests but does not say outright, is that the doctors aren't really being very thorough or honest, as this transcript from their dialogues show:
"If you don't do it, [angiogram/PCI], what could happen? Well, you could infarct or have a heart attack involving that area which can lead to a sudden death potentially, or at the very least could damage more of the heart as you go into worse heart failure because the heart muscle is pretty weak already.""It's a fairly straightforward procedure. I would guess you'd probably feel better if it is opened up," read a comment from one doctor.
"This study reveals that some cardiologists overstated the benefits of angiogram and PCI implicitly or explicitly," the authors wrote. What is needed, they said, is a system that bring informed consent documents and decision aids to the patient to improve their understanding "and enable them to make decisions that are fully informed, and consistent with their preferences, values, and goals."
The third study from the Veterans Affairs Eastern Colorado Health Care System and Saint Luke's Mid America Heat Institute describes the likelihood of a "diagnostic-therapeutic cascade" for 308,083 asymptomatic patients at who underwent elective angiography in 544 U.S. hospitals. In a nutshell, the inappropriate angiography was widely variable, but at hospitals that performed angiography inappropriately, the more likely those hospitals were to inappropriately place stents.
Dudley says that in discussing the issue with cardiologists over the years, and in his own research, he noted that "part of it is just a 'boys-will-be-boys' kind of attitude."
But also, they think the primary care doctor wants this for their patient, or if they fail to do the procedure they'll get sued, "without considering that if they do the procedure and the patient gets a ruptured coronary artery, they might get sued."
But overall, Dudley says, for cardiology, "there's not a lot of time to think deeply about this, or to have long great conversations with their patients."
The attitude persists regardless of whether the cardiologists work in their own private practices, or for large systems like the VA Healthcare System or Kaiser Permanente, Dudley says.
Chambers believes that today, the same studies would find a much lower rate of inappropriate cardiac catheterization procedures and stents.
But there's another issue at stake, which is the patient's chest pain, "which can be a very scary thing." With better appropriateness criteria and guidelines, however, cardiologists may cut the inappropriate procedure rate in half.
"But it will never go away," Chambers says. "Because there are times when, as a doctor, you will look at that lesion and… realize it isn't classified as appropriate [for a stent]. But realize as a doctor taking care of my patient, you can't always go by what's right by what's on paper."