Is the angioplasty bubble going bust?

New Media editor Don Fenley casts a big net for hidden gems about and behind the news

Published Thursday, June 11 2009 - (2) Comments

Here part of President Obama's speech to the AMA Monday - a week after the blog below was written.

Some sources in the medical community are saying the message in this part of the speech was heard and is gaining traction among some medical professionals.

"Less than one percent of our health care spending goes to examining what treatments are most effective. And even when that information finds its way into journals, it can take up to 17 years to find its way to an exam room or operating table.

"As a result, too many doctors and patients are making decisions without the benefit of the latest research. A recent study, for example, found that only half of all cardiac guidelines are based on scientific evidence. Half.

"That means doctors may be doing a bypass operation when placing a stent is equally effective, or placing a stent when adjusting a patient's drugs and medical management is equally effective--driving up costs without improving a patient's health."

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The American Diabetes Association and New England Journal of Medicine have given another heads-up about patient oriented, conservative fiscal management health care reform.

Here's how BusinessWeek headlined what I'm talking about: : "Another blow for angioplasty - A major heart study adds to the growing evidence that expensive angioplasties are no better than drugs alone in saving lives."

This new study tromps on the logic behind the $25 billion-a-year spent on 1.2 million angioplasties performed in the U.S. every year. This procedure seems to be to some hospital administrators and cardiologist what overdrafts is to bankers.

In a nutshell, the study shows that most of these procedures don't reduce the chances of a heart attack or death. Combine that with the previous studies that show aggressive drug treatment and lifestyle changes can produce the same - or better - patient outcomes at a third of the cost and you have what would seem like a logical science-based heath care reform slam dunk. But neither science nor logic has made a dent in the number of these procedures performed so far.

"There are people in the cardiology community who don't believe the results. They don't believe it applies to the patients they see," Dr. Judith S. Hochman, director of the Cardiovascular Clinical Research Center at New York University School of Medicine told BusinessWeek. "So we still see a lot of angioplasty being done without patients really understanding that it will not reduce their chances of heart attack or death."

Angioplasty is sometimes called the poster child for supply-induced demand. Hospitals have big investments in their catherization laboratories and an economic incentive to use them - so they do. And patients have bought into the myth that clogged arteries should be propped open.

To get a better feel of the local implications of this issue I logged into vimo.com.

Here what that turned up:

Balloon angioplasty of coronary artery and related procedures has an average list price of $39,900 and an average negotiated price of $11,800. The average patient is in the hospital for four days. Then you have the surgeon's fee, lab fees etc., etc.

Vimo.com says Holston Valley Hospital's negotiated price range for the procedure is $12,500 to $17,500. The list price is $29,900.

Bristol Regional Medical Center's negotiated price range for the procedure is $12,400 to $17,300. The list price is $33,200.

Over at Johnson City Medical Center the negotiated price range for it is $13,100 to $18,300, and the list price is $29,300.

Balloon angioplasty of a coronary artery without heart attack with the drug-eluting stent is the third most common procedure performed at Holston Valley and Johnson City Medical. It doesn't take a rocket scientist to see that it's as big business for local hospitals and cardiologists as it is elsewhere.

It makes you wonder if the angioplasty bubble is going the way of the dot.com bubble and the housing bubble.

Dr. Elliott S. Fisher, a professor of medicine and director of the Center for Health Policy Research at Dartmouth Medical School, told BusinessWeek, "As many as 40 percent of the angioplasties performed today are unnecessary, "so limiting the procedure to those who really need it-such as those having a heart attack or with severe angina-could save billions of dollars in health-care costs. But the real reason to reduce the number of angioplasties and other unnecessary procedures is to provide better care, Fisher says: "This is not about cost. This is about effectiveness."

The doctors quoted by BusinessWeek are not lone voices in the health-care wilderness. There's a network of health-care professional across the nation talking about it and pushing for change.

Dr. W.H. Bestermann Jr. at Holston Medical Group here in Kingsport has built a practice on the advanced medical home model that he describes as a "Special Forces Team" in the local battle against heart and vascular disease.

According to Bestermann, "We need to stop paying for stents and bypasses in stable angina patients until they receive a trial of optimal medical therapy."

For the record, nowhere in the research about this issue does anyone say bypass surgery and stents should disappear. But they do make a compelling argument why they should become much less common.

Besterman explains the big picture this way, "cardiovascular events and the arterial and metabolic diseases that lead to them are responsible for one-half of total health care spending. Most of the money is spent late in the process on hospital care for revascularization procedures and events like heart attack and stroke. The number one cause of hospitalization for a medicare patient is congestive heart failure that occurs most often as the result of poor blood pressure and poor risk factor control."

He contends that the best way to fix this economic and patient care problem is to identify the patient with early disease and then treat them aggressively to stabilize plaques in diseased arteries. His term for this is "pushing the care downstream."

"Now for the hard part," Bestermann says. "Optimal medical treatment is obviously the better course for high-risk patients prior to the development of symptoms. Most stents in stable angina are not necessary as an initial strategy and they should not be paid for prior to a trial of optimal medical therapy. We should pay for treatments with evidence of event reduction. That single change in policy should provide the revenue to begin the reform needed in cardiometabolic care in a budget neutral fashion."

Such a change would have a colossal impact on health care. The nation wouldn't need as many cardiologists, and a major source of revenue for some hospitals would be kicked out from under them.

Proponents for this type health-care reform say it would require a systematic restructuring designed around the needs of the patient, then around evidence and science.

Here's a couple of related articles Dr. Bestermann wrote in the The Health Care Blog:

Thomas Kuhn, Health Care Reform and Vascular Disease
The New Science of Vascular Disease
Following the Science to a New Era in Medicine

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No one is questioning this Michael...Glad to hear the "pops in law" is still kickin' about. The overall situation with the arterial and metabolic diseases is that much risk can be reduced. Dr. Bestermann's suggestion of "pushing the care downstream." Preventative maintainence is the remedy for most everything. The common sense cure...One of the many that lead right back to square one. One must simply move this plaque ridden artery illustration into something we are personally more familiar with...Like cleaning out a drain, or cleaning a cooking pan, or even cleaning a wheel on the hot rod...Sometimes a simple less labor intensive method of using chemicals and water does well, while the more stubborn malodies require some elbow grease, and then the worst boogers require ALL OF THE ABOVE. Never getting the items "greased up" in the first place would be the best scenario, but how can that honestly happen if it is part of our daily lives? Keeping the pipes clean of plaque starts all the way back into grade school with diet and education,,, then as simple blood tests as we enter into adulthood. Lets face it, America has destroyed the diet with marketing, fast food, frozen "meals" and everything else all in the name of the mighty dollar. Maybe we should all eat as Bear Gryllis does....Less the urine of course!

Michael Johnson | 7/3/2009 - 2:45 PM - ( Comment

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angioplasty is a life saver. My father in law should have been dead several years ago. With the ad of angioplasty thru stents he is still with us and is getting stronger then ever.

Michael Denman | 6/17/2009 - 10:39 PM - ( Comment

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