Random Thought: Treatment for heart stenoses

Thursday, (2/11/10) was "heart" day in the media.  First there was an article in the Wall Street Journal (   http://online.wsj.com/article/SB10001424052748703652104574652401818092212.html?mod=WSJ_newsreel_us) that discussed the problem with getting physicians to change treatments even when studies suggest that (cheaper) options (a drug regimen)  exist that work as well -- casting doubt on one of the proposed ways to lower health care costs, then late in the day came news that former President Bill Clinton had two stents inserted into one of his coronary arteries.  This was evidently an almost emergency procedure that would not have indicated drugs.

The WSJ article referred to a landmark medical study, entitled "COURAGE" that appeared in the New England Journal of Medicine in 2007. The primary findings where that catheterization and the insertion of stents (percutaneous coronary intervention (PCI) ) people with "stable" coronary artery disease along with a standard drug regimen did not have fewer deaths and subsequent heart attacks than the other group who just received the drug therapy.  It was found that pain from angina was relieved more quickly with the stent procedure (I have heard this is likely to be immediate.)

The WSJ article stated that when the study first came out, the stock prices of some of the stent manufacturers went down and the number of stents inserted went down, but after a few months both recovered to their pre-study values.  Perhaps the most tangible statements in the article were that either $5BIL or $8BIL (two different places in the article) could be saved each year if the guidelines suggesting drug treatments should be used instead of catheterizations.  The argument about the economic incentive for the cardiologist to do the procedure, for say $900 as opposed to only $100 for an office visit was given.  As was the statement that cardiologists now could have yearly compensations of $500,000 which is much more than a decade before, when stenting had not yet become common.

As articles in the popular press go, this one is better than most.  Information that is direct synopsis of the original article appears to be correct.  However, there are several problematics issues that arise because of the lack of context of PCI within all possible treatment of heart disease and by thinking a switch of treatment (e.g., to just drugs) will save costs in every case.  In addition, the statement about the increase in compensation to surgeons appears to be a back handed slap.

So without claiming universal knowledge on this issue, let me make the following statements.

While I could not find a definitive reference, I suspect that the number of coronary artery bypass surgeries, which (almost always) require an open chest incision, have dropped substantially in the last decade or so.  (Here is an indication -- about 1/2 a page down:http://yourtotalhealth.ivillage.com/quality-care-not-number-procedures-determines-bypass-results.html).  So (even if you don't care), perhaps compensations for docs doing catheterizations have increased as they provide what is almost certainly an improved treatment that is replacing bypass surgeries.  (Which incidentally has saved substantial amounts of health care dollars!)  So any complaints in overuse of catheterizations needs to be considered in light of the clear benefits that it has provided.

The original article notes that angina pain is not immediately relieved by the drug treatment regimen and in many cases existed for an extended time.  While some people may be able to tolerate some pain, I have to expect that this would reduce the chances that these people increase their exercise activities which could improve their health.  Whereas, if the pain had been relieved, they would able to exercise.  Presumably a physician should be free to take this into account.

In addition, while the on-line literature claims that angina is not associated with irreversible heart damage.  If this is true, great, but what it if is not?  In addition, what about the people for who pain causes significant suffering.

So does this provide any insight into the issue of how to effect changes in treatment when better treatments become available?  Well as I mentioned above, catheterization has been increasingly used instead of open surgery and studies note that this is a good thing (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60552-3/fulltext#article_upsell). Further a recent study about heart disease in Great Britain has shown that outcomes in heart surgeries have improved significantly in recent years http://www.sciencedirect.com.proxy.library.nd.edu/science?_ob=ArticleURL&_udi=B6T1B-4WXYSYG-1&_user=489835&_coverDate=08%2F14%2F2009&_alid=1205567476&_rdoc=16&_fmt=high&_orig=search&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=717&_acct=C000022718&_version=1&_urlVersion=0&_userid=489835&md5=e31062b447ab49018e14462301b1a93b.

I am certainly sure that there is still much work to be done.  No doubt that many unnecessary  procedures are performed, either to protect against possible litigation or simply because the physician does not know everything.  In addition, it is hard to imagine that if expensive instruments are available ( e.g., MRI), that they are not over-utilized to some extent.  Or in communities where there is excess hospital or physician capacity, that there is little chance of downward cost pressure.  However, I don't think that the example given the WSJ article really tells us that medical care is not adjusted toward the best treatments for patients.