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In 2007, we learned from the COURAGE trial that angioplasty and stents don’t reduce the risk of death or heart attack, but patients didn’t seem to get the memo. Only 1 percent realize there was no mortality or heart attack benefit. Perhaps because most cardiologists failed to happen to mention that little fact. One can imagine that if patients actually understood all they were getting was symptomatic relief that they’d be less likely to go under the knife. But then, ten years later, the ORBITA trial was published, showing even the promise of symptom relief was an illusion.
The implications are profound and far-reaching. First and foremost, the results showed unequivocally that there are no benefits to angioplasty and stents for stable heart disease. Basically, patients would be risking harm for no benefit whatsoever; so, it’s hard to imagine a scenario where a fully-informed patient would choose an invasive procedure for nothing. Remember the stent consent form? Now, it looks like this.
So, is the ORBITA trial the last nail in the coffin for stents in non-emergency situations? An editorial in the journal Cardiovascular Revascularization Medicine disagreed, pointing to the broad angina relief that occurred in both arms. In other words, “stents helped” (even if the fake operation without stents helped just as much. So hey, if I give a patient a stent and they are beneﬁting from the “placebo effect,” who am I to interfere with that beneﬁt of this quote-unquote “therapy”? Well then, why not do fake surgeries? Stent placement can go for like $40,000. It’d be cheaper to just fake the whole thing. The reason we shouldn’t keep electively stenting people is because there’s a body count. During stent placement, 2 percent of patients develop bleeding or blood vessel damage, and another 1 percent die or have a heart attack or a stroke. And then, because you are having something stuck in your chest, 3 percent of patients have a bleeding event from the blood thinners you have to be on, or the blood thinners don’t work, and the stent clots off and causes a heart attack.
Why are they still done when we don’t just have no evidence of benefit, but in many cases explicit evidence of no benefit? One of the sources of resistance may be all the financial gain. These procedures make a lot of money for hospitals. Don’t expect them to be promoting lifestyle changes anytime soon, nor will physicians quickly abandon a practice that seems to make sense and supports their income. Is it that simple? Is it that famous Upton Sinclair quote on how “[i]t is difficult to get a man to understand something when his salary depends upon his not understanding it?” Think that’s just cynicism? Let’s ask doctors themselves.
Thousands of physicians were surveyed, and 70 percent believed that physicians provide unnecessary procedures when they profit from them. That’s what doctors themselves believe. And the data bears this out. Doctors have been shown to make different clinical decisions for patients based on how much they get paid. For example, when choosing which chemotherapy to treat breast cancer, increasing a physician’s margin by 10 percent can yield up to a 177 percent increase in the likelihood of choosing one drug over another.
That may be why Caesarean sections are more likely to be performed by for-profit hospitals compared to non-profit hospitals. Operating on commission. Pay surgeons per procedure and you can increase surgery rates 78 percent. Could that explain why we do 101 percent more angioplasties than any other rich country? A study on physician ﬁnancial incentives and treatment choices in heart attack management found that they do indeed respond to payments, and the response is quite large. Unconditionally, plans that pay physicians more for more invasive treatments seem to result in more invasive treatments. So, it may actually be quite common for patients to receive different treatments based on whether the doctor is getting paid per procedure.
One of my heroes, Dr. Caldwell Esselstyn—who always tries to see the best in people—even he had to break down and admit that compensation may be playing a role, after evidence surfaced that doctors are running up millions doing unnecessary stent implants: doctors like Mark Midei, who inserted 30 in a single day. That could be like a million dollars’ worth of billing. As a token of their gratitude, a sales representative from the stent company spent $2,000 to buy him a whole, slow-smoked pig, peach cobbler, and all the fixins.
We’re the only developed country where health care is delivered like this, explained the chief of cardiovascular medicine at the Cleveland Clinic. “The economic incentives are just too strong.”
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