Saturday, June 27, 2009

Oh, those greedy cardiologists

I'm all over health care variation and non-evidence based medicine (N-EBM) these days. They're hot topics because of their close ties with the current health care reform debate.

If you want some entertainment on the subject, and can stomach a little demagoguery and name calling about greedy cardiologists and pigs running the AMA by all means check out this post by Doug Bremner, M.D. If you want something factual look elsewhere.

Bremner's post is so over the top and patently absurd one wonders whether it even merits a serious response, but, evidently, some people take Bremner's blog seriously. Besides, all I have to do to smack it down is cite some simple facts, so here goes.

He starts with this:

I just found a way to save 25 billion dollars a year for President Barack Obama’s healthcare plans. That is to cut out angioplasty, for which multiple studies, including one in the June 11 edition of the New England Journal of Medicine. The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with heart disease doesn’t stop doctors from performing them.

Wrong, wrong, wrong, Dr. Bremner.

First, I'll give him the benefit of the doubt and assume he's not really talking about angioplasty but rather coronary stenting. Angioplasty as the principal coronary intervention is seldom performed anymore. In the NEJM study he cited almost all the PCI patients underwent some form of stenting.

Concerning stenting, most are not done in patients addressed in that NEJM study or the other landmark trial with similar findings, the COURAGE trial. In fact, patients with stable angina represent less than a third of those who get stents nowadays.

Let's pick apart Bremner's statement a bit more---

The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack----

Huh? Cardiologists have known for over a decade that revascularization doesn't prevent heart attacks. No one is promoting it for that indication. Where does Dr. Bremner get his “information?”

Let's parse it a bit more (my italics):

The mounting evidence that angioplasty is not more effective than medication treatment alone in preventing heart attack and death in people with heart disease doesn’t stop doctors from performing them.

Nonsense. The COURAGE trial certainly did stop doctors from performing them in patients with stable angina, almost immediately:

ResultsThere was a significant increase in anti-ischemia medication use prior to catheterization referral following the COURAGE trial (mean = 1.31 [SD 0.83] medications pre-COURAGE, mean = 1.54 [SD 0.84] medications post-COURAGE, P = 0.012). Among 217 patients with coronary disease on catheterization, treatment with medication rather than percutaneous or surgical revascularization increased after COURAGE (11.1% pre-COURAGE vs 23.0% post-COURAGE, P = 0.03). There was also a significant decrease in referral volume following the COURAGE trial (3.12 referrals/day pre-COURAGE vs 2.51 referrals/day post-COURAGE, P = 0.034).

ConclusionsThe COURAGE trial immediately impacted the management of stable angina. Catheterization referral volume decreased, medication use increased, and the use of medical therapy rather than revascularization increased among patients with coronary disease.

And, there was this from Heartwire:

Use of coronary stents, including drug-eluting stents (DES), "dropped sharply" in April, the Wall Street Journal reports, citing a marketplace report conducted by Millennium Research Group in 140 US hospitals [1].

According to Journal reporter Keith J Winstein, doctors did roughly 71 200 stenting procedures in April: 10% less than in March and 15% less than the previous year. Physicians believe that drop, writes Winstein, is "an unusually quick response" to the COURAGE trial, presented at the ACC 2007 meeting in March. In COURAGE, stents (primarily bare-metal stents) were no better than optimal medical therapy at preventing future death or MI in people with stable coronary artery disease.

So here's the bomb in Bremner's post:

But I’ll give the reason why they still perform 1.2 million of these procedures every year. It is pretty simple really. Greed.

The moral preening and finger pointing that goes on in our profession is astounding.

Evidence, please, Dr. Bremner.

Perhaps the most concerning problem with Dr. Bremner's post is that he conflates stenting for stable angina with it's real evidence based use, which is in patinets with acute coronary syndromes. Emergent PCI for patients experiencing acute STEMI has been shown over and over again to save lives, save ejection fractions and get people back to work. Let's hope some misguided folks in Washington don't deprive them of it. I personally believe the doctors taking care of patients who know what they're doing should be the ones responsible for critical appraisal of best evidence, not some policy wonks from afar. See why?


Terry said...

Well said Dr. RW.

#1 Dinosaur said...

How about just foregoing annual stress tests and echoes on every person who's ever had an MI unless they're actually having, you know, symptoms?

(Actually, most cardiologists do them on all their patients, MI or not. After all, if they're seeing a cardiologist, they need an echo and a stress test.)

Would you approve of the savings engendered just by that little tweak in practice?

R. W. Donnell said...

I agree with you that such tests should not be done absent some specific clinical reason.

I don't know how many docs do them annually just because they can, so I have no idea how much money would be saved.

Orac said...

Somehow I ended up on Bremner's e-mail list. Between reasonable criticisms of various medical practices, he also spews out a whole lot of crankery. Given my blogging history, what has in particular caught my attention is intermittent utter nonsense about vaccination (particularly flu vaccines) and exaggerations about the problems associated with cancer screening (both of which I've been meaning to take him to task for for a long time now in a not-so-Respectfully Insolent smackdown).

Doug Bremner said...

Me here. OK I stand corrected on the conflation of terms and I was already corrected by a comment on my blog with a link to the appropriate reference that most PCIs are performed in the setting of acute cardiac events... although many are not done within the appropriate time period which my understanding is 12-24 hours... However you still have over 300,000 PCIs on patients with stable coronary disease by your own figures, right? And some cardiologists going to jail for doing PCI on people with little or no disease?

R. W. Donnell said...

Dr. Bremner,
Thanks for your comment. I'll address the patients with stable coronary disease in a future post.

Didn't the guys who went to jail falsify patient records?

I'm not a cardiologist, by the way.

Doug Bremner said...

Well, thank god for that. There was one in FL and one in LA, I think the one in LA was putting stents in people without disease