An invasive cardiologist in Maryland recently had his license revoked by the state medical board for 2 years, for implanting unnecessary cardiac stents in his patients. He was the head of cardiology at his hospital. One day he had implanted 30 stents. Review of his cases revealed that he had overestimated the degree of blockage, and between 2007 and 2009 had inserted 585 unnecessary stents, at a cost of $3.8 million paid by Medicare.

Six hundred thousand angioplasties are performed in the US every year. Cardiac stents are of value in patients with new heart attacks, where they may reduce the extent of damage, and in patients with disabling angina, whose chest pain prevents them from performing daily activities or exercising. In patients with stable, non-limiting chest pain, heart catheterizations and stents offer no benefit, either in preventing heart attacks or prolonging life, over optimal medical therapy.

In other words, medical therapy alone, including dietary changes, exercise, weight loss, stress reduction, and medication, offers the best prognosis in heart disease, and invasive procedures provide no additional gain. Despite these findings, catheterizations and stents continue to be offered inappropriately. Patients submit to them with the misplaced hope that their lives will be extended. They are thus exposed to unnecessary risks of bleeding, infection, anesthesia, stroke from pieces of plaque that break off and go to the brain, ruptured blood vessels, and the subsequent need for blood-thinning medications for years afterwards. Billions of dollars go for stents that are of no value.

Cardiac disease has long been identified as one condition for which the risk factors are well-known and modifiable. We should go after these risk factors far more vigorously than we do now, and avoid giving patients false data and false hope that the answer lies in a piece of coated metal shoved into the heart.

Other procedures are also suspect for excessive use. These include MRI and CT scans, back and neck surgery, knee replacements, and laser eye surgery.

I do not believe that putting doctors on salary, and removing production as the basis for physician payment is the answer. Rather, physicians need to be better informed so they themselves know the best courses of action, systems of monitoring activities and results need to be in place, and patients need to be educated as well. They should not wholly surrender responsibility for their health to another, even a professional, without asking questions and getting educated. The consequences may be severe, and permanent.

Allan Sosin MD

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