The New Health Dialogue

Credit: fx57

A new study in the Journal the American College of Cardiology finds that doctors at different hospitals vary widely in their assessment of who qualifies as an appropriate candidate for elective coronary angiography (a way to look for clogged coronary arteries).  If Jack Wennberg and his daring band of disruptive Dartmouth Atlas docs have taught us anything, it’s that variation marks the spot for the inconsistent -- and often inappropriate -- use of health care services.

According to researchers at Duke University Medical Center, different hospitals use wildly disparate criteria for determining which patients need non-emergency coronary angiography.  The authors found that hospitals with a lower rate of positive tests -- meaning they test a lot of people who end up not having heart disease -- tend to be more likely to perform angiography on younger, asymptomatic patients. Out of more than half a million medical records examined, the researchers found some hospitals with rates of positive tests as low as 23 percent.

Basically, they’re testing the wrong people. Low-risk patients are both unlikely to have heart disease, and unlikely to be diagnosed any more accurately by angiography than less invasive methods such as a stress test.

And coronary angiography itself comes with risks. The dyes used can cause kidney damage, and the procedure can lead to potentially fatal bleeding, blood clots, heart attacks and stroke. Additionally, the high-dose of x-rays can increase a patient’s chances of cancer down the road (Gonzales, Arch Int Med., 2008). Though the risks of such complications are small, they do happen and can be life-altering. (See this YouTube video)

Simply put, in low-risk patients the downside of coronary angiography outweighs the (non-)benefit of the screening, say the study’s authors:

“We’re not doing as well as we thought. We need to improve,” said Dr. Pamela S. Douglas. “You don’t want to do this in people who don’t need it.” (Health Day)

Maybe the larger mesasge here is that coronary angiography acts as one of the "gateway drugs” to our addiction to costly overtreatment. Not only is the test itself quite expensive, but doctors will often follow-up any sign of blockage, no matter how asymptomatic, with arterial stenting. Those procedures also carry potentially fatal risks, are very expensive, and have not been shown to prevent heart attacks or stroke any better than drugs and healthy lifestyle changes. Stents in these cases are purely for managing symptoms of heart disease such as chest pain. 

We may sound like broken records, but “Bring on the decision aids!” Patients need to know the true risks and benefits of elective procedures before going under the knife or into the angiography lab. Many believe angiography and stents are saving them from a heart attack down the road, but they won't. The American College of Cardiology is updating its guidelines for doctors on the topic of angiography, but if the past in any indication, guidelines often aren't enough.  We need insurance plans -- public and private -- to stop paying doctors for unnecessary procedures. And we need it now. Our health care system’s (and nation’s) fiscal sustainability depends on it.

Hey “Congressional Super Committee,” are you listening?