Are All Those Angioplasties Necessary?

A new study helps explain why American medicine is so expensive, and why it's so hard to cut costs. It focuses on angioplasty — one of the most common procedures in modern medicine. The research finds that doctors often do angioplasty before finding out if patients would do just as well with treatment that costs a tenth as much.

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A new study helps explain why American medicine is so expensive, and why it's so hard to cut costs. It focuses on angioplasty, one of the most common procedures in modern medicine. Doctors use a tiny balloon to clear blocked coronary arteries. Then they insert a tube called a stent to maintain the flow. The new research finds that doctors often do angioplasty before checking whether a patient would do just as well with treatment that costs a tenth as much. NPR's Richard Knox reports.

RICHARD KNOX: When somebody is actually having a heart attack, there's no argument that angioplasty and stents can be lifesaving. The problem is how to treat millions of people who suffer mild or moderate chest pain only when they exercise, or who have some test that indicates the arteries in their heart are partially blocked. It seems counterintuitive, but researchers know that clearing the obvious blockages in coronary arteries in these patients does not reduce their risk of heart attack more than medication would. But many patients expect doctors to do more than write a prescription. Dr. Sanjay Kaul of Cedars-Sinai Medical Center in Los Angeles sees patients who are so grateful after the procedure, they hug their doctors.

Dr. SANJAY KAUL (Cardiologist, Cedars-Sinai Medical Center, Los Angeles): I see a lot of patients' family members hug the cardiologist who performs the angioplasty. I don't see them hugging individuals who prescribe optimal medical therapy. Nobody ever gave me a Lipitor hug.

KNOX: In fact, Lipitor or some other cholesterol-lowering drug is what many patients really need, along with aspirin, a blood-pressure drug, maybe a beta blocker or nitroglycerin. San Francisco cardiologist Rita Redberg agrees many patients want the high-tech procedure.

Dr. RITA REDBERG (Professor of Clinical Medicine, UCSF Medical Center): We've had studies that show that most patients who get a stent think they're getting a stent because it is going to save their life or prevent a heart attack. Neither of those are true.

KNOX: Official guidelines say for many patients, medication and lifestyle change are just as likely to prevent a heart attack. Guidelines also say patients with non-emergency chest pain should have a treadmill or exercise stress test before they get an elective angioplasty. Redberg and her colleagues at the University of California looked at how often U.S. doctors skip that treadmill test. Their study is in the current Journal of the American Medical Association.

Dr. REDBERG: What we found when we looked at the Medicare patients was that 44 percent of them had a stress test before elective stenting. That was a lot lower than we were expecting. We didn't expect everyone would have a stress test. We expected 70 to 80 percent would have a stress test before a stenting.

KNOX: That's worth repeating. More than half the 24,000 patients they studied who got angioplasty and stents for non-emergency chest pain did not have a simple exercise test that would have shown who really needs the expensive procedure. Many doctors clearly aren't following official guidelines. Sanjay Kaul, the Los Angeles doctor, says stronger measures are needed. In an editorial that accompanies the study, he and Dr. George Diamond say Medicare should stop paying full price for angioplasties that are done without a clear need.

Dr. KAUL: If a patient has not been tried on optimal medical therapy first before being offered angioplasty, we're saying they ought to scale it down by 20 percent.

KNOX: In other words, instead of paying $15,000 for the procedure, Medicare would pay 12,000. Other experts doubt this approach would work. It might be too much paperwork. Doctors might rebel. But Redberg likes the idea.

Dr. REDBERG: I think it's worth trying. I think we need to do something, because right now we have a health-care system that's about to break.

KNOX: It's just one of the cost-cutting strategies we'll probably hear more about after the election. Richard Knox, NPR News.

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