"Why Are Stents Still Placed If They Don’t Work?"
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% realize that there was no mortality or heart attack benefit.
Perhaps because cardiologists failed
to happen to mention this little fact.
One can imagine that if patients actually understood
all they were getting was symptomatic relief
then 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.
So 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,” well who am I to interfere
with that beneﬁt of this “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% of patients develop bleeding
or blood vessel damage, and another 1% die
or have a heart attack or a stroke.
And then, because you are having something stuck in your chest,
3% 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% 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% can yield up to a 177% increase
in the likelihood of choosing one drug over another.
That may be why Caesarean sections are more likely to be performed
in for-profit hospitals compared to non-profit hospitals.
Operating on commission.
Pay surgeons per procedure
and you can increase surgery rates 78%.
Could that explain why we do 101% 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 docs are running up millions
doing unnecessary stent implants:
docs 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 rep
from the stent company spent $2,000 to buy him
a whole, slow-smoked pig, peach cobbler, and all the fixin’s.
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.”