"Heart Stents and Upcoding: How Cardiologists Game the System"
The history of medicine abounds with false dogmas
that were simply assumed and later,
sometimes much too long later, overcome.
Like the Women’s Health Initiative study that showed
that giving women Premarin, a hormone replacement therapy,
increased the risk of the #1 killer of women, heart disease,
as well as breast cancer risk to boot.
Millions of women stopped taking it,
and the breast cancer rates came down.
Another such reversal of an established medical practice
is angioplasty and stents for stable coronary artery disease,
for which billions are spent on procedures
shown unequivocally to offer no benefits.
So, why are cardiologists still doing them?
Researchers did some focus groups and concluded
that although cardiologists may believe that they are benefiting
their patients, this belief appears to be based on emotional
and psychological factors rather than on evidence.
“The sense of irrationality surrounding this practice
is so strong that the phenomenon has been coined
the oculostenotic reflex”— like you see a narrowing,
and they stent it like they can’t even help it.
Since the procedure carries some risks, including death,
there’s an argument that stents should only be used
for people who are actively having heart attacks,
in an emergency or unstable situation.
Thankfully, they are now, published appropriate-use criteria
in place to help guide cardiologists.
And the good news is that now 82% of stents are reported
to be performed in these emergency or unstable situations.
So, we can disregard that study that showed there was
no benefit in stable patients, since now it’s almost always done
just in unstable patients like it should be.
Or, at least it's almost always reported that way.
There are two ways a physician could comply with the rules.
One is to do fewer unnecessary procedures,
which is the whole point, but hey— where’s the money in that?
The other way to comply is to make
unnecessary procedures seem necessary.
Wait, are they implying that a doctor would try to game the system
by telling a patient that they had much more serious,
unstable disease than they actually had,
so they could carry out the procedure anyway?
This is referred as “upcoding.”
Another word for it would be fraud.
Researchers found that some of that decline in inappropriate use
may indeed be doctors falsely and intentionally misclassifying
patients with stable angina as unstable angina.
Because as soon as those appropriate use criteria
went into effect, all of a sudden there was suspiciously
a 4- to 10-fold increase in the rates of stents for
acute coronary syndromes like heart attacks.
In New York, the proportion of stents labeled as acute,
but performed as outpatient procedures, increased 14-fold.
There’s no biologically plausible reason why that would happen;
so, they were unnecessary procedures,
unnecessary cost, and unnecessary patient harm.
Harm not only from the risk of getting an unnecessary stent,
but also by lying to the patient by exaggerating
how bad their heart disease is.
At best, this practice damages the credibility of the profession,
violates patient autonomy, and puts the patient at risk
for complications and, at worse,
may cross the threshold into criminal activity.
What’s the solution?
There could be like an independent review panel
to protect patients, or we could simply remove
the financial incentive to perform more procedures.
How many other established standards of medical care are wrong?
Who knows. Bloodletting was standard of care
for thousands of years.
Rigorous questioning of long- established practices is difficult.
There are thousands of clinical trials,
but most deal with trivialities or efforts
to buttress the sales of specific products.
Given this conundrum, it is possible that some
entire medical subspecialties are based on little evidence.
Ironically, in the case of heart stents,
in the landmark COURAGE trial that showed stents
were useless for extending life, what did seem to determine
longevity was how many risk factors they were able to control.
Those that nailed all six by lowering their blood pressure,
cholesterol, weight, smoking, and improving their diets
and activity had five times the survival over the
subsequent 14 years than those who didn’t.
I mean, should we be surprised that angioplasty
and stents fail to improve prognosis?
After all, it does nothing to modify
the underlying disease process itself.
In other words, it doesn’t treat the cause.
Even if stents helped with symptoms beyond the placebo effect,
it would still just be treating the symptoms and not the disease.
And so, no wonder the disease continues to progress
until the patient is disabled into death.
Thus, Dr. Esselstyn wrote, the leading killer of men and women
in Western civilization is being left untreated.
What is instead being practiced is “palliative cardiology”:
non-treatment of heart disease leading to disease extension
and frequently an eventually fatal outcome.
Deaths by the planeload every week, just regarded as unfortunate
rather than a national, preventable tragedy.
It is as though in ignoring this dairy, oil,
and animal product-based illness, we are wedded
to providing futile attempts at temporary
symptomatic relief rather than the cure.
Thankfully, we are on the cusp of a seismic revolution in health:
not another pill, procedure, or operation,
but instead treating the underlying cause of heart disease
with whole food plant-based nutrition,
perhaps the mightiest tool medicine has ever had in its toolbox.
To get there, we need to fight
a key nutrition deficiency in education.
90% of cardiologists, 90% reported
receiving no or minimal nutrition education during
their cardiology training, leaving fewer than
1 in 10 confident in their nutrition knowledge.
So, maybe it’s a good thing that most spend three minutes or less
discussing nutrition with their patients.
Only one in five themselves even ate five servings
of fruits and veggies a day.
Thankfully, this life-saving information is slowly
but surely getting out there.
Medical education has focused on being the ambulance
at the bottom of the cliff rather than a fence at the top.
Money talks, and there’s very little money in promoting
eating broccoli and going for a walk.
I was so eager to see the citation they used for that,
and was so honored when I did.