Cardiac stents are often a low value procedure
January 9, 2024
Heart disease remains the leading killer in the US and the rest of the developed world, and we know much more about preventing cardiac death than we did just a few years ago. Good diet and healthy exercise can reduce weight, blood pressure, and cholesterol. Quitting smoking prevents many heart attacks, and we have good inexpensive generic medicines to treat high blood pressure and elevated cholesterol. When I did my clinical training, I frequently cared for men in their 40s and 50s with life-ending or life-altering heart attacks; this is now a rarity.
We also know much more about how to prevent death from people having heart attacks. Defibrillation saves many lives, which is why we should make AEDs (automated external defibrillators) widely available. Bypass surgery or angioplasty (using a catheter to insert a small spring-like device to keep a heart artery open) performed during an acute heart attack can avert heart damage and prevent death.
But over the last decade we’ve learned that bypass surgery and angioplasty reduce symptoms but don’t prolong life in most groups of patients with “stable” coronary disease. Therefore, these procedures should generally be used only for people during an acute heart attack or those who have symptoms that cannot be controlled with medication. They can also sometimes be appropriate for blockages of certain major coronary blood vessels. Still, it’s hard to get providers who have built all the infrastructure to do a lot of procedures to stop doing them! And most doctors deeply believe that their procedures genuinely help their patients, even if that is not borne out in rigorous studies.
Researchers at the Lown Institute, which is focused on reducing medical waste, reviewed Medicare claims data from 2019-2021 to identify angioplasties performed on people with known coronary artery disease without recent emergency department visits, unstable angina or an acute heart attack. They found that 229,000, about 22% of stents placed, with a cost to Medicare and patients of about $2.4 billion, were likely unnecessary. Rates of apparently inappropriate angioplasties were over 50% at some high-volume hospitals, but under 5% unnecessary at other high-volume hospitals.
Important caveat: the researchers did not publish their results in a peer-reviewed journal, and some cardiologists disagree with the finding. This study did not review medical records, and there could be some patients identified who met the American Heart Association guidelines for stenting.
Implications for employers:
This study uses Medicare claims data, but angioplasties are a common procedure for patients on commercial insurance, too.
Low value care continues to absorb far too many resources
We should expect carriers to evaluate appropriateness of elective procedures such as angioplasties and put pressure on their participating hospitals with exceptionally high rates of questionable procedures.
Decreasing reimbursement for specific low-value procedures can also lower overuse.
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Illustration by Dall-E
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