A JAMA study is getting attention today, which reports that some cardiologists are going straight to angioplasty without a non-invasive stress test:
They found that fewer than half of the patients took a stress test on a treadmill within 90 days of their elective surgery. This rate varied significantly depending on the hospital patients were referred to, with rates ranging from a low of 22.1 percent to a high of 70.6 percent.
There are indeed good reasons not to undergo a stress test, including whether the patient is mobile or well enough to walk briskly on a treadmill.
But the take-home point is how the payment emphasis on procedures profoundly affects medical decision making. Medicare needs to take responsibility for setting the nonsensical ground rules.
Recent evidence suggests that angioplasty for stable coronary disease doesn’t offer clear long-term advantages. Despite this, the procedure-skewed payment system gives doctors the financial incentive to skip the stress test and go straight to cardiac catheterization, increasing the likelihood of angioplasties.
Another noted point is wide practice variation, with 22 to 70 percent of hospitals electing for patients to undergo a stress test prior to intervention. With the data continuing to evolve, there are no clear, consensus guidelines. This is an ideal situation for an authoritative comparative effectiveness institute to intervene.
Finally, patients have to be educated that “more medicine,” in the form of balloon angioplasties, does not necessarily translate into better care. If someone is diagnosed with a coronary artery blockage, it may seem intuitive that “clearing it out” or stenting the lesion would be the best course of action.
Consequently, I see trouble with patients accepting a more conservative medical management route, despite the supporting evidence. Most would want it “taken care of,” which often means intervention.
Although doctors are responsible for favoring procedures, patients also need to be educated that treatments like watchful waiting, conservative therapy, or medical management can be just as, if not more, beneficial.
