Overuse of heart stents and the response of Abbott Labs

“Someone needs to take this writer out and kick his ass.”

The quote leaped out at me from a New York Times article.

Now, maybe I’m a little sensitive about using physical threats to try to silence writers, since I am a writer. Maybe I am especially sensitive about threatening to kick someone’s ass for writing about healthcare. To my eyes, the quote stood out as emblematic of the tumor of waste at the heart of healthcare economics.

The quote was from an email, written (according to the NY Times) by Abbott Laboratories executive David C. Pacitti. The owner of the targeted ass was the author of an article in the Baltimore Sun about a Baltimore cardiologist who had become a champion installer of Abbott Labs’ stents, until someone complained that a second opinion showed that the stent was unnecessary. The hospital where the cardiologist had installed these stents put together an independent panel of experts to review the medical records. Looking just at the period of January 2007 to May 2009, this panel found that the cardiologist, a Dr. Mark Midei, had installed 1878 stents in that period. In their group second opinions, they felt that at least 538 stents may have been medically unnecessary.

The NY Times summarized what followed: “When asked to review the cases himself, Dr. Midei found far less blockage than he had initially, according to the Maryland Board of Physicians. The hospital suspended his privileges and eventually sent letters to all 585 patients. Hundreds of lawsuits against Dr. Midei and St. Joseph followed, including from patients treated well before January 2007.”

Abbott Lab’s response to the controversy was to hire him as a consultant. After all, he had long been a celebrated exemplar of all that they found estimable in a doctor. As an Abbott executive put it in an email, “It’s the right thing to do because he helped us so many times over the years.” In August 2008, when Dr. Midei had put in a record 30 stents in one day, Abbott threw a massive barbecue for him to celebrate. They bought a whole roast pig.

A whole roast pig

Out of all the possible imagery that we might associate with healthcare, what could be better a better symbol to call up than a whole roast pig?

That’s right, let’s celebrate the outliers. They are heroes, avatars of the age, benefactors of the suffering. Let’s not refer to sound medical evidence, the gathered and collegial understanding of medical researchers, the peer-reviewed literature, to decide what to do and to defend what has been done. No, let’s use money, lawyers, and PR firms. And threats to kick the ass of anyone who says otherwise.

At a time when the country is drowning in the costs of the largest national industry of any kind in the history of the world, when there is incontrovertible evidence that at least 30 percent and perhaps much more of that cost is simply wasted and useless, when tens of thousands every year die from lack of access to good sound medicine, and tens of thousands more from complications of unnecessary, imprudent, unhelpful procedures, let’s not bend our corporate efforts to making healthcare actually better and cheaper for everyone. Let’s bend every corporate asset necessary to doing more and more of whatever makes the most money – and fighting or silencing anyone who complains.

From the NY Times article:

A landmark 2007 study published in the New England Journal of Medicine showed that many patients given stents would fare just as well without them. … Prosecutors, malpractice lawyers and state medical boards are only now waking up to the issue. The Texas Medical Board last month accused a widely known cardiologist in Austin of inserting unnecessary stents. In September, federal prosecutors accused a cardiologist in Salisbury, Md., of performing unnecessary stent surgeries, and last year a Louisiana doctor was sentenced to 10 years in prison for inserting unneeded stents. “What was going on in Baltimore is going on right now in every city in America,” said Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic, who said he routinely treats patients who have been given multiple unneeded stents. “We’re spending a fortune as a country on procedures that people don’t need.”

Cases are legion

Cases like this are legion, and they are an ongoing and gut-wrenching amazement to me and to anyone who looks at them squarely. Our capacity for surprise seems endless, but we should not be surprised at all. After all, our system of healthcare is mostly financed as “fee for service,” that is, it does not pay clinicians or pharmaceutical companies or device manufacturers to heal, or to keep us healthy. It pays them to do procedures and tests, and to sell products. And people, by and large, do what you pay them to do. And some people will do as much as they physically can.

Now the Senate Finance Committee has looked into the case, and issued a voluminous report that does not seem to have come down on the side of Abbott Labs and Dr. Midei. Committee chair Max Baucus (D-Montana), commented, “Hospital patients expect their care to be based on medical need, not profits. Even more disconcerting is that this could be a sign of a larger national trend of wasteful medical device use.”

The lawsuits are ongoing. I have not been holding my breath for a mea culpa, an apology, a new and bracing accession of humility by Abbott Laboratories or the good doctor, and it has not happened. According to the NY Times, Abbott Labs has only said that its affiliation with Dr. Midei ended early this year: “‘Dr. Midei has been a highly regarded physician in his field, with whom Abbott had consulted in the past,’ said the spokesman, Jonathan Hamilton. ‘We have no further comment at this time.’ Meanwhile, Dr. Midei has apparently decamped to Prince Salman Heart Center in Saudi Arabia, where perhaps he will be less bothered by lawsuits, Senate committees, or questioning peers. Meanwhile, his lawyer, doing what he is paid to do, continues to insist that Dr. Midei will be completely exonerated.”

If Abbott Labs wants to celebrate heroes of medicine, let them celebrate the volunteer doctors and nurses who have been in Haiti facing riots and deprivation and their own health to fight the ghastly and ongoing cholera epidemic. Or the volunteers who staff free clinics for the massive crowd of the uninsured that descend on them across our own blessed land. Or the doctors and nurses by the thousands and scores of thousands who come to work every day to do their best by the patient, with the best medical knowledge available, even when their decisions do not make them the most money possible.

But Abbott Labs, like many parts of this massive, profligate industry, does not seem to celebrate heroes of medicine. It celebrates heroes of selling, champions of installing their products.

Sometimes, in the right light, on the right morning, healthcare in the U.S. looks like the world’s most amazing scientific and humanitarian enterprise, a vast and noble struggle to end suffering. Far too often it looks like an eating contest, with table after table of people face-deep in pies, sausage, chili, poi, pudding, cheeks smeared and dripping, gorging away. Yeah, let’s celebrate that. Buy another whole roasted pig. Tie balloons to the trees.

Joe Flower is a healthcare speaker, writer, and consultant who blogs at Healthcare Futurist: Joe Flower.

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  • http://www.preemieprimer.com Jennifer

    Great article. Couldn;t agree more. As long as Big Pharma and lawyers hold the reins of health care, I’m not sure how thing can change.

  • stitch

    I am absolutely one who believes that there is a tremendous amount of unnecessary procedurizing of patients going on, and that the current system promotes that problem.

    But while I am sure Mark Midei did his share of overusing stents, there is a tremendous backstory here that has been pushed under the carpet and he has been left hanging out to dry. This backstory, which includes hospitals competing across Baltimore for bigger market share and pressure by hospital administrators to keep up the volumes and procedures, has significant implications for the implication of so-called Accountable Care Organizations. It’s a big part of the story in Baltimore.

    Abbott certainly shares its part of the blame, and if we are going to look at costs of medicine, we need to look at the ridiculous costs of medical devices, including the money made by the detail people who work for these companies. Stent reps get paid per procedure as do the cardiologists, but have you ever heard Medicare say they are going to reduce the payment to these reps? No, just to the professionals. Meanwhile, some of these people make north of $500K or more per year. At least they don’t have a conflict of interest; they are just in it for the money.

    I’ve heard many, many cardiologists tout the benefits of stents, particularly the very expensive drug-eluting stents, but careful review of the evidence fails to demonstrate a significant benefit. But do keep in mind, Dr. Midei effectively stopped practicing in Baltimore in 2008, whereas the NEJM review you cite had come out less that a year earlier. Many of his cases in question pre-dated the recommendations. And he would take patients that no one else would touch, including many of the cardiac surgeons.

    Please, regarding your piece here, go back and read some of the earlier stories in the Sun regarding comments made by Dr. Midei’s former boss who said he was going to “destroy” him because his leaving one medical group for another effectively scuttled a multi-million dollar deal between a cardiology group and a hospital association in Baltimore that now wants to function as an ACO.

    • ninguem

      What stitch said.
      It reminds me of the last time my wife sat for jury duty.
      She wanted to put them all in jail. Defendant, prosecutor, defense attorney, the judge, they were all scum.

      It’s the best argument for consumer-directed healthcare.

      I love how the critics of HSA’s spout off how patients are not capable of making major decisions like interventional heart procedures.

      Now you gain a great insight into the people who ARE making those decisions.

      The high-end proceduralists, often with exclusive pop stands in the hospital. The hospitals themselves. Insurers, the lawyers who make it all possible.

      And Obamacare is about to take the cronyism that already exists, and put it on steroids.

      • Marc Gorayeb, MD

        What ninguem said. This type of problem has a relatively easy free-market fix:
        1) Having insurance companies encourage patients to obtain a second opinion, possibly even paying for one,
        2) and having the patient bear a small portion of the cost for the procedure to give him or her an incentive to ask: “is this really necessary?”
        A bureaucratic/technocratic approach to address this problem (a.k.a. Obamacare) is completely unnecessary.

  • http://myheartsisters.org Carolyn Thomas

    After my own heart attack, I had a stent implanted inside a 99% blocked left anterior descending coronary artery. Any patient who, like me, has made even one trip to the cath lab is duly impressed by the number of nurses and technicians working alongside interventional cardiologists – a reality that implies collusion on the part of Midei’s cath lab colleagues at St. Joseph’s Hospital.

    St. Joseph’s then agreed to pay a $22 million fine to settle charges that it paid illegal kickbacks to Dr. Midei’s medical practice in exchange for patient referrals. More collusion?

    Where does this end? It’s a hugely troubling issue for heart patients who are becoming increasingly alarmed by doctors making decisions about our health care using marketing-based medicine. More on this at: http://ethicalnag.org/2010/09/29/cardiologists-implant-unnecessary-stents/

  • Jose “Joe” RF

    This is an alarming news ; I had a total of 8 implanted stents in my arteries and how’d I know if some or all of the stents implanted were unnecessary? After all these implantations, I never felt better and I’ve been going the other way around. The last time I had the 8th stent implanted was Aug 23 2010 when a doctor ordered me a medication that was discontinued by my own cardiologist and I developed a heart attack. I guess this one was necessary ‘coz of the heart attack, but it was implanted without my consent, verbal or written. Since then, as to my situatuation, I’m feeling worse, more chest pain that don’t go away , felt like it’s not anginal but seemed like it’s caused by too many stents. I heard from my cardiologist that some of the stents overlap each other. Another angiogram was done last week and my cardiologist said that he wants to talk to me in a week for a possible angioplasty procedure. Again, how will I find out if my stents were implanted unnecessarily? What if my cardiologist tells me next week that I’m getting the 9th stent?

  • gzuckier

    In one memorable day he implanted stents in 29 patients, including the mailman and somebody who had accidentally gotten off the elevator on the wrong floor. (kidding0

  • Molly Ciliberti, RN

    This is the definition of “living high on the hog.”

  • Anonymous

    I don’t necessarily blame  the companies or the Dr.’s for this behavior. Having worked with  both for 25 years in the trenches I have seen the best and the worst when it comes to ethical behavior. The failures of  Academia as well as the practices  of the medical and business communities practicing the art of medicine.
    One area that has had little blame placed on them are the CEO’s and top management of hospitals having little knowledge of what really goes on in the trenches of these institutions. On the other hand I have seen nurses stand up time and again for the safety and well being of the patients and then being treated poorly after the attempt to make their concerns known. Patient advocacy should be a position that is highly sought after by the institutions of health. Unfortunately that costs added dollars to the hospitals that are financially suffering in this down economy. .
    If a physician is given the freedom to bring in new technology along with a salesmen to perform a procedure there are  often no governing bodies passing or failing the patients current medical condition. Approving and signing off the procedures. If there were such a process in place these activities would cease to exist.If a medical student watches this behavior day in and day out early in their internships they will develop the same kind of behaviors their chiefs have developed .
    If there were a governing body not associated with the pocket books of either institution or corporations overseeing the implementation of these new technologies there may be less shenanigans going on in this area of patient care.
    As long as you have uninformed CEOs of hospitals and uninterested managers running our hospitals. And educational institutions backed by corporations  and corporations that run on the heels of the share holders we are not safe when we enter through the doors of a hospital. If we as patients are uninformed and ill equipped to maked informed discisions on what kind of procedures we will under go. This type of behavior will continue.  Children have in past decades had their tonsils removed unnecessarily  C-sections performed unnecessarily. The way they are caught is they have committees that count the number of procedures done across the nations hospitals and when they see a spike in a hospitals rate of tonsillectomies then and only then does a red flag go up. That’s not preventative medicine ! That’s oops we got found out about now what do we do to rectify the problem.  The cookie jar is full of hands! When the jar runs empty then and only then does the hammer of justice take notice. Ignorance is bliss until someone dies!

    Im not against technology I love the art of science and medicine working together to create new and innovative ways to prevent disease and to manage, treat and hopefully cure existing diseases. But the way the systems work  and have worked for decades is always with a notion of the bottom line. Whose going to pay! And whose going to get paid for this technological advancement. Lets fill the cookie jar with good incentives for prevention and advancement in technologies that support  the  Physicians , Corporations, Hospitals and academic institutions that will advocate for the practice and the act of prevention . Prevention of harm to the patient first followed by preventative medicine! The buck stops here!