Do physicians have the courage to implement comparative effectiveness?

Comparative effectiveness outcome studies have shown that while percutaneous coronary intervention (PCI) may be more effective than optimal medical therapy (OMT) for treatment of acute coronary syndrome, it is not more effective for treatment of stable ischemic heart disease.

Results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, published in 2007 and 2008 in the NEJM, demonstrated that PCI did not improve survival or prevent myocardial infarctions more than OMT, and had a limited role in symptom relief.

Dr. Raymond Gibbons, professor of medicine at Mayo, in December 2007 in a Webcast Video Interview in the Medscape Journal, stated that physicians should replace PCI with OMT in these patients.

Dr. David Maron, professor of medicine and emergency medicine at Vanderbilt, in December 2008 in a Webcast Video Editorial in the Medscape Journal, urged that physicians convert their practice from PCI to OMT in these patients.

Both Gibbons and Maron cautioned that the strong financial incentives to continue usual use of PCI would be a substantial barrier.

What actually happened? Borden, et al., utilizing a massive database, reported in JAMA in May 2011, that physician practices re: OMT and PCI in these patients changed almost NOT AT ALL after these reports and numerous commentaries.

Why did American primary care physicians and cardiologists continue the old, high-tech, institutional, expensive, invasive, not-better PCI treatment for stable coronary artery disease (CAD) once diagnosed, and not convert to the better, safer, faster, cheaper OMT?

There was massive dissemination of the results of the COURAGE trial and major changes in guidelines. The OMT combination of aspirin, beta-blockers, and statins can be prescribed by any licensed physician in America and found at any American pharmacy, 24/7.

Why did the use of OMT rather than PCI not quickly become the dominant mode of therapy for stable CAD?

American physicians are not stupid. They know where the money is.

Established referral patterns, collegial medical relationships, flashy glitz for the patient to experience and describe versus ordinary pills, no pesky lawyers, country club shoulder rubbing, the payroll, and marketing of the local hospital. All these factors, and more.

Wanted in 2011: American physicians with the COURAGE to implement the results of comparative effectiveness research and evidence-based medicine to benefit their patients, their professionalism, and their country, even if it may hurt the pocketbooks of themselves and their institutions.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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  • http://deleted pcp

    PCPs do PCI? Sorry, this mess is the cardiologists’ baby.

    • Family Physician

      Why did American primary care physicians and cardiologists continue the old, high-tech, institutional, expensive, invasive, not-better PCI treatment for stable coronary artery disease (CAD) once diagnosed, and not convert to the better, safer, faster, cheaper OMT?

      Yeah, how totally insulting & ignorant that the author would blame primary care physicians as part of the cause. It’s the cardiologist that gets to decide whether PCI or OMT is utilized. What’s up with that?

    • http://www.endoflifeblog.com Jim deMaine, MD

      Every dollar being spent is “benefiting” someone – the patient, the drug company, the equipment manufacturer, the doctor, the hospital, the advertising industry, TV networks, etc. About one-third of those dollars are wasted on excess, duplication, overhead, administration, billing, accounting, oversight, etc. Trimming waste is not “rationing”, it’s simply good medical practice and good business practice. In this country, we want unlimited choice and autonomy no matter what the consequences even if the country is going broke. Doctors are the “purchasing agents” for their patients and have the power to modify health care. But until we can align incentives for medical providers with best practices, the waste will continue.

  • buzzkillersmith

    No, we don’t have the courage. Ask something hard, dude.

  • Freeflow

    Comparative effectiveness is a covert way for government to implement rationing. We all know that some treatments work better for some patients than others and that limiting choices will ultimately harm our patients.

  • http://www.cardiac-risk-assessment.com/ Joan Tryzelaar, M.D.

    Like you I have wondered at the lack of response to COURAGE in 2007. The latest article in JAMA about PCI usage confirms that up to 60% of elective PCI procedures may be unnecessary, 70% of whom have private insurance. Financial incentive do not play a role? I think not!
    http://www.cardiac-risk-assessment.com/ca-blog/are-insured-patients-an-easy-target-for-unnecessary-procedures/

    • http://ethicalnag.org/2011/06/04/unnecessary-stents/ Carolyn Thomas

      Well, except for the unfortunately used interchangeable words ‘physician’ and ‘cardiologist’, the question here remains important. The answer, as the Los Angeles Times put it recently in a piece called ‘Cardiologists Rush to Angioplasty Despite Evidence for Value of Drugs’:

      “You can lead a cardiologist to water, but you cannot make him drink!”

      As a heart attack survivor, I’m so glad to see this topic raised (and raised! and raised!) here on KevinMD. More on this, including links to Dr. Lundberg’s excellent prior comparisons between unnecessary PCIs and the unnecessary but still widespread use of antibiotics for strep throat (another case where the evidence clearly does not support the practice) at – http://ethicalnag.org/2011/06/04/unnecessary-stents/ The difference between the two examples: prescribing antibiotics for strep is not seen by the public as a blatant cash grab, nor would stopping the practice be trashed as merely “…a covert way for government to implement rationing.”

  • http://drpauldorio.com Paul Dorio

    Ok, let’s be reasonable here. Fiinancial incentive exists in health care. Of course.

    But do we really think it would be reasonable for the entire health care system to alter their practices based on ONE research study? If that were the case we’d be flip-flopping more than John Kerry. I can’t imagine that the public would like to visit their doctors one day, get told to do something, only to find the opposite recommendation being thrown at them during the next visit.

    It should surprise me, but it does not, that you ignore the fact that research studies have routinely refuted predecessor reports since research began. I for one, pay close attention to research evidence and, when the preponderance of evidence suggests a change, I advocate for it with complete courage and conviction.

    There is no courage in changing with each recently-published report. There is only ignorance of the possibility that said report might not be supported by future studies (i.e. “reproducible results”).

    • http://www.cardiac-risk-assessment.com/ Joan Tryzelaar, M.D.

      While COURAGE is only one study, there has been plenty of evidence that most stable CAD patients are managed equally well with OMT. Read the ACC/AHA recommendations for PCI in patients with chronic stable angina!
      To just accept that “… Fiinancial incentive exists in health care. Of course…” is preposterous. What should distinguish physicians from other professions is their commitment to provide the best care possible w/o considering their pocketbook first!
      http://www.cardiac-risk-assessment.com/cardiac-healthcare-providers/therapy/chronic-stable-a-refractory-angina

      • http://drpauldorio.com Paul Dorio

        I certainly didn’t mean to imply that I “accept that” financial incentive exists and leave it at that. Please understand (what I should have amplified) that I think that there is FAR too much in the way of direct financial incentive in our health care system, which is precisely why I am all for eliminating self-referral.

        And as far as the cardiac literature: If the literature supports medical management instead of intervention, then absolutely the former should prevail in practice. Again, it has little to do with “courage,” in my opinion. It has more to do with doctors understanding the literature and having confidence in the reported results. It also has to do with that old financial incentive too, as in – if there is no financial incentive, then patients can rest assured that their doctor is trying to take care of them and improve their health to the best of their abilities.

        That’s my goal each day anyway – appropriate care with the knowledge at hand.

  • Marc Gorayeb, MD

    Academic sophistry. “PCI did not improve survival or prevent myocardial infarctions more than OMT.” Let’s assume that this is a valid conclusion from the study. These are obvioiusly important variables, but certainly not the only ones that might matter to patients. What about difference in incidence of angina? Capacity for strenuous activity? Speed of resolution of chronic ischemic symptoms? Effect on every-day life activities? It is certainly appropriate to consider other clinical variables before ditching PCI in non-urgent patients.