Study: More heart surgery centers mean more unnecessary heart surgery
By Sarah Kliff,
Catheterization labs are decidedly dull places. They are the hospital David Goldman AP exam rooms where doctors put catheters into arteries to test for heart disease. If they find it, surgery — also performed in the catheterization lab—often follows.
This isn’t surgery that lends itself to “Grey’s Anatomy” drama. It’s routine stuff, among the most common medical procedures in the United States.
But here’s where catheterization labs get exciting (yes, exciting!): Cath labs tell us tons about why health care costs skyrocketed in the past few decades. And, in a new paper, the labs make a useful case study for understanding how medical supply can create demand without making us any healthier.
The supply of catheterization labs has boomed as of late, becoming a staple for hospitals across the country. There’s even a trade publication dedicated the this specific exam room, Cath Lab Digest , where one can read up on the latest and greatest in cath lab news.
As catheterization labs have become more common, so have the procedures performed there: The number of angioplasties, for example, increased by 326 percent between 1987 and 2004. That’s a bit odd when you consider rates of heart disease are declining with fewer Americans smoking.
What’s more, numerous studies have shown that treating heart disease with medication can be produce better outcomes at a lower price. A 2007 trial found that, in many cases, medical treatment for certain heart disease patients could prove equally effective to surgery, without the risks of going under the knife. It also costs about $10,000 less than the $35,000 surgery.
But that evidence isn’t changing medical practice. A new study of Michigan, about half (43 percent) of the one type of heart surgery performed were among patients for whom the risks of the procedure outweigh the possible medical benefit.
The research comes from the University of Michigan’s Center for Health Research and Transformation. And while it shows the overall number of heart surgeries going down, these un-indicated procedures are becoming a larger share of the surgeries performed.
“In these cases, there ought to be a choice between medical intervention and [surgery],” says lead study author Marianne Udow-Phillips. “But what we think happens is, when the patient is in the cath lab, they’re on the table, anesthetized, and a surgeon might come out to the spouse and say ‘we can take care of this right now,’ even though that might be the wrong treatment based on the evidence.”
This actually happens so much that there’s even a term for it in the medical literature. “Oculostenotic reflex” was defined over a decade ago as the “‘irresistible temptation” on the part of interventional cardiologists to expand narrowed coronary arteries, despite evidence-based guidelines” suggesting that they shouldn’t.
But, as you might expect, this happens more often in places with a lot of catheterization labs than in places with fewer facilities.
Regions with “cardiac intervention rates furthest below the Michigan average also have below-average or average numbers of cardiac catheterization laboratories,” the report concludes. Among the five regions with the highest intervention rates, “three also have above-average rates of cardiac catheterization laboratories.”
This is a pretty common story in American medicine right now: A 2008 Congressional Budget Office report estimated that new technologies account for about half of the growth in health care costs. And some do indeed make us healthier: The rise of minimally invasive surgical equipment, for example, has cut the health risks and recovery time for undergoing surgery.
But some may just make healthcare more expensive — without delivering better health outcomes. And that’s not just true for catheterization labs: Another study this year looked at how this happens with prostate cancer treatments. Doctors with access to pricier proton therapies tend to use it more, even though its outcomes have proven no better than less-expensive radiation treatments.
There is some good news in the Michigan report: Overall, the number of cardiac surgeries have declined at the same time that mortality rates. That suggests that less heart surgery has correlated with better outcomes, lending some credence to the medical guidelines suggesting so for decades.
“The amazing and fantastic news is we’ve reduced the amount of surgery and mortality,” says Udow-Phillips. “The fact that variation in treatment has increased, and almost all of it is due to elective procedures, that’s more troubling.”