Inappropriate heart procedures are expensive and risky. And studies show thousands happen every year.

August 8, 2012
Kevin Clark, The Washington Post

In 2006, a trio of medical professors gathered 20 cardiologists and asked them to discuss a hypothetical heart patient with a blocked artery and no symptoms. Removing the blockage would be riskier and costlier than giving the patient a few pills to take. The professors wanted to know: Would the cardiologists do the procedure?

Yes, nearly all of them agreed. Yes, they would.

“We had one physician say something I thought was pretty amazing. ‘We know the evidence shows not to do this, but we’re still going to,’ ” recalled Grace Lin, the lead researcher on the study at the University of California San Francisco Medical School. “There were some very strong financial and emotional biases towards going ahead with the procedure.”

Questionable cardiac procedures are at the center of a Justice Department investigation into HCA Holdings, the nation’s largest for-profit hospital chain. In an unusual move, HCA revealed the probe Monday ahead of publication of a New York Times story revealing that cardiologists in some of its hospitals, mainly in Florida, were unable to justify many procedures performed between 2002 and 2010.

The federal government “requested information on any reviews that were assessing the medical necessity of interventional cardiology services at any of our facilities,” HCA senior vice president Vic Campell said on a conference call with investors.

In the Washington area, HCA owns Reston Hospital Center, a 187-bed, acute-care facility. A spokeswoman there declined to say whether the hospital is among the 95 HCA facilities whose records are expected to be reviewed.

Share prices for the Nashville-based firm jumped more than 5 percent Tuesday, bouncing back from a 4 percent loss recorded after the company posted a letter about the Times story on its Web site.

The probe comes on the heels of a federal crackdown on fraudulent cardiac procedures that appears to have ratcheted up in recent years. A District judge sentenced a Maryland cardiologist to eight years in federal prison last November after finding him guilty of charging health insurers thousands of dollars for unnecessary procedures.

John McLean of Salisbury, Md., was the second doctor to be indicted in such a case. In 2009, a Louisiana cardiologist was sentenced to 10 years in prison on similar charges.

But the big problem with unwarranted cardiac care may not be the high-profile fraud cases. Instead, researchers say thousands of procedures are performed across the nation each year in circumstances that are probably at odds with medical guidelines.

“The media tends to focus on the especially egregious cases,” Lin said. “The bigger problem is all these borderline or uncertain cases where physicians go ahead with the procedure . . . when it may not be indicated.”

Inappropriate cardiac interventions occur so regularly that a term for it has been coined in the medical literature: “Oculostenotic reflex” is defined as the “‘irresistible temptation” to expand narrowed coronary arteries, despite evidence-based guidelines” suggesting it shouldn’t be done.

Much of the attention has focused on a procedure called a percutaneous coronary intervention, or PCI. Approximately 600,000 are performed each year, at a cost of about $1.2 billion.

PCI can reduce death rates among patients with acute heart disease and serious symptoms such as heart attacks. But the operation can cause blood clots and long-term bleeding. It can also be expensive: One study found that a cardiac operation, including the necessary follow-up medications, costs an average of $35,000.

And for those with less-advanced heart disease, a major 2007 study showed that drug treatment works as well as surgical intervention.

“There has never been a study that shows fixing these blockages makes patients live longer or feel better, because they never felt bad to begin with,” said Paul Chan, a cardiologist at St. Luke’s Health System in Kansas City, Mo.

Chan’s own research has found that only half of PCIs performed in the United States are indicated by medical guidelines. An additional 38 percent fall into a gray area, and 12 percent are inappropriate.

“Many cardiologists today work in a procedure-based economy,” Chan said. “We get paid . . . for how much we do. There’s no motivation to self-regulate.”

A separate study at the University of Michigan produced similar results. Among subscribers to Blue Cross Blue Shield of Michigan, the state’s largest insurer, researchers found that the risks outweighed the benefits of 43 percent of invasive cardiac procedures.

And there was more: Areas of the state that had more catheterization labs, where the procedures are performed, had more operations — though their populations did not have higher rates of heart disease.

“When there’s more technology available,” said Nancy Baum of the University of Michigan’s Center for Health Research Transformation, “you do see a higher number of procedures being done.”

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