Can American doctors say “No” to an aggressive and high-tech treatment they’re used to providing even when it turns out a less heroic and cheaper one works just as well?
It’s an important question.
Why do cardiologists often pass up safe, low-tech treatments for chest pain?
The affordability of American medical care in the future will depend, in part, on the ability of physicians to simplify and economize, which are two things they’ve never been good at. With national health expenditures amounting to $2.6 trillion a year — 45 percent of it paid by government — prosperity and political stability may also be at stake.
Different versions of this question are behind the debate about whether women should get mammograms annually or every other year; whether cancer patients should be denied the expensive and usually ineffectual drug Avastin; and whether curative surgery should be attempted in most cases of prostate cancer.
“Medicine is often not agile in incorporating new knowledge into practice, and as a result many patients are treated in anachronistic ways,” said Harlan M. Krumholz, a cardiologist and outcomes researcher at Yale School of Medicine. “The health-care system of the future must be able to adapt more quickly, and also have a way to evaluate how the changes it makes actually affect people.”
The question is being posed to cardiology — the medical specialty that treats heart disease, the nation’s leading cause of death — in a most interesting way.
At issue is how to treat about 500,000 Americans who each year develop “stable angina,” which is chest pain that occurs in predictable fashion and is caused by blockages in the heart’s coronary arteries. There are two common treatment approaches. One is angioplasty with stenting, in which a catheter is threaded into the narrowed artery, which is then propped open with a tube made of metal mesh. The other is medication and changes to lifestyle.
In many people’s minds, this issue is settled. The answer came in a $33.5 million clinical trial called COURAGE, whose results were announced five years ago.
In that experiment, 2,300 people with stable angina were given “optimal medical therapy” consisting of aspirin, beta blockers and statin drugs, along with help losing weight, quitting smoking and keeping blood pressure under control. Half were also randomly assigned to get angioplasty and stenting. (The varieties of the procedure are known collectively as “percutaneous coronary intervention,” or PCI.)
After nearly five years, the rate of heart attack and death in the two groups was essentially the same: 18.5 percent in those getting only medical therapy and 19 percent in those who also got stents. The only difference between the groups was that people getting stents were slightly more likely to be angina-free (66 percent vs. 58 percent after one year).
The financial stakes
Stable angina isn’t the main reason Americans get angioplasty and stents. It accounts for about 30 percent of patients receiving the procedure. Most who get it have rapidly worsening chest pain (“unstable angina”) or are having a heart attack.
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