Tuesday, June 19, 2007

Unnecessary medical procedures

The Street Light points out a
"Pennsylvania government survey of the state’s 60 hospitals that perform heart bypass surgery, the best-paid hospital received nearly $100,000, on average, for the operation while the least-paid got less than $20,000. At both, patients had comparable lengths of stay and death rates"...

With respect to heart surgery, I noticed a roundtable discussion in Businessweek about cardiac surgery that opens the discussion as follows:
Each year, Americans get about 400,000 bypass operations and 1 million angioplasties, in which doctors open up narrowed arteries and typically insert metal tubes to hold the vessels open. That works out to a rate far higher than that of any other country.

Are we performing too many of these heart operations? Some doctors say yes, pointing to data that show only a small minority of patients get a longer life or suffer fewer heart attacks as a result of the operations. Other physicians say that the benefits, mainly in reducing angina and disability, outweigh the risks.

There are many good quotes from the researchers participating. The participants in the discussion included:

-Nortin Hadler, M.D., is a professor of medicine at the University of North Carolina at Chapel Hill

-Timothy J. Gardner, M.D, is co-editor of Operative Cardiac Surgery. Formerly a professor of surgery at the University of Pennsylvania School of Medicine, he is now a cardiothoracic surgeon at the Christiana Care Health System in Delaware.

-Robert A. Guyton, M.D., a professor of surgery and chief of the division of cardiothoracic surgery at Emory University School of Medicine,

-L. David Hillis, M.D., is professor and vice-chairman, department of internal medicine/division of cardiology at the University of Texas Southwestern Medical School

Dr. Hadler says "Americans invented the concept of a back injury in the 1930s. Before that, if your back was hurting, you would not come in to the doctor -- instead you'd consider it like a headache [which would eventually go away or you would live with it]. With workers compensation, it became an injury, and doctors did surgery. Other countries never leapt to that. Similarly, for carpal tunnel syndrome. Only the American wrist gets sliced. Ours is the only country willing to do the surgery and pay for it."

The moderator of the discussion, responding to Dr. Hadler, states that "you show in your book that, except in a small percentage of cases, patients in clinical trials got no benefit in survival from coronary bypass surgery or angioplasty"...that is quite provocative...

Dr. Gardner, referring to coronary bypass surgery, says "The issue when you look at coronary bypass surgery is whether it's justified to put yourself though that kind of procedure to improve quality of life and longevity. It's one of the questions that have been there from the beginning of the bypass era...Certainly it isn't the majority of patients who get a clear survival benefit. Here's an example of the dilemma for a heart surgeon. We see an 85-year-old woman in assisted living. She has chest pain and shortness of breath with minimal exertion and is unable to function comfortably. Is it reasonable to offer her surgery? We say to her, You're at a stage where your heart is deteriorating. You will be increasingly limited, and no medical therapy can restore you to your old level of activity. But we have an operation. It has a 10% risk of death and other risks, but it can get you back on your feet and allow you to live out the next several years with more functional capacity. A lot of people want that"...

Q: Does coronary bypass surgery extend life?
Guyton: The average prolongation comes to six to seven months. In patients where the degree of impairment of [blood flow] to the heart is serious, we can prove statistically that coronary bypass will prolong life...

Q: But the clinical trials showed only a small percentage of patients survived longer than those who didn't get the surgery.
Guyton: The problem with many clinical trials is...you're not going to get a statistically significant difference unless you're looking at 100,000 patients. Some would leap to the conclusion [that there's no survival benefit in most patients] when the real answer is that the trials are just underpowered.

Beyond that, even if there isn't an expectation of prolonging life, we often operate for relief of symptoms.

Q: The clinical trial data suggest that coronary bypass surgery and angioplasty don't enable most people to live longer. Are those data right?
Hillis: The overwhelming number of heart procedures that are done these days exert no influence whatsoever on mortality. The patient's survival would be similar with only medical therapy.

The conclusions that I draw from the discussion are that in many cases, a person won't seek out a medical professional unless someone else is perceived to be paying the bill; that most heart procedures do not prolong life, and that operations are being performed on individuals whose life expectancy is effectively zero. Cost-benefit analysis of medical care is long overdue in the US system...

1 comment:

Anonymous said...

I found this story refreshing: It's one man's perspective on the health care system following coronary bypass surgery....and it's a far cry from a horror story:

Canadian Health Care: Even The Food Was Good