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New
York Times: "In an Ohio City, Heart Procedure is Off the Charts" |
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| August 22, 2006 -- Too many angioplasties? That's what an article in Friday's New York Times said about a regional hospital in the small city of Elyria, Ohio. The EMH Regional Medical Center is 30 miles from Cleveland, at the junction of I-80 and I-90. And it performs angioplasties four times the national average. Of course, news items such as this one fuel the latent public distrust of medicine, as can be seen in the "Readers Opinion" section that was linked to the article. On the day of publication, no less than 237 readers sent emails, many of them highly critical and accusatory toward the medical profession. The Times disabled the link Friday afternoon. The center of the story was the very high rate of angioplasty procedures performed on Medicaid patients at this hospital, mostly by cardiologists from the North Ohio Heart Center, a single specialty cardiology practice. The article notes that the outcomes for the hospital are very good -- its heart program has been highly rated -- but there are many questions raised by the article, and by the study on which it was based. Dartmouth Medical School has been running a project, the Dartmouth Atlas of Healthcare, since 1996 to study the way in which healthcare is distributed. It has previously pointed out several "high volume" situations, including a cardiac surgeon in Redding, California who was accused of doing unnecessary procedures -- he is no longer with the hospital and Tenet Healthcare settled with the U.S. Government for $54 million without admitting wrongdoing. Another cardiologist from Lafayette, Louisiana (not California, as The Dartmouth article below states) was also recently the subject of a fraud indictment for performing unnecessary procedures. It was the Atlas Project that uncovered the high rates in Ohio, although in no way do any of the articles or reports about the Ohio hospital imply fraud or wrongdoing -- they just state that the angioplasty rate is inexplicably high. Dr. Elliot Fisher, one of the physicians conducting the Dartmouth review, stated that, while angioplasties are proven to reduce chest pain, "there is not sufficient data to say that it is safer or more effective in the long run than treating those blockages with medication" or a healthier lifestyle. Dr. Fisher's statement would be strongly debated by many cardiologists today who would ask how should one treat a patient with a 90% blockage in one of the primary coronary arteries, especially if a nuclear stress test is positive and reveals ischemia, reduced blood flow and oxygen to the heart. Should that patient just be given medications and lifestyle advice? Probably not. And that's a major reason why Dr. Fisher is correct -- there is not what he might refer to as "sufficient data" to show angioplasty, or bypass surgery, is safer or more effective than drugs and diet. And there probably never will be, because most patients and doctors would not participate in such a randomized clinical trial -- they would want their arteries unblocked. As for the North Ohio hospital, they have asked the highly-regarded professional group, The Society for Cardiovascular Angiography and Interventions (SCAI) to review their cases and make an independent determination whether angioplasties done were unnecessary and too often. One explanation noted in the New York Times article is the practice of the cardiologists in the North Ohio group to "stage" their procedures, often spreading out the unblocking of arteries into two sessions. This effectively doubles the angioplasty rate, and the compensation from Medicare. However, the doctors claim that, when it is done, it is for safety reasons. Staging procedures has been a standard of care since angioplasty began -- and while some cardiologists feel it is fine in today's world to do multiple angioplasties in a single session, others take a more conservative approach by doing one and then waiting to make sure everything is stable before doing the next. Another reason for the high rate of angioplasties may be that EMH Regional Medical Center has gained a reputation for doing the procedure, and also because it does a good job marketing itself. Whether these factors are enough to explain the four-fold higher rate may be revealed in the SCAI review. related
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