When it comes to health care, most consumers worship the newer, the more technologically advanced, and the most expensive. If an X-ray is good, an MRI is better. If three Advil relieves your knee pain, arthroscopy may eliminate it completely. As long as someone else is paying, why restrict your choices? In other words, we don’t want rationing, we want everything fully loaded.
We are like folks set free at the auto mall with someone else’s credit card. We may be content with a Honda Civic, but wind up demanding the most expensive car on the lot because someone else is picking up the tab. No wonder we spend $2 trillion a year on healthcare.
If the average person is buying a new car, they research options, gather information from different sources, and comparison shop. With health care, consumers do not engage in the regular sort of cost-benefit analysis they use when shopping for a new automobile. Our health care system fails, in part, because it fails to engage the consumer in purchasing decisions. Instead, these decisions are left in the hands of doctors, hospitals, insurance companies, pharmaceutical companies and device manufacturers, all of whom have vested interests in treatment choices that are made.
Is it any wonder that managed care has stepped in to try to ration what we get?
Now let’s imagine that you are having symptoms of a heart attack and are taken to the ER. The ER doctor diagnoses you with a STEMI (a ST-segment elevation myocardial infarction). For a STEMI, there are two basic treatment options - either a combination of fibrinolytic and antiplatelet agents administered at the ER or rapid transfer to a facility, at the hospital or off-site, where a specialist will open the blocked coronary artery by performing a procedure called primary percutaneous coronary intervention (PCI), which costs around $25,000 a pop give or take. Furthermore, whether in the ER or at the PCI, you may receive additional costly biotechnology drugs, like abciximab (ReoPro®),eptifibatide (Integrilin®) or tirofiban (Aggrastat®). These drugs cost up to $500.00 per vial, with drug selection based on clinicians' preference and each patient getting multiple vials. Finally, let's imagine that you had to decide there and then, which procedure you want.
If you personally had to pay an extra $25,000 for PCI, wouldn't you want to know for sure that it was better?
More than 800,000 PCI procedures are performed each year, which adds up to quite a tab for insurers, whether private or public. And while PCI can be life-saving, it also can lead to serious complications. Still, the bottomline remains cost – it is more expensive to get a PCI than medical treatment.
How does the effectiveness of PCI vs medical therapy, compare in demonstrating short and long term outcomes? Most studies indicate that PCI is more effective than medical treatment. However, those benefits (e.g. reductions in 30-day mortality, likelihood of experiencing a recurrent heart attack) are very dependent on a complex set of factors, such as how soon after your symptoms started you reached the ER, your age and gender and the time delay in getting you to a PCI facility. Whether you choose to focus on the benefit of PCI, or the risks, depends to a large extent on who is in the driver seat. If you are an interventional cardiologist making $500,000 a year doing PCI, you are going to favor PCI. If you are a hospital administrator who spent millions building a state- of -the art cath lab, you are going to want as many patients as possible to use the facility. On the other hand, if you are an ER director of a hospital, your point of view may be a bit different.
Like many things in medicine, the devil is in the details. For example, while PCI may be better for most patients, there are many patients who don’t need it or in whom the risks outweigh the benefits. Ironically, one of the cheapest life-saving interventions, taking an aspirin the moment you experience initial cardiac symptoms and before you arrive at the hospital, is frequently overlooked.
Every health care treatment decision is a form of rationing. The ER doctor “rations” out STEMI treatment based on a wide array of variables, including his/her clinical judgment, the hospital guidelines, your age and health risk factors, laboratory results, geographic location, and many individual thoughts and attitudes, and institutional norms, that color the clinical decision making process. So, here begins the first part of the conundrum. Medical decisions are based on hospital protocols, in this case guided by recommendations from the American College of Cardiology and American Heart Association. However, as discussed elsewhere in these blog posts, guideline committees are frequently funded by device and drug manufacturers and made up of physicians with financial ties to industry and/or personal biases based on their medical specialty. As a result, there are likely to be more positive articles published about PCI than negative articles that highlight the dangers or the costs associated with overutilization.
Some studies address the fact that the popularity of PCI has caused a high degree of “false positives”, meaning that ER doctors send patients to the cath lab who don’t really need it. For example in this study published in JAMA, 14% of of 1,335 patients with suspected STEMI who underwent angiography had no culprit coronary artery and 9.5% did not have significant coronary artery disease. These false positives result in insurers paying for risk-prone interventions where there is no benefit to the patient (for example, patients with stable coronary artery disease). In medicine, appropriate patient selection is critical to contain costs.
Patients who undergo primary PCI are at high risk for a complication called contrast-induced nephropathy (CIN), a disorder that develops as a result of exposure to contrast agents, which are used during PCI. CIN, which has a reported incidence rate of 5% to 50%, can increase mortality up to 30% following angiographic procedures. In a small percent of cases, CIN will result in dialysis. Unfortunately, the risk of CIN in patients with renal dysfunction has remained unchanged despite advances in catheter-based technology and adjunctive antithrombotic therapy. Furthermore, while the antiplatelet drugs used in conjunction with PCI to treat STEMI may lower the incidence of cardiac mortality, these improved outcomes come at a cost. Many articles highlight the fact that these powerful drugs cause increased bleeding complications, including higher rates of intercranial hemorrhage in patients over the age of 75.
Physicians, like everybody, have differing points of view. And like all of us, their personal biases affect their attitudes, perceptions and behaviors.
Such bias is evidenced in reading comments about a June 2009 article published in Circulation. This meta-analysis, which included both randomized clinical trials (RCTs) and observational studies, compared mortality rates of PCI vs medical treatment. The authors concluded that primary PCI is associated with long-term reductions in mortality and reinfarction in RCTs, but that there is no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies. Physician raters participating in the McMaster Online Rating of Evidence (MORE) system commented about the article online.
Reading the raters interpretation of this article is a powerful example of how point of view affects perception. For example, a cardiovascular surgeon commenting on the Circulation article concludes that the analysis confirms the superiority of PCI over fibrinolysis for STEMI.
“This is a very nice collation of RCTs and observational studies showing practitioners that even in their practices, the benefits of acute intervention far exceed use of fibrinolytics for STEMI patients. This is a more expensive approach, but the data certainly supports transfer to a PCI center whenever possible and should be information about which all practitioners are aware.”
In contrast, an internist commenting on the same article online finds the analysis less convincing.
"...shows a clear early mortality benefit of primary angioplasty over fibrinolysis in STEMI. However, less convincing evidence exists that primary angioplasty in the real world is associated with a better long-term outcome."
To view McMaster comments, click here. Registration may be required.