BlogMedicine & Treatments

How Much Do You Know about Your Luxury Cardiac Procedure?

When it comes to healthcare, most consumers worship the newer, the more technologically advanced, and the most expensive. If an x-ray is good, an MRI is better. If taking three Advils relieves your knee pain, arthroscopy may eliminate it completely. What about PCI (percutaneous coronary intervention), a common cardiac procedure for opening coronary artery stenoses? Why not, if someone else is paying? 

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 $450 billion a year on prescription medicines.

When the average person buys a new car, they research options, gather information from different sources, and comparison shop. With healthcare, consumers do not engage in the same sort of cost-benefit analysis they use when shopping for a new automobile. Our healthcare system fails, in part, because it does not 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 the 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 have 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 medications at the ER or transfer to a facility, at the hospital or off-site, where a specialist will open the blocked coronary artery via the PCI procedure, which costs around $20,000, give or take. 

During your PCI, you are likely to receive additional costly biotechnology drugs, like abciximab (ReoPro®), eptifibatide (Integrilin®) or tirofiban (Aggrastat®). These drugs cost up to $450 per vial, with drug selection based on clinicians’ preferences and each patient getting multiple vials. Or perhaps you are treated with medications and told you need to schedule an appointment with an interventional cardiologist to discuss PCI. Finally, let’s imagine you have to decide there and then which procedure you want. 

If You Personally Had To Pay An Extra $20,000 For PCI, Wouldn’t You Want To Know For Sure it Was the Better Treatment?

More than 950,000 PCI procedures are performed each year, which adds up to quite a tab for insurers. And while PCI can be lifesaving, it also can lead to serious complications. Bottom line: It is more expensive and riskier to get a PCI than medical treatment, so we want to get them only when needed.

How does the effectiveness of PCI compare with medical therapy in terms of short- and long-term outcomes? Studies indicate that PCI is more effective than medical treatment for certain patients. The benefits (e.g., reductions in 30-day mortality, reduced likelihood of experiencing a recurrent heart attack) are very dependent on a complex set of patient factors, such as age, gender, cardiac status, and presence or absence of other chronic conditions. 

Whether you choose to focus on the benefits of PCI or the risks depends to a large extent on who is in the driver’s 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 that facility. And if as a consumer you had to pay for the procedure yourself, you might go with the cheaper alternative if research indicates that the procedure is not necessary.

Like many things in medicine, the devil is in the details. While PCI is better for certain patients, others who undergo PCI don’t need it or face risks that outweigh the benefits. A 2011 study published in JAMA examined PCI data from the National Cardiovascular Data Registry. For acute situations, most PCI procedures were deemed appropriate. The problems arose with the ones that were elective.

The authors found that among 30% of PCIs performed in a nonacute (elective) setting for stable coronary artery disease, 50% were classified as “uncertain,” meaning there was insufficient clinical evidence to determine if the procedure was appropriate. More startling was that the remaining 12% of nonacute, elective PCIs were classified as “inappropriate.” The overwhelming majority of the individuals undergoing this procedure had few or no symptoms, were not on optimal medication therapy, and had low-risk findings on noninvasive tests.

RXBALANCE VIEWPOINT

Rationing

Every healthcare 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, the patient’s age and health risk factors, laboratory results, geographic location, 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 costs associated with overutilization.

Overutilization

The popularity of PCI has led to a high degree of “false positives” — in other words, patients having a PCI when they don’t need one. In the COURAGE trial, PCI in patients with stable coronary disease failed to reduce the risk of death, myocardial infarction, or other major cardiovascular events versus optimal medical therapy (OMT) alone, even after 15 years of follow up. Freedom from angina occurred slightly more frequently with PCI early in the trial, but by 5 years, did not differ from the other group, with both arms experiencing marked reductions in angina throughout the trial. Why pay for risk-prone interventions like PCI where there is no benefit? In medicine, appropriate patient selection is critical to contain costs.

Complications

Iodine contrast medium is used in many diagnostic and therapeutic medical imaging tests, including PCI. Patients undergoing PCI are at high risk for a complication called contrast-induced nephropathy (CIN). CIN is the third most common cause of hospital-acquired acute renal injury and represents about 12% of cases. CIN can increase mortality up to 30% following angiographic procedures. In a small percent of cases, CIN may lead to a need for dialysis. Furthermore, while the antiplatelet therapies used in conjunction with PCI to treat STEMI may lower the incidence of cardiac mortality, these improved outcomes come at a cost. Many studies attribute serious bleeding following PCI to antiplatelet inhibitors, particularly dual antiplatelet therapy (DAPT). This 2018 medical review highlights two important points about DAPT following PCI: 1) major bleeding increases mortality 3-fold, and 2) major bleeds are frequently fatal or disabling in those over 75 years of age. Oddly enough, the strongest predictor of being a 1-year survivor in this VA study comparing OMT to PCI was a set of (mostly lifestyle-related) factors: not smoking, regular physical activity, systolic blood pressure <130 mmHg, and a diet that follows the American Heart Association step 2 diet recommendations. 

Costs

In a economic cost analysis of OMT versus PCI, the cost of PCI was up to $6,020 higher than medical therapy. PCI was estimated to cost $217,000 per quality-adjusted life-year gained. Yet, healthcare economists use $50,000 as the benchmark for acceptable cost-effective therapies. 

Consumers seem indifferent to healthcare costs as long as someone else is footing the bill. However, making consumers pick up some of the costs of unnecessary treatment might make sense. Our love of luxury brands is based on erroneous thinking. Until people realize the errors inherent in this type of thinking, healthcare consumers will continue to clamor for the newest medications, medical devices, or surgical interventions, even when little evidence exists to support the more expensive option. We want everything fully loaded. No matter what the cost.