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Online Extra: A Coronary Conundrum


Americans like to think that they have the best medical-care system in the world. But international comparisons show that survival rates for a whole variety of diseases and treatments -- from breast cancer to kidney transplants -- aren't, on average, any better in the U.S. than in other industrialized nations.

Yet the U.S. spends as much as two and half times more per person than any other country. Studies show that many people aren't receiving treatments they need, while others may be getting too many tests, procedures, and treatments.

BENEFIT VS. LIABILITY. One area that puts these issues in stark focus: cardiac surgery. 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.

Four doctors shared their views with John Carey, a senior correspondent for BusinessWeek. Edited excerpts follow:

Nortin Hadler, M.D., is a professor of medicine at the University of North Carolina at Chapel Hill and author of The Last Well Person. In his book, Hadler argues that many medical interventions are misguided at best and that most people should avoid procedures like heart-bypass surgery, mammographies, and treatments for lower back pain.

Q: Tell me how you came to question so many medical procedures.

Hadler: It started in 1950 when I went to work in a proprietary hospital as a teenager. I had a dream of being a doctor, but I saw a lot of unnecessary surgery and clinical incompetence. My quest became how to make decisions where there's no data set.

Q: You got involved in worker injuries, like back pain. Do you think it's over treated?

Hadler: 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.

Q: So there's something particularly American about wanting to fix a problem with surgery, when other treatments might be better?

Hadler: Yes, it's a window on our society and an image of ourselves as invincible and powerful and able to overcome all odds. I also think the lay press is gullible. It's too quick to talk about the latest widget and gizmo without asking what it is and if it works.

There is a willingness to believe that miracles can be purchased. We have a society that loves its bells and whistles, even when we have the data to say that the bells are off-pitch.

Q: Speaking of data, 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. But surgeons argue that there are big improvements in pain reduction and quality of life. Are these gains real?

Hadler: Every cardiologist and surgeon knows of their remarkable person [who does well after surgery]. But these tend to be highly advantaged, remarkable people going in -- the Henry Kissingers and Bill Clintons. If you look at all comers, the average person doesn't do as well. The majority don't go back to work. The majority don't say they're happy.

Q: So why has the death rate from heart disease been dropping?

Hadler: The reason we're better, why there's less incidence of all causes of mortality, has much more to do with the structure of society. We're less desperately poor than a generation or two generations ago, and the income gap has shrunk.

Employers would do more good by improving job security, job mobility, and job satisfaction than they would in paying for coronary bypass grafts. In our country, that sounds counterintuitive. It sounds like rationing, but it is rational. We need to be more rational. We're spending a fortune [on health care] that doesn't benefit our citizens.

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.

Q: What should we think about the doubts concerning coronary bypass surgery?

Gardner: It's a real conundrum for very thoughtful people. 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.

Q: Even though the data do suggest that the surgery won't bring longer life to most patients?

Gardner: 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. And I have more faith in the operation than someone who thinks it's terrible to put people through these difficult operations.

Q: But are we doing too many of these operations?

Gardner: One thing we know is that coronary bypass surgery is declining about 5% a year and has been over the last three to five years. The main reason is that many patients with coronary artery disease are being successfully treated with stents. Today, I'd say the question is whether we are doing too many stents.

Q: One argument is that some of these people getting angioplasty and stents would do as well with drugs and lifestyle and diet changes.

Gardener: [Some patients who] are really successful at lifestyle change might get away with not requiring surgery. But why knock the whole treatment by saying some patients are getting angioplasties when other treatments might work?

The medical profession is trying to sort this all out. It's why we do these studies. There's plenty of hard work going on to try to determine the patients for whom such treatments are necessary.

In late 2004, the American College of Cardiology/American Heart Assn. Task Force of Practice Guidelines came out with an update on its guidelines for coronary artery bypass graft surgery. Robert A. Guyton, M.D., a professor of surgery and chief of the division of cardiothoracic surgery at Emory University School of Medicine, was co-chair of the writing committee for the task force.

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. If a patient is 62 years old, that's too young to say, "You will never run again." So they might take that 2% risk [of death with the operation] for quality of life. [In these cases], we try to be clear that the reason to operate is not to prevent a heart attack or prolong life.

I certainly have patients who [were very sick and disabled] and had coronary bypass surgery. A month later, they're walking around as healthy as you and me. To say the whole operation ought to be scrapped is nuts.

Q: Could we get better answers to some of these questions by following patients for years after surgery?

Guyton: I would love to persuade the government to do follow-up. But with HIPAA [Health Insurance Portability & Accountability Act] guidelines, I can't call my own patients to see how they're doing. The cost of doing follow-on research is prohibitive.

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.

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.

On the other hand, these procedures are superior to medical therapy in relieving symptoms. This is not a trivial or unimportant matter, since one can help the patient a great deal by making him or her feel better.

My only criticism of many invasive cardiologists is that they express little, if any, understanding of these data. They tell their patients [maybe because they truly believe it] that the planned procedure will prevent or delay death.

Q: Are there other treatments that really would extend life?

Hillis: The way to make a reduction in mortality is through better diet, better lifestyle, better [blood] lipids, better medical therapy. I think people will live longer...by not smoking, by lowering [blood] lipids, by not being overweight -- things that have nothing to do with the [surgical] procedures.

But medical therapy is just not nearly as sexy as doing a procedure. The patient often believes that having a procedure fixes the problem, as if a plumber came in and fixed the plumbing with a new piece of pipe.

Especially in this country, there's the assumption that the more aggressive your medical care is the better it is. But the assumption is not correct. In certain cases, less aggressive is better. EDITED BY Edited by Patricia O'Connell


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