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JULY 7, 2005
By John Carey, with Amy Barrett Is Heart Surgery Worth It? Physicians are looking at troubling studies and questioning whether bypasses and angioplasties necessarily prolong patients' lives You start breathing hard after climbing stairs, and your chest hurts. You go to your doctor. Scans reveal that arteries feeding your heart are severely narrowed. Your doctor sends you to the hospital for coronary bypass surgery or angioplasty to restore the blood flow to your heart. Despite the trauma of surgery, you're glad the blockage was caught in time, saving you from a potentially fatal heart attack. There's just one problem with this happy tale of modern medicine: More and more doctors are questioning whether such heart procedures are actually extending patients' lives. One of them, Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill and author of The Last Well Person, is urging the U.S. medical establishment to rethink its most basic precepts of cardiovascular care. Bypass surgery in particular, he says, "should have been relegated to the archives 15 years ago." UNLIKE PLUMBING. That is an extreme view that is disputed by cardiac surgeons. "The reason thousands and thousands of bypass surgeries have been done is that [the procedure] is successful," says Dr. Timothy J. Gardner, co-editor of Operative Cardiac Surgery and a cardiothoracic surgeon at Christiana Care Health System in Wilmington, Del. Nevertheless, the data from clinical trials are clear: Except in a minority of patients with severe disease, bypass operations don't prolong life or prevent future heart attacks. Nor does angioplasty, in which narrowed vessels are expanded and then, typically, propped open with metal tubes called stents. "People often believe that having these procedures fixes the problem, as if a plumber came in and fixed the plumbing with a new piece of pipe," explains Dr. L. David Hillis, professor of cardiology at the University of Texas Southwestern Medical School. "But it fundamentally doesn't fix the problem." IMAGE OF INVINCIBILITY. With doctors doing about 400,000 bypass surgeries and 1 million angioplasties a year -- part of a heart-surgery industry worth an estimated $100 billion a year -- the question of whether these operations are overused has enormous medical and economic implications. "It is one of the major issues in cardiology right now," says Dr. David Waters, chief of cardiology at the University of California at San Francisco. It is also part of a far broader problem -- what some health-care experts call the medicalization of life. "None of us will live long without headache, backache, heartache, heartburn, diarrhea, constipation, sadness, malaise, or other symptoms of some kind," argues Hadler. Yet under relentless bombardment by messages from the pharmaceutical and health-care industries, Americans increasingly believe that these symptoms -- and many others -- are conditions that can and should be cured. "We have an image of ourselves as invincible and powerful and able to overcome all odds," Hadler says. "And the lay press is too quick to talk about the latest widget and gizmo without asking what it is and does it work." HIGHER COST, BIGGER RISK. Indeed, there is compelling evidence that more health care and more aggressive treatment across the complete spectrum of illnesses is not necessarily better. When Dr. Elliott S. Fisher, professor of medicine at Dartmouth Medical School, first looked at regional differences in health-care spending in the U.S., he assumed that people in areas with lower expenditures would have worse health than people in regions where spending was 1 1/2 to 2 times as high because they were failing to receive needed care. It turned out that the opposite was true. "Patients have a substantial increased risk of death if cared for in the high-cost systems," he says. Why? For one thing, additional doctor visits and testing often lead to unnecessary procedures and hospitalizations, which carry risks. "My data suggest that we are wasting 30% of health-care spending on stuff with no benefit and perhaps causing harm," says Fisher. International comparisons support his reasoning. The U.S. spends 2 1/2 times as much as any other country per person on health care, but that doesn't translate into better outcomes, according to studies that compare such indicators as fatality rates after a heart attack and length of survival after a kidney transplant. That suggests that "the investment in health care in the U.S. is just not paying off," says Gerard Anderson, director of the Center for Hospital Finance & Management at Johns Hopkins Bloomberg School of Public Health and co-author of a 2004 study that looked at 21 different health-quality indicators in five nations. LUCRATIVE CARDIAC UNITS. Similar comparisons can help pinpoint dubious treatments. The classic case: tonsillectomy. In the early 1970s, Dr. John E. Wennberg, now director of the Center for Evaluative Clinical Sciences at Dartmouth Medical School, showed that some hospitals removed tonsils 10 times as often as others. But the children in areas with low rates weren't worse off, so the operation fell out of favor. More recently, Dr. James N. Weinstein, chair of orthopedic surgery at Dartmouth-Hitchcock Medical Center, found that people with back pain are up to 20 times as likely to have back surgery in some parts of the country as in others. Yet it's not clear that they do better as a result. Weinstein is comparing the outcomes in patients who get different treatments, from rest and physical therapy to spinal fusion. Meanwhile, he says, "billions of dollars are being spent without good information." This is of obvious concern to those who pay for health care, from the government to private insurers, which are struggling to better balance costs and benefits. And nowhere are the financial and health stakes higher than in the area of cardiac surgery. U.S. patients and insurers will spend $3.4 billion this year on drug-coated stents from suppliers Boston Scientific (BSX ) and Johnson & Johnson (JNJ ), according to Citigroup. At many hospitals, cardiac units have become major profit centers. "We've shown that it is a lucrative area for hospitals," says Paul B. Ginsburg, president of the Center for Studying Health System Change. But are heart procedures always the best path for patients who currently get them? HEART ATTACK'S CAUSES. The answer seems to be no. As Hadler describes in his book, data from bypass-surgery clinical trials in the late 1970s show that the procedure extends life or prevents heart attacks only in a small percentage of patients -- those with severe disease. More recent trials with angioplasty show it reduces deaths mainly just in emergencies. "For people in the throes of heart attacks, opening the artery definitely prolongs life," says UCSF's Waters. Not so for patients with stable chronic disease. "The overwhelming number of heart procedures done these days do not affect patients' life span at all," says Hillis. The latest thinking on heart attacks may explain why not. In the traditional view, the slow accumulation of plaque inside arteries gradually narrows the vessels. Reduced blood flow causes chest pain, or angina. Eventually the arteries are blocked, bringing on heart attacks. Newer evidence, however, pins the blame not on this gradual narrowing but on unstable plaque that breaks off and causes clots. The clots are what obstruct the arteries, causing the heart attacks -- which is why so many such events are unexpected and why "there is no evidence that opening chronically narrowed arteries reduces the risk of heart attack," says Waters.
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