Did you ever wonder if the food you eat has a direct effect on your health, well-being – and longevity? Well, I’m here to end that mystery. You ARE the foods you eat. Welcome to the Nutrition Facts podcast – I’m your host, Dr. Michael Greger.
Today – it’s part three in our series on the coronary procedure – known as stents.
It probably comes as no surprise – but over and over, studies have shown that doctors tend to make different clinical decisions for patients based on how much they will get paid personally.
In 2007, we learned from the COURAGE trial that angioplasty and stents don’t reduce the risk of death or heart attack, but patients didn’t seem to get the memo. Only 1 percent realize there was no mortality or heart attack benefit. Perhaps because most cardiologists failed to happen to mention this little fact. One can imagine that if patients actually understood all they were getting was symptomatic relief that they’d be less likely to go under the knife. But then, ten years later, the ORBITA trial was published, showing even the promise of symptom relief was an illusion.
The implications are profound and far-reaching. First and foremost, the results showed unequivocally that there are no benefits to angioplasty and stents for stable heart disease. Basically, patients would be risking harm for no benefit whatsoever; so, it’s hard to imagine a scenario where a fully-informed patient would choose an invasive procedure for nothing.
So, is the ORBITA trial the last nail in the coffin for stents in non-emergency situations? An editorial in the journal Cardiovascular Revascularization Medicine disagreed, pointing to the broad angina relief that occurred in both arms. In other words, “stents helped” (even if the fake operation without stents helped just as much. So hey, if I give a patient a stent and they are beneﬁting from the “placebo effect,” who am I to interfere with that beneﬁt of this quote-unquote “therapy”? Well then, why not do fake surgeries? Stent placement can go for like $40,000. It’d be cheaper to just fake the whole thing. The reason we shouldn’t keep electively stenting people is because there’s a body count. During stent placement, 2 percent of patients develop bleeding or blood vessel damage, and another 1 percent die or have a heart attack or a stroke. And then, because you are having something stuck in your chest, 3 percent of patients have a bleeding event from the blood thinners you have to be on, or the blood thinners don’t work, and the stent clots off and causes a heart attack.
Why are they still done when we don’t just have no evidence of benefit, but in many cases explicit evidence of no benefit? One of the sources of resistance may be all the financial gain. These procedures make a lot of money for hospitals. Don’t expect them to be promoting lifestyle changes anytime soon, nor will physicians quickly abandon a practice that seems to make sense and supports their income. Is it that simple? Is it that famous Upton Sinclair quote on how “[i]t is difficult to get a man to understand something when his salary depends upon his not understanding it?” Think that’s just cynicism? Let’s ask doctors themselves.
Thousands of physicians were surveyed, and 70 percent believed that physicians provide unnecessary procedures when they profit from them. That’s what doctors themselves believe. And the data bears this out. Doctors have been shown to make different clinical decisions for patients based on how much they get paid. For example, when choosing which chemotherapy to treat breast cancer, increasing a physician’s margin by 10 percent can yield up to a 177 percent increase in the likelihood of choosing one drug over another.
That may be why Caesarean sections are more likely to be performed by for-profit hospitals compared to non-profit hospitals. Operating on commission. Pay surgeons per procedure and you can increase surgery rates 78 percent. Could that explain why we do 101 percent more angioplasties than any other rich country? A study on physician ﬁnancial incentives and treatment choices in heart attack management found that they do indeed respond to payments, and the response is quite large. Unconditionally, plans that pay physicians more for more invasive treatments seem to result in more invasive treatments. So, it may actually be quite common for patients to receive different treatments based on whether the doctor is getting paid per procedure.
One of my heroes, Dr. Caldwell Esselstyn—who always tries to see the best in people—even he had to break down and admit that compensation may be playing a role, after evidence surfaced that doctors are running up millions doing unnecessary stent implants: doctors like Mark Midei, who inserted 30 in a single day. That could be like a million dollars’ worth of billing. As a token of their gratitude, a sales representative from the stent company spent $2,000 to buy him a whole, slow-smoked pig, peach cobbler, and all the fixins.
We’re the only developed country where health care is delivered like this, explained the chief of cardiovascular medicine at the Cleveland Clinic. “The economic incentives are just too strong.”
Finally – we look at how cardiologists can criminally game the system by telling a patient they have a much more serious, unstable disease than they really have, fraud that results in unnecessary procedures, unnecessary cost, and unnecessary patient harm.
The history of medicine abounds with false dogmas that were simply assumed and later, sometimes much too long later, overcome. Like the Women’s Health Initiative study that showed that giving women Premarin, a hormone replacement therapy, increased the risk of the #1 killer of women, heart disease, as well as breast cancer risk to boot. Millions of women stopped taking it, and the breast cancer rates came down.
Another such reversal of an established medical practice is angioplasty and stents for stable coronary artery disease, for which billions of dollars are spent on procedures shown unequivocally to offer no benefits.
So, why are cardiologists still doing them? Researchers did some focus groups and concluded that although cardiologists may believe they are benefiting their patients, this belief appears to be based on emotional and psychological factors rather than on evidence. “The sense of irrationality surrounding this practice is so strong that the phenomenon has been coined the oculostenotic reflex”—they see a narrowing, and they stent it like they can’t even help it.
Since the procedure carries some risks, including death, there’s an argument that stents should only be used for people who are actively having heart attacks, in an emergency or unstable situation. Thankfully, now, there are published appropriate-use criteria in place to help guide cardiologists. And the good news is that now 82 percent of stents are reported to be performed in these emergency or unstable situations. So, we can disregard that study that showed there was no benefit in stable patients, since now it’s almost always done just in unstable patients like it should be. Or, at least it’s almost always reported that way. There are two ways a physician could comply with the rules. One is to do fewer unnecessary procedures, which is the whole point, but hey—where’s the money in that? The other way to comply is to make unnecessary procedures seem necessary.
Wait, are they implying that a doctor would try to game the system by telling a patient that they had much more serious, unstable disease than they actually had, so they could carry out the procedure anyway? This is referred to as “upcoding.” Another word for it would be fraud. Researchers found that some of that decline in inappropriate use may indeed be doctors falsely and intentionally misclassifying patients with stable angina as unstable angina. Because as soon as those appropriate use criteria went into effect, all of a sudden there was suspiciously a 4- to 10-fold greater increase in rates of stents for acute coronary syndromes like heart attacks. In New York, the proportion of stents labeled as acute, but performed as outpatient procedures, increased 14-fold. There’s no biologically plausible reason why that would happen; so, they were unnecessary procedures, unnecessary cost, and unnecessary patient harm. Harm not only from the risk of getting an unnecessary stent, but also by lying to the patient by exaggerating how bad their heart disease is. At best, this practice damages the credibility of the profession, violates patient autonomy, and puts the patient at risk for complications and, at worse, may cross the threshold into criminal activity.
What’s the solution? There could be like an independent review panel to protect patients, or we could simply remove the financial incentive to perform more procedures.
How many other established standards of medical care are wrong? Who knows. Bloodletting was the standard of care for thousands of years. Rigorous questioning of long-established practices is difficult. There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. Given this conundrum, it is possible that some entire medical subspecialties are based on little evidence.
Ironically, in the case of heart stents, in the landmark COURAGE trial that showed stents were useless for extending life, what did seem to determine longevity was how many risk factors they were able to control. Those that nailed all six by lowering their blood pressure, cholesterol, weight, smoking, and improving their diets and activity had five times the survival over the subsequent 14 years than those who didn’t.
I mean, should we be surprised that angioplasty and stents fail to improve prognosis? After all, it does nothing to modify the underlying disease process itself. In other words, it doesn’t treat the cause. Even if stents helped with symptoms beyond the placebo effect, it would still just be treating the symptoms and not the disease. And so, no wonder the disease continues to progress until the patient is disabled into death. Thus, Dr. Esselstyn wrote, the leading killer of men and women in Western civilization is being left untreated. What is instead being practiced is “palliative cardiology”: nontreatment of heart disease leading to disease extension and frequently an eventual fatal outcome.
Deaths by the planeload every week, just regarded as unfortunate rather than a national, preventable tragedy. It is as though in ignoring this dairy, oil, and animal product-based illness, we are wedded to providing futile attempts at temporary symptomatic relief rather than the cure.
Thankfully, we are on the cusp of a seismic revolution in health: not another pill, procedure, or operation, but instead treating the underlying cause of heart disease with whole food plant-based nutrition, the mightiest tool medicine has ever had in its toolbox.
To get there, we need to fight a key nutrition deficiency in education. A study found that 90 percent of cardiologists reported receiving no or minimal nutrition education during their cardiology training, leaving fewer than 1 in 10 confident in their nutrition knowledge. So, maybe it’s a good thing that most spend three minutes or less discussing nutrition with their patients. Only one in five themselves even ate five servings of fruits and veggies a day.
Thankfully, this life-saving information is slowly but surely getting out there. Medical education has focused on being the ambulance at the bottom of the cliff rather than a fence at the top. Money talks, and there’s very little money in promoting eating broccoli and going for a walk. I was so eager to see the citation they used for that, and was so honored when I did.
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