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.
Heart Stents and Upcoding: How Cardiologists Game the System
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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
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.
Please consider volunteering to help out on the site.
- Nabel EG. The Women's Health Initiative—a victory for women and their health. JAMA. 2013;310(13):1349-50.
- Lowe J. Estrogen plus progestin increased coronary heart disease and breast cancer events in postmenopausal women. ACP J Club. 2002;137(2):41.
- Krieger N, Chen JT, Waterman PD. Decline in US breast cancer rates after the Women's Health Initiative: socioeconomic and racial/ethnic differentials. Am J Public Health. 2010;100 Suppl 1(Suppl 1):S132-9.
- Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA. 2012;307(1):37-8.
- Brown DL, Redberg RF. Last nail in the coffin for PCI in stable angina? Lancet. 2018;391(10115):3-4.
- Lin GA, Dudley RA, Redberg RF. Cardiologists' use of percutaneous coronary interventions for stable coronary artery disease. Arch Intern Med. 2007;167(15):1604-9.
- Brown DL, Redberg RF. Continuing Use of Prophylactic Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease Despite Evidence of No Benefit: Déjà Vu All Over Again. JAMA Intern Med. 2016;176(5):597-8.
- Kolata G. ‘Unbelievable’: heart stents fail to ease chest pain. The New York Times. November 2, 2017.
- Harrington RA. Appropriate Use Criteria for Coronary Revascularization and the Learning Health System: A Good Start. JAMA. 2015;314(19):2029-31.
- Rajkumar CA, Suh WM, Francis DP. Upcoding of Clinical Information to Meet Appropriate Use Criteria for Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes. 2019;12(3):e005025.
- McNeely CA, Brown DL. Gaming, Upcoding, Fraud, and the Stubborn Persistence of Unstable Angina. JAMA Intern Med. 2019;179(2):261-3.
- Wadhera RK, Sukul D, Secemsky EA, et al. Temporal Trends in Unstable Angina Diagnosis Codes for Outpatient Percutaneous Coronary Interventions. JAMA Intern Med. 2019;179(2):259-61.
- Maron DJ, Mancini GBJ, Hartigan PM, et al. Healthy Behavior, Risk Factor Control, and Survival in the COURAGE Trial. J Am Coll Cardiol. 2018;72(19):2297-305.
- Timmis A, Wragg A. Coronary intervention for stable angina. BMJ. 2018;363:k5351.
- Esselstyn CB Jr. Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). Am J Cardiol. 1999;84(3):339-41.
- Esselstyn CB Jr. Defining an Overdue Requiem for Palliative Cardiovascular Medicine. Am J Lifestyle Med. 2016;10(5):313-7.
- Esselstyn CB. A plant-based diet and coronary artery disease: a mandate for effective therapy. J Geriatr Cardiol. 2017;14(5):317-20.
- Devries S, Agatston A, Aggarwal M, et al. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130(11):1298-305.
- Coylewright M, O'Neill ES, Dick S, Grande SW. PCI Choice: cardiovascular clinicians' perceptions of shared decision making in stable coronary artery disease. Patient Educ Couns. 2017;100(6):1136-43.
- Craig MF. Prevention and lifestyle therapies are the way forward. BMJ. 2018;363:k4229.
Video production by Glass Entertainment
Motion graphics by Avocado Video
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
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.
Please consider volunteering to help out on the site.
- Nabel EG. The Women's Health Initiative—a victory for women and their health. JAMA. 2013;310(13):1349-50.
- Lowe J. Estrogen plus progestin increased coronary heart disease and breast cancer events in postmenopausal women. ACP J Club. 2002;137(2):41.
- Krieger N, Chen JT, Waterman PD. Decline in US breast cancer rates after the Women's Health Initiative: socioeconomic and racial/ethnic differentials. Am J Public Health. 2010;100 Suppl 1(Suppl 1):S132-9.
- Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA. 2012;307(1):37-8.
- Brown DL, Redberg RF. Last nail in the coffin for PCI in stable angina? Lancet. 2018;391(10115):3-4.
- Lin GA, Dudley RA, Redberg RF. Cardiologists' use of percutaneous coronary interventions for stable coronary artery disease. Arch Intern Med. 2007;167(15):1604-9.
- Brown DL, Redberg RF. Continuing Use of Prophylactic Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease Despite Evidence of No Benefit: Déjà Vu All Over Again. JAMA Intern Med. 2016;176(5):597-8.
- Kolata G. ‘Unbelievable’: heart stents fail to ease chest pain. The New York Times. November 2, 2017.
- Harrington RA. Appropriate Use Criteria for Coronary Revascularization and the Learning Health System: A Good Start. JAMA. 2015;314(19):2029-31.
- Rajkumar CA, Suh WM, Francis DP. Upcoding of Clinical Information to Meet Appropriate Use Criteria for Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes. 2019;12(3):e005025.
- McNeely CA, Brown DL. Gaming, Upcoding, Fraud, and the Stubborn Persistence of Unstable Angina. JAMA Intern Med. 2019;179(2):261-3.
- Wadhera RK, Sukul D, Secemsky EA, et al. Temporal Trends in Unstable Angina Diagnosis Codes for Outpatient Percutaneous Coronary Interventions. JAMA Intern Med. 2019;179(2):259-61.
- Maron DJ, Mancini GBJ, Hartigan PM, et al. Healthy Behavior, Risk Factor Control, and Survival in the COURAGE Trial. J Am Coll Cardiol. 2018;72(19):2297-305.
- Timmis A, Wragg A. Coronary intervention for stable angina. BMJ. 2018;363:k5351.
- Esselstyn CB Jr. Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). Am J Cardiol. 1999;84(3):339-41.
- Esselstyn CB Jr. Defining an Overdue Requiem for Palliative Cardiovascular Medicine. Am J Lifestyle Med. 2016;10(5):313-7.
- Esselstyn CB. A plant-based diet and coronary artery disease: a mandate for effective therapy. J Geriatr Cardiol. 2017;14(5):317-20.
- Devries S, Agatston A, Aggarwal M, et al. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130(11):1298-305.
- Coylewright M, O'Neill ES, Dick S, Grande SW. PCI Choice: cardiovascular clinicians' perceptions of shared decision making in stable coronary artery disease. Patient Educ Couns. 2017;100(6):1136-43.
- Craig MF. Prevention and lifestyle therapies are the way forward. BMJ. 2018;363:k4229.
Video production by Glass Entertainment
Motion graphics by Avocado Video
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Title
Heart Stents and Upcoding: How Cardiologists Game the System
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor's Note
Damn, cardiologists criminally gaming the system by lying to patients for personal gain. What about all the people who then die on the table or have a massive stroke? How do the doctors sleep at night? I’m pretty cynical when it comes to much of modern medicine, but even this threw me for a loop. And, it was just so brazenly discussed and dismissed in the journals. “Yeah, we know this happens. Oh well.” Just goes to show what happens when there’s so much money in the mix!
This was the final video in my seven-part series on stents. If you missed any, check out:
- Do Angioplasty Heart Stent Procedures Work?
- Why Angioplasty Heart Stents Don’t Work Better
- The Risks of Heart Stents
- Angioplasty Heart Stent Risks vs. Benefits
- Do Heart Stent Procedures Work for Angina Chest Pain?
- Why Are Stents Still Used If They Don’t Work?
As I say over and over in this video series, during a heart attack, in an acute setting, angioplasty can be life-saving. As I reiterate, when I’m talking about stable CAD, I’m talking nonemergency situations. In an upcoming series I talk about pros and cons of statin drug therapy. Spoiler: If you have a history of heart disease or stroke, taking a statin is recommended. All of these videos, including the upcoming statin series, are available on a digital download of a webinar I did last year. You can find it here.
Update: A new meta-analysis was just published last month and alas, there is still zero survival benefit to stent placement for stable coronary artery disease, but at least there were fewer heart attacks. Since this still didn’t translate into actually living any longer, the foundation of treatment remains medical and lifestyle management. Hat tip to Dr. Bitterman!
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