Reference no: EM132796200

Stents vs Bypass: Expanding the Evidence Base by Curtis P McLaughlin and Craig D McLauglinIntroduction

Researchers at Dartmouth Medical School have studied small area variations using the Medicare databse. Reporting in August 2006, for example, they cited the example of cardiac revascularization in Elyria, Ohio. Medicare patients in this city of 55,953 (2000 census), the county seat of Lorain County, received angioplasty at a rate nearly four times the national average. Thirty-one of the area's 33 cardiologists belonged to the North Ohio Heart Center and performed 3400 angioplasties in 2004. The Elyria rate in 2003 was 42 angioplasties per 1000 Medicare enrollees versus 13.5 for all of Ohio and 11.3 nationwide.

All three treatment approaches to blocked coronary arteries drugs, bypass surgery, and unblocking procedures such as angioplasty with or without stents are used there. In Elyria, however, cardiologists rely heavily on angioplasty. THere is open debate on where and when to use which procedure some experts say that they are concerned that Elyria is an example, albeit an extreme one, of how medical decisions in this country can be influenced by financial incentives and professional training more than by solid evidence of what works best for a particular patient. Both angioplasties and bypass surgery are considered to be highly profitable procedures, so profitable that Medicare has been trying to lower payment rates markedly but has been forced through lobbying to enact only a very small cut. At Elyria's community hospital Medicare pays the hosptial about 11000 for an angioplasty with a coated stent and up to 25000 for bypass operations. The cardiologist receives about 800 for the angioplasty and the surgeon up to 2200 for bypass surgery. The bypass surgery in Elyria is done by surgeons from the Cleveland Clinic who have priviledges at the community hospital.

Looking back from 2010

A Wall Street Journal article entitled "a simple health care fix fizzles out" suggested that the lack of change based on the COURAGE trail showed that comparative effectiveness research migh not produce the results claimed for it by the Obama Administration.

Doctors and health care watchers point to several reasons Courage didn't move the needle. Patients have little incentive to decline costly care when insurers are paying. Interventional cardiologists, on the other hand, have a financial incentive to use stents they receive 900 per stenting procedure, roughly nine times the amount they get for an office visit. Over the past 10 years, improvements in stents have coincided with an explosion in their use, as the hour long procedure edged out bypass surgery as the preferred treatment for clogged arteries in all but the sickest patients. the average cardiologist who installs stents made about 500,000 in 2008, up 22% from 10 years prior adjusted for inflation.

Case analysis

This case is inteneded to focus your thoughts on the nature of scientific evidence in health care both in terms of stability and strength of evidence. Continous clinical quality improvement will have to take into account the changing nature of evidence, the importance of learning by doing and the adjustments that need to be made to individual patient differences including comorbidity and genetic variablity in responses to treatment.

1. What do you think of using small area studies based on large Medicare databases to identify outliers like the cardiology treatment in Elyria, Ohio?
2. Contrast the information from such a study with the knowledge available from a double-blind clinical trial comparing the same two interventions?
3. Salaried cardiologists at Kaier Parmente in northern Ohio tended to use drugs more and cardiac procedures at a rate slightly below the national average. Analyze the role that differing financial incentives might be playing here?
4. If you were Anthem Blue Cross and Blue Shield in Ohio, what studies would you conduct to attempt to explain and/or deal with these striking local differences in treatments and costs?
5. How would the findings of the COURAGE study affect your strategy as an Ohio insurer?
6. What do you think of the Wall Street Journal's concerns about the effectivesness of comparative effectiveness research?