Friday, October 17, 2008


The George Bush era has been marked by severe controversy, ranging from the war in Iraq, to the state of the American Banking system and the world economy, and now to healthcare, in particular cardiac care. Dr Grace Lin and colleagues from San Francisco published a paper in the Oct 15th issue of the Journal of the American Medical Association, that 56% of PCIs done in America, was done without the patient having a stress ECg ( as recommended in the clinical guidelines ). They came to this conclusion by looking a 24,000 medicare claims for PCI reimbursement.They found that in this population with chronic stable CAD ( most of whom were asymptomatic ), no stress ECG was done to document reversible ischemia, at least 3 months before the index PCI, meaning that clinicians who do the angioplasty, decided on bedside ECG and clinical assessment to send a patient for PCI and claim for reimbursement. It is important that many of these patients had almost no chest pains, or chest pains not suggestive of angina. Only 44% had a preceding stress ECG at least 3 months before their index PCI, and some angiograms were done in patients with minimal chest pains and negative stress ECGs. This is of course not what the guidelines recommend. Once a patient is on the angiography table, the "oculo-stenotic-dilatory reflex " kicks in, and invariably, any stenosis gets a stent.
It is of course fair to say that just checking through medicare papers to establish appropriateness of care may not be the best way to make such a conclusion. Even allowing for some misreads, 56% of PCIs done without a preceding stress ECG, is a very large number. If no stress ECG is done as a preliminary assessment, and the cardiologist is the one recommending the PCI and also he is the one doing the PCI and getting re-imbursement, one wonders whether the PCI was undertaken "for bread ".
When we first started angioplasty, we recognise that the present system of referals and deciding PCIs is basically wrong and severely conflicted, because the cardiologist is the one who sees the patient first, the one to decide on the need to do the PCI and also the one to do the PCI ( and also collect the fees ). There is no check here on potential abuse.
Maybe that is why there are so many cardiac interventionist around. The money is good. OR am I becoming too cynical. Do we "dilate for bread "?

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