Friday, September 03, 2010


Recently, two US interventional cardiologist, both in Maryland, had been indicted by the US Federal court on charges of medical fraud, including the implantation of unnecessary coronary stents. I believed that one has been found guilty and the other is awaiting trial. Besides many other irregularities in their practice, they were alleged to have implanted stents in lesions that did not require them. Sounds familiar. I believe that the medical insurance fraternity in USA is looking into many other centers to see how rampant the problem is.
I must say that as a senior interventionist in this country, I have also heard of many such instances of stents being implanted for patients with almost no symptoms and lesions of almost no significance. But then, those who complain unofficially usually have a conflict of interest. I have always maintain that should such practice occur, a report should be made to a neutral body and both sides of the story be heard as it is a very serious allegation.
I fee l in someway responsible because when we started the coronary angioplasty program in this country in 1988, that was what we advocated, thinking that there was cost savings. What do I mean.
In 1988, after the intensive training program by Dr David Clark and Dr Tim Fischell, both of USA, we began to do angioplasties. That was the start of the angioplasty program. Dr Clark and Dr Fischell, had both advice that we should do the diagnostic angiogram, and discuss the findings with the patient and also get cardio-surgical backup ( this was the era before the introduction of coronary stents for bailout ). Therefore, angioplasty was not performed at the same sitting as angiogram. Probably about 2-3 weeks later. That was how we started. Then we began to hear patient feedback that it would have been more cost effective and time effective to do the procedures, one following the other at the same sitting. Some of the feedback implied that we were separating the procedures so as to gain more fees ( something I was very uncomfortable with ). You see how things change.
Then was got the coronary stents and cardio-surgical standby was much less an issue. And with cost savings in mind, we told the hospital that since coronary angioplasty is always preceeded by a routine check coronary angiogram, when angioplasty is done at the same sitting, the coronary angiogram fees should be waived by the hospital. To this, they agreed. We then begin a startegy to brief patient on coronary angiogram and coronary angioplasty, during the clinic and pre-angiogram discussion / consultation, explain all the risk and benefits, and proceed to list for coronary angiogram +/- angioplasty. Upon completion of the angiogram, when a significant lesion ( usually a lesion narrowing of 70% or more ), we would then again ask permission from the patient and relatives waiting in attendance, the consent to proceed on to angioplasty. This then slowly became routine, I believe for the country. All was done in one admission and only angioplasty fees were levied. Nice and tidy.
Little did I realise at that time that I was committing a gross error in medical audit. That I was the one who decided on the need to do the angiogram, and that following the angiogram, I was also the one to decide on the need for angioplasty. I was severely conflicted and my decision may be open to questioning.
This may have contributed to the many " so-called " unnecessary stenting that some are now accused of doing. In the initial strategy of separating the angiogram from the angioplasty, the patient had a chance to leave the angio suite, back to the ward, consult their friends and relatives, and maybe even a cardiac surgeon, and then return ( if he/she so wishes ), for the angioplasty.
Should we now return to this strategy? seeing what is happening in the USA. The Europeans, ( many centers are also doing the same as us ), is now advocating a return to the old ways. They call it a heart team. Each medical center will have a Heart Team. After each angiogram, the findings will be presented to the heart team and a collective decision made as to the need for optimal medical therapy, angioplasty, or bypass surgery. I suppose this is ideal, but is it enforceable in Malaysia? At this point in time, I really doubt it.
I suppose, my thoughts were to throw this out in a blog like this and to continue to educate the public. At the end, it is the payers, who will decide and control what a doctor can and cannot do. Those are the facts of life. Is the future going back to the past?

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