October 15, 2008

Doctors Often Skip Recommended Stress Tests Before Surgery

U.S. researchers said on Tuesday that people on Medicare who get elective surgery to open blocked heart arteries often do not get the recommended stress tests to confirm the surgery is warranted.

PCI, or percutaneous coronary intervention, is a surgery that involves threading a balloon-tipped catheter through the arteries and opening up a clog. A tiny wire-mesh coil called a stent is often inserted to prop open the artery.

PCI costs Medicare $10,000 to $15,000 per procedure and has contributed significantly to increases in Medicare spending since the mid-1990s.

Dr. Grace Lin of the University of California, San Francisco said it's important to document that patients are receiving PCI for appropriate indications to ensure the optimal use of Medicare resources. Dr. Lin's study appears in the Journal of the American Medical Association.

Each year, more than 800,000 PCI procedures are performed and they represent big business for medical device makers including Boston Scientific Corp, Medtronic Inc, Abbott Laboratories Inc and Johnson & Johnson.

Many stable patients with chest pain can get about the same level of relief with standard drug therapy, but at far lower cost, according to a number of prior studies.

The research team wanted to see if doctors who are performing PCI surgeries were following widely accepted practice guidelines that call for people to undergo a stress test to determine whether the procedure is needed.

Stress tests, which are typically done on a treadmill, can show whether a person has ischemia, or inadequate supply of blood to the heart caused by a blocked artery.

"What really matters is whether or not that blockage is affecting blood flow to the heart. That is why the stress test is important," Lin said.

The study looked at insurance claims in 2004 from Medicare beneficiaries.

Fewer than half of the patients took a stress test on a treadmill within 90 days of their elective surgery, researchers said. This rate varied significantly depending on the hospital patients were referred to, with rates ranging from a low of 22.1 percent to a high of 70.6 percent.

Lin said there was a tremendous amount of variation in the amount of stress testing that was done.

Older doctors and those who did a high volume of procedures tended to order fewer stress tests, Lin said. She thinks local practice patterns also played a role in the decision to do the test because the rates differed widely by geography.

The results warrant concern, according to the Society for Cardiovascular Angiography and Interventions. But it said stress tests are not always appropriate, including for patients who are too sick or immobile to take them.

"The guidelines are important, but they are meant to guide physicians based on the data available at the time of their development, not serve as a substitute for clinical judgment," said Dr. Bonnie Weiner, the group's immediate past president.


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