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Coronary Stents: Why The Guidelines Are Not Often Followed

The Case
In 2009, administrators at St. Joseph Medical Center in Maryland wrote letters to patients of Mark Midei, informing them that its staff cardiologist may have subjected them to a coronary artery stenting procedure inappropriately. That communication prompted an article in a local newspaper, which triggered an investigation by the Senate Finance Committee.

lightening 300x199 Elective Coronary Stenting: A Case in ContextThe Committee subsequently released a report which asserted that Midei performed nearly 600 stenting procedures unnecessarily, and charged Medicare nearly $4m for these procedures. According to the report, all the procedures involved stents made by Abbott Labs. Abbott, in turn, had paid Midei $31,000, added him to its roster of top stent volume cardiologists, and feted him with a pig roast at his home to celebrate a prodigious day in which he implanted 30 stents (apparently a company record). Then, after St. Joseph’s dropped Midei from its roster, Abbott hired him to provide services in Japan and China. In the subsequent year, the number of patients who received stents at the hospital fell to 116 from 350 in the previous year.

Most recently, the Maryland Board of Physicians revoked Midei’s license to practice medicine after concluding that he did implant stents into the coronary arteries of 4 patients inappropriately. The Board also determined that he exaggerated the severity of coronary blockages, and claimed incorrectly that they had unstable angina. Midei has denied the allegations and sued St. Joseph for damaging his career.

The Context Read more »

*This blog post was originally published at Pizaazz*

Understanding Treatment: The Communication Disconnect Between Doctors And Patients

Over the long week­end I caught up on some read­ing. One arti­cle* stands out. It’s on informed con­sent, and the stun­ning dis­con­nect between physi­cians’ and patients’ under­stand­ing of a procedure’s value.

The study, pub­lished in the Sept 7th Annals of Inter­nal Med­i­cine, used sur­vey meth­ods to eval­u­ate 153 car­di­ol­ogy patients’ under­stand­ing of the poten­tial ben­e­fit of per­cu­ta­neous coro­nary inter­ven­tion (PCI or angio­plasty). The inves­ti­ga­tors, at Baystate Med­ical Cen­ter in Mass­a­chu­setts, com­pared patients’ responses to those of car­di­ol­o­gists who obtained con­sent and who per­formed the pro­ce­dure. As out­lined in the article’s intro­duc­tion, PCI reduces heart attacks in patients with acute coro­nary syn­drome — a more unsta­ble sit­u­a­tion than is chronic sta­ble angina, in which case PCI relieves pain and improves qual­ity of life but has no ben­e­fit in terms of recur­rent myocar­dial infarc­tion (MI) or survival.

The main result was that, after dis­cussing the pro­ce­dure with a car­di­ol­o­gist and sign­ing the form, 88 percent of the patients, who almost all had chronic sta­ble angina, believed that PCI would reduce their per­sonal risk for hav­ing a heart attack. Only 17 percent of the car­di­ol­o­gists, who com­pleted sur­veys about these par­tic­u­lar patients and the poten­tial ben­e­fit of PCI for patients fac­ing sim­i­lar sce­nar­ios, indi­cated that PCI would reduce the like­li­hood of MI.

This strik­ing dif­fer­ence in patients’ and doc­tors’ per­cep­tions is all the more sig­nif­i­cant because 96 percent of the patients “felt that they knew why they might undergo PCI, and more than half stated that they were actively involved in the decision-making.” Read more »

*This blog post was originally published at Medical Lessons*

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