Journalism in the Public Interest

To Stent Or Not To Stent, That Is In Question

As Hospital Corporation of America comes under scrutiny, experts say unnecessary heart procedures are common, costing taxpayers, driving insurance premiums and putting patients at risk.


An internal review by Tennessee-based Hospital Corporation of America found unnecessary heart procedures being performed at several facilities, according to The New York Times. (Rusty Russell/Getty Images)

Aug. 8: This post has been corrected.

New accusations that one of the nation's largest hospital chains performed more than a thousand unnecessary heart procedures grabbed headlines this week, but the practice is far from unique in U.S. health care.

A 2011 study in the Journal of the American Medical Association found that only half of 144,000 nonemergency heart catheterizations — typically the use of tiny balloons and stents to clear blocked arteries — were appropriate; 38 percent were "uncertain" and 12 percent were "inappropriate."

"It's presented in the media as if it's an aberrancy, when actually it's the rule," said Dr. David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School of Medicine of the unnecessary heart procedures. "The medical system is addicted to the revenues that it generates."

In 2011, Medicare alone spent nearly $1 billion on the procedures. While they boost revenues for doctors and hospitals, unnecessary procedures consume taxpayer money, raise insurance premiums and put patients at risk. Studies show that about 3 percent of patients experience serious complications.

The New York Times reported this week that the U.S. attorney's office in Miami is investigating allegations that patients underwent unnecessary heart treatments at facilities owned by Tennessee-based Hospital Corporation of America, a 163-hospital chain.

According to the Times, an internal HCA review found unnecessary procedures being performed at several facilities, including more than 1,200 at Lawnwood Regional Medical Center & Heart Institute, in Fort Pierce, Fla.

HCA did not return a call for comment, but said in a statement posted on its website that there's wide disagreement among physicians about which procedures are medically necessary and its use of stents was within the range of those at other hospitals.

Comparisons to common practice among doctors and hospitals may not be the best barometer of proper patient care. Studies show that doctors often do not adhere to best practices when they treat patients who have plaque buildup in their coronary arteries but whose condition is stable.

About 600,000 procedures are performed every year to clear coronary artery blockages, according to the American Heart Association. The procedure involves snaking a catheter through the patient's arteries and clearing the blockage with a tiny balloon and a small wire cage — the stent — that holds the artery open.

But studies show that medicine alone is as effective in patients with stable heart disease and that many procedures to clear blockages are unnecessary. Brown published a review of eight studies and found "there's absolutely no evidence" for substituting stents for medical therapy in patients with stable heart disease, he said.

The American Heart Association recommends putting patients with stable heart disease on blood thinning medication before they try a stent, said the authors of a May 2011 study in the Journal of the American Medical Association. Yet it happens in fewer than half of the cases where doctors use stents, the study found.

There is some debate about the scope of the problem.

Dr. William Zoghbi, president of the American College of Cardiology, says there are "pockets" around the country where unnecessary procedures are more prevalent. The college offers seminars and guidelines on appropriate use for doctors, he said, and keeps a national registry so they can compare their practices to others. Zoghbi said the educational efforts are showing signs of success.

Unnecessary stenting persists in part because doctors are not explaining the medication-alone option to patients, said Dr. Michael Barry, president of the Informed Medical Decisions Foundation, which has created a guide of treatment choices for patients with stable heart disease.

Barry was part of a team of researchers that surveyed 472 Medicare patients with stable heart disease about their interactions with doctors who performed nonemergency stent procedures on them. A key finding: Only 6 percent of the patients said their doctor offered medication as an alternative to a stent.

Editor's Note: ProPublica is working on a project to document cases of harm to patients. You can share your story by filling out our Patient Harm Questionnaire, or by joining our ProPublica Patient Harm Community on Facebook.

Correction: This post originally said that the Archives of Internal Medicine found that only half of 144,000 nonemergency heart catheterizations were appropriate. It was actually the Journal of the American Medical Association.

I’m in healthcare and can tell you that there’s an enormous amount of unnecessary procedures performed for the $$$. Also a lot of billing for procedures never performed, and even in some cases for patients never even seen. Some of the worst fraud and abuse is in cardiology, and… gastroenterology.

With licenses to steal, only the scrupulous place the patient ahead of the $$$

Eric Manheimer MD

Aug. 8, 2012, 3:09 p.m.

Very fine article. It is not just about “stents”. Virtually all aspects of medicine from colonoscopies to mammography, to PSA’s to what we pay for medications is part of the huge issue of “more is better” practice of US Medicine Inc.

Warren Liebman

Aug. 8, 2012, 8:42 p.m.

I see that your survey is about patients that suffered harm through the insertion is stents. I had day surgery for a procedure unrelated to my heart. I had heart failure in the recovery room and was sent by ambulance to the nearby heart center where I had three stents inserted the next day.

My cardiologist thought the stents were the best alternative. I deferred to his opinion as I was unqualified to make the decision.

I was on Plavix for three years and now just blood pressure and cholesterol drugs. I am very pleased with the outcome.

M Felix Freshwater MD

Aug. 8, 2012, 8:58 p.m.

Carefully read the HCA online document that alleges that the number of cardiac caths and stent procedures has decreased per year.
Missing from the document is the number of HCA cath labs and HCA cardiologists doing the procedures.
As we know, HCA downsized so if it has fewer hospitals and or fewer cardiologists then there may be an increase in the number of procedures done per remaining hospital or remaining cardiologist.

Sadly, in America, Power & Profit take Precedence over People.

Given the setup, this is the inevitable result.  With insurance in the way, doctors jump through hoops to get paid and money is invisible to the patient.  Put those together, and the doctor has strong incentive (even if we completely ignore pressure from the pharmaceutical and other supply companies) to give everybody the most expensive health care possible, whether or not it’s the best.

As Warren points out, stents are wonderful tools.  But sledgehammers are also wonderful tools, and I wouldn’t want to use such a tool to clean a dirty window.  When you have the right tool for the right job, there’s not much better.

And since, in this country, we confuse “health care” with “health insurance”—two completely unrelated things except through their placement in the dictionary—we drive to make it worse, every time.

And note, the organization in the middle always benefits.  And they sell the idea to doctors that the problem with health care is fraudulent malpractice claims (i.e., blame the patient), while selling the idea to patients that we need protection from the big, bad doctor bills.

It’s one of the best scams running, really.  You keep the parties blaming each other AND play on the fear and implied threat that “it’d be a shame if something…happened to your health,” while raking in profits from a biased system.

Patrick Hughes, MD, FACC

Aug. 9, 2012, 9:59 a.m.

The placement of a stent in a coronary artery that has no blockage (as described in the NY Times) is fraud. It also exposes the person receiving the stent to life-threatening complications at the time of the procedure and for years afterward. This is a criminal act that should be prosecuted aggressively. Innocent people deserve protection.

I myself have had 6 procedures done, and they have been done because of actual blockage. My cardiologist that I have now is a very good Doctor; who use other ways of preventive care for someone like me, before doing any kind of senseless procedure. He communicates with me in every aspect of the disease that I have. As far I am concerned here in Austin Tx. I have had 2 cardiologist and have been wonderful, and I see no fraud in any of the cases that I have been with. what ever goes on in those parts of the country its because they have Dr. who don’t care about their patients; only about how to rip off the federal government.

So what are the guidelines for who ought to be stented vs those that ought to be treated with pharmacology?  Is there ever a proper non-emergent stent?  I am familiar with guidelines for who gets cathed emergently vs those that ought to receive fibrinolytics in the presence of mi.

I don’t know any guidelines, I am merely stating incidents that has happened to me. Believe me when I say that at the time of my procedures I felt I was on my dying bed massive MI and it took a lot out of me. I am still struggling but not as bad as I was then, and I am also under a major meds regimen, including blood thinner Effient. I have tried many other thinners that have failed me and appears that this one is doing its job (Effient).

This is just the beginning of this reporting I hope ProPublica because you are hitting on THE most important driver of the ever increasing costs of healthcare.  There is very little health in healthcare but there are huge profits. 

And who pays when things go wrong?  It’s not the manufacturers or the doctors because you know frivolous lawsuits.  The patients’ in this country, if they were informed consumers would want more legitimate lawsuits that would weed out faulty products and procedures.  Instead what we get are lawsuits that vilify a doctor when he doesn’t use an expensive scan or treat with an expensive drug.  Those lawsuits are allowed to proceed, step right up we’ll help you sue your doctor.  But when a product like gadolinium based contrasting agents is maiming and killing millions and GE is the manufacturer with the least stable product, the injuries go uncompensated.  In these situations we have to pick up these costs through higher premiums, our largest employers pay and so do health insurance companies and the government.  No matter what you think about health insurance companies and how evil they are they still shouldn’t have to pay for GE’s faulty products or other faulty products.  Those costs should be borne by the ones that caused them.  Great work ProPublica.  I’m be watching and waiting for more reporting.

While many unnecessary procedures are performed, some are actually related to the fact that patients consider one approach as ‘doing something’, and the medical approach as being passive and less thorough. A physician who does not perform a procedure has nothing to lose by recommending it. Any complications are the result of the operator. But if a procedure is not recommended and an event occurs, such as a heart attack, a physician may be blamed by the patient for ‘not doing enough’. The fact that medical therapies may indeed be better than procedures is not strongly embedded in the culture of patients. And there is an aura of higher technology to procedures compared with medications.

This is an attitude that needs to change, both on the part of physicians and patients.

Perhaps everything that is being discussed here may make sense to some but not all. I’m sure that people are not ignorant; when they are being treated by a good Dr. or a very bad Dr.: that is why its always best top go for first, second, and even third diagnoses. As the old cliche goes we are only human, and we all make mistakes, must not be taken as advise when it comes down anybodies health. I my self am against lawsuits of any kind, as this is very degrading on both parts. Plus it goes contrary to what I believe and what I have been taught through the word of God. One thing I will say in the six procedures that I have had; I would rather do it all over again instead of having open heart surgery. The basic fact is, that we all have the cure within ourselves if we know how to do what is right, admittance, acceptance, and avoidance.

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