Opportunities for Cost Reduction of Medical Care: Part 3

Monte Malach; William J. Baumol

Disclosures

J Community Health. 2012;37(4):888-896. 

In This Article

Cardiovascular Disease

In our prior publications[2,3] we have noted that the evolution of diagnostic and therapeutic management of acute myocardial infarction (AMI) has dramatically changed. In addition, there is continuing controversy regarding the need for interventional coronary artery procedures following AMI versus the use of optimal medical therapy (OMT), which has proven beneficial and adequate in asymptomatic patients after AMI (Note: OMT includes aspirin, beta blockers, ACE or ARB drugs, and lipid-lowering drugs). The mortality rate of patients with AMI and acute coronary syndrome (ACS) has been dramatically reduced from a rate that hovered above 50% half a century ago to a rate in the single digits in recent years.[10,11]

Evidence indicates that the benefits of vascular intervention for AMI and ACS by bypass, angioplasty, and stenting primarily result in the relief of acute symptoms of ischemic disease but do not necessarily increase longevity.[12] The low diagnostic and therapeutic yield of elective coronary angiography in a study of 398,878 patients suggests that it is wasteful and expensive, since 39% of patients in the study needed no coronary intervention but, rather, benefited from OMT.[13] In addition, early invasive percutaneous coronary intervention (PCI) resulted in a 22% rate of death or AMI, while delayed PCI resulted in an 18% rate of death or AMI for patients with non-ST elevation AMI.[14] Current guidelines discourage the performance of multi-vessel primary PCI for ST elevation AMI. Timing delays in PCI, due to geographic or administrative problems, result in poorer outcomes with more prolonged and expensive care and mortality.[15] Patients who undergo PCI may subsequently have a major adverse cardiovascular event due to re-occlusion of the original culprit lesion or due to another non-culprit vessel occlusion.[16] This emphasizes the need for aggressive OMT, in addition to an intervention, as a means of preventing progressive ischemic coronary disease. In another study of 500,000 non-emergency angioplasties in 1,000 US hospitals in 2009 and 2010, 50% were considered to be appropriate by American Heart Association/American College of Cardiology guidelines, 38% were undetermined, and 12% were inappropriate.[17] This is another example of expensive but unnecessary interventional procedures.

The risk of atrial fibrillation (AF) increases with age and presents the risk of embolic stroke by allowing clots to form in a poorly contracting atrium. Standard anticoagulation with Coumadin® has been the predominant therapeutic direction, along with attempts at ablation of the cardiac focus that is the source of AF. However, new anticoagulation studies suggest that three new drugs, Apixabin®, Rivaroxaban®, and Dabigatran®, are non-inferior to Coumadin® and are associated with reported decreases in embolism and stroke[18] and also offer a decreased risk of bleeding from anticoagulation. This removes the expensive and frequent need for regular International Normalized Ratio blood tests. Unfortunately, there is no antidote for these new drugs, such as Vitamin K for Coumadin®, which causes concern about treating bleeding that may result from these new drugs.

In the past, mitral valve insufficiency repair has required a thoracotomy, but valve replacement via a percutaneous catheter approach permits placement of a clip to repair the insufficient valve, via a minor skin and blood vessel incision. This is especially effective for patients who are too sick for a thoracotomy and, moreover, the procedure can be performed at a fraction of the cost of a thoracotomy.[19] Forty percent of patients have required a second catheter-placed clip, but a 2-year follow up found that 78% of patients were much improved. Aortic valve replacement by catheter in high-risk patients is now possible and successful, though it carries a high risk of stroke and the use of TAVI (Transcatheter Aortic-Valve Implantation) is not yet approved for payment by Medicare.[20]

Endovascular stenting of aortic aneurysms[21] and for the treatment of obstructive peripheral vascular disease of the legs has been shown to be safer, simpler, and much less costly than open chest and leg operations.[22]

The treatment of vascular stroke from obstructive cerebrovascular disease (carotid, vertebral, basilar, cerebral) lags behind that for obstructive coronary artery disease via use of angioplasty and/or thrombolytics.[23] Early relief of vascular obstruction results in decreased permanent disability and reduces long-term spending. However, stenting of cerebral vessels, in the hope of preventing strokes, was recently declared unsuccessful by the US Food and Drug Administration (FDA) after 6 years of study. Drug therapy is considered to be safer and more effective than the stenting of cerebral vessels.[24]

A decade of misuse resulted from the premature promotion of a medication for treating heart failure, nesiritide (Natrecor®), which had been approved by the FDA after a single trial.[25] The drug was promoted as a necessary therapeutic additive for heart failure, but a subsequent study of 7,141 patients showed that it lacked efficacy despite its huge costs.

Finally, it appears that too many implantable cardioverter-defibrillators are being placed for arrhythmia or bradycardia without sufficient guideline indication.[26] This is a wasteful expenditure with potentially negative patient outcomes.

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