Peripheral stenting: It’s not that simple

The top story in The New York Times on Jan. 29 focused on peripheral stenting. The article used some superficial data gleaned from the Medicare data dump and accusations against a few physicians accused of performing unnecessary procedures. I would not be surprised if readers, some of whom might even have peripheral artery disease and not realize it, read this article and drew conclusions about the motivations and ethics of cardiologists as a group. Yes, the article attributed the increase in procedures to cardiologists, not including any of the other specialists who treat peripheral blood vessels.

It’s just not that simple.

John P. Reilly

Outliers are the exception not the rule. When performing right heart catheterization, several injections to measure thermodilution cardiac outputs are usually performed. If one of the measurements is different from all the rest, it is deleted. Because including all the measurements, no matter how wide ranging, would not accurately reflect reality.

Malcolm Gladwell wrote an entire book about how the outliers are not representative of the general population. To highlight the outlier, and in the same story describe the typical physician, is to invite the reader to infer that what may be true for the outlier is true for the general population.

Last year, Medicare made its data available about its payments to physicians. It is natural to look among these data to find the extremes — those physicians who had received the greatest payments — and to try to explain how they are so different from the rest of the physicians. The cynic in us looks for a business or economic explanation for these payments. That may likely help make sense of some or possibly most of their outliers.

Technological improvements

But there are several other explanations for why there is an increase in peripheral endovascular procedures over the past 10 years that do not deal with dollars and cents (or stents). Endovascular technology has greatly improved during the last decade. The platforms are more accessible for interventional cardiologists and other specialists in vascular disease because they use smaller sheaths and are more deliverable. More lesions are accessible with current technology, and more lesions can be treated. Compared with 10 years ago, current technology can be used to successfully treat more lesions. A decade ago, many patients would have had to undergo surgical treatment. Ten years ago, fewer vascular surgeons were performing endovascular procedures than today. So many of the patients treated by surgeons with open procedures 10 years ago are now treated endovascularly.

Inaccuracies abound

The inaccuracies in the article in The New York Times make its implications more concerning.

The article quotes a source who says a medical society released guidelines on the treatment of PAD last year. This is true: SCAI released four such statements. But the article ignores the fact that American College of Cardiology, Society of Vascular Surgery and American Heart Association released PAD guidelines in 2005 and an update to these guidelines in 2011.
The chart in the article clearly depicts that the greatest growth in endovascular procedures was among venous procedures. The chart depicts a half-million venous procedures performed. This is similar to the number of PCIs performed. It is not in keeping with our experience that there could be an equal number of coronary and venous angioplasty procedures performed. This suggests that nonangioplasty procedures must be included in this number. Endovenous laser therapy procedures for varicose veins have increased during the same period, but are completely different from the population discussed in this article. And, endovenous laser therapy procedures are not limited to interventional cardiologists, but may be performed by vascular surgeons, cardiac surgeons, vascular medicine specialists and dermatologists. At a minimum, based on preliminary analysis of the data, it seems that at least 100,000 of the procedures called out by The New York Times article are endovenous laser therapy procedures.

As a result of the article, some readers might believe that following the money can fix the health care system. But I’m pretty sure it’s not that simple.

Let us know your thoughts on this Eye on Intervention blog by commenting below. Do you think articles like these affect our patients’ trust?

John P. Reilly, MD, FSCAI, is vice chairman of the department of cardiology, section head of the interventional cardiology program and director of fellowship in interventional cardiology at Ochsner Health System, Jefferson Parish, La.

Disclosures: Reilly reports no relevant financial disclosures.