Two ways to stop unnecessary stenting

Since the ORBITA trial, more cardiologists have recognized that placing coronary stents for stable heart disease has limited clinical benefit for patients. But it takes more than this knowledge to change clinical practice. Research on coronary stents in US hospitals from the Lown Hospitals Index found high rates of overuse: About 75% of stents placed in US hospitals from 2015-2017 were for stable heart disease.

How can we reduce unnecessary stenting? A series of articles in JAMA Internal Medicine provides some suggestions.

1. Update guidelines to incorporate more recent studies

An analysis in JAMA Internal Medicine from Dr. Ali O. Malik at St. Luke’s Mid America Heart Institute and colleagues looked at what would happen if leading cardiovascular societies incorporated findings from the recent ISCHEMIA study. The ISCHEMIA trial found that stents did not prevent strokes or heart attacks for for patients with stable heart disease, providing more evidence that stenting is not indicated for asymptomatic patients unless management of heart disease with medication fails.

Malik et al. examined a cohort of more than 350,000 patients with stable heart disease who had a stent placed from April 2018 to June 2019. They wanted to know, based on the findings of the ISCHEMIA trial, who in this cohort received a stent unnecessarily, and do these numbers differ from the appropriate use criteria (AUC) that cardiovascular societies generally use?

They found that 13% of the patients in the sample did not have symptoms but that the AUC originally categorized their procedures as “appropriate,” “maybe appropriate” or “unable to be classified.” However, incorporating the ISCHEMIA results would have led to these procedures being categorized as “rarely appropriate.” That 45,442 people who could have avoiding an unnecessary stent if the guidelines reflected the most recent evidence. The authors estimate that the number of stent procedures that are “rarely appropriate” could be as much as seven times higher than the amount the AUC currently classifies as “rarely appropriate.”

2. Hold providers accountable for egregious overuse

The second research letter in JAMA Internal Medicine investigates whether investigations of providers by the US Department of Justice for submitting false claims helps reduce unnecessary stent procedures. Dr. David H. Howard, Professor of Health Policy and Management at Emory University, and Dr. Nihar R. Desai, Associate Professor of Medicine at the Yale School of Medicine, looked at eight hospitals that were investigated for performing unnecessary stent procedures between 2007 and 2015. They matched these hospitals to hospitals in the same state that had similar volumes of stent procedures in 2006. Then they compared the number of low-value stent procedures performed at hospitals that were investigated with matched hospitals from 2006 to 2017.

Howard and Desai found that both groups of hospitals decreased their number of unnecessary stents substantially, but the hospitals that were investigated reduced their number of unnecessary stents more. In the 8 investigated hospitals, the average number low-value stents declined from 1440 procedures in 2006 to 271 procedures in 2017, a reduction of 81 percent. For hospitals that were not investigated, the average number of low-value stents declined by 68 percent, from 1168 to 369 procedures per year.

The hospitals that were investigated were perhaps more egregious in their submission of false claims, but they were not the only hospitals that performed a large number of unnecessary stent procedures. According to Howard and Desai’s analysis, the hospitals that were investigated performed about 14% of the unnecessary stents in the states they studied (Florida, New Jersey, Kentucky, and Maryland) in 2006. There were more than 200 other hospitals that performed at least 25 low-value stent procedures in these states during the study period.

These two studies provide avenues for reducing unnecessary stents, an endeavor that could save as much as $6 billion a year, estimate UCSF physician Dr. James Salazar and UCSF Professor and JAMA Internal Medicine Editor Rita Rubin in an accompanying Editor’s Note. However, Salazar and Rubin emphasize that much more needs to be done to reduce low-value stents in our health care system, such as our “enthusiasm for technology regardless of net benefits” and eliminating the incentive of fee-for-service payments for procedures that aren’t appropriate for the patient.