When to just say no

Three cheers for the primary care physicians who answered the call to identify the most useless treatments and tests routinely administered by their peers. If you want to protect yourself from unnecessary and often risky medical care, check out the list below. It will help you recognize the circumstances when it is entirely appropriate to just say “no” to your doctor.

Rare is the medical test that is 100% accurate, and anxiety-producing false alarms are far more likely when a test is given to young or symptom-free healthy people at low risk for the condition or disease of interest. More than wasted money is at stake. A false alarm heart test result, for example, often leads to risky invasive procedures like cardiac catheterization and angioplasty. Each has a small risk of death and stroke even when performed at what are perceived to be the best hospitals in the U.S.

Too often we consumers assume that early medical interventions—be it back surgery or antibiotics for sinusitis—will always lead to improvements. Too many of us believe in the “more is better” practice of medicine, for example, the doctor who orders a lot of tests is seen as thorough. Too often, we have no idea whether a frequently administered test has any solid research behind it.

The list below is part of the ongoing “Less is More” series which appeared online first in Archives of Internal Medicine. It was put together by working groups formed under the sponsorship of the National Physicians Alliance, which represents 22,000 physicians and takes no funding from drug or device manufacturers. The evidence to support this list of “don’ts” is based on the research conducted by highly-respected review teams such as the U.S. Preventive Health Services Task Force and the Cochrane Collaboration. Each primary care specialty—internal medicine and family medicine— was tasked with coming up with the top five “don’ts” for the care of adults. The two lists are merged to total seven “don’ts” because of overlap. Tweaked here and there to eliminate medical jargon, this list is largely as it appeared online at the AIM website:

1.Don’t do CT scans or other imaging tests for low back pain within the first six weeks unless red flags are present. Reason: Studies failed to demonstrate that imaging of the lumbar spine before six weeks improves outcomes. Red flags include but are not limited to severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are present.

2.Don’t obtain blood chemistry panels [i.e., blood tests] or urinanalyses for symptomless healthy adults. Exceptions: screening for LDL cholesterol and screening for type 2 diabetes mellitus in symptomless adults with hypertension.

3.Don’t order annual electrocardiogram or any other cardiac screening tests for symptomless, low-risk patients. Reasons: There is little evidence that the detection of constricted coronary arteries in symptomless people at low risk for heart disease improves health outcomes. False alarms are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis. Potential harms exceed the potential benefit.

4.Don’t use bone density scans to detect osteoporosis in women under age 65 years or men under 70 years with no risk factors. Reasons: not cost effective in younger, low-risk people. Risk factors include but not limited to fractures after age 50 years, prolonged exposures to corticosteroids, dietary deficiencies of calcium or vitamin D, cigarette smoking, alcoholism, thin and small build.

5.Don’t perform Pap tests in women who have had a hysterectomy for benign disease. Reason: there is poor evidence of improved outcomes.

6.Use only generic statins when initiating lipid-lowering drug therapy. Reasons: All statins are effective in decreasing mortality, heart attacks, and strokes when dose is appropriate for LDL cholesterol reduction. Switch to more expensive brand-name statins only if generic statins cause adverse reactions or do not achieve LDL cholesterol goals.

7.Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms (which must include purulent [pus] nasal secretions AND maxillary pain or facial or dental tenderness to percussion) lasts for seven or more days OR symptoms worsen after initial clinical improvement. Reasons: most maxillary sinusitis is due to viral infection that will resolve on its own.

The National Physicians Alliance is to be commended for putting together this list, as well as its stated aims of “improving patients’ access to high-quality care, practicing evidence-based care, advocating for just and cost-effective distribution of finite resources, and maintaining trust by minimizing conflicts of interest.”

Maryann Napoli, Center for Medical Consumers©

Heart surgery 2nd opinion center

For years, we have been reporting the overuse of the coronary artery-opening procedure called angioplasty, aka percutaneous coronary intervention. About one million people in the U.S. undergo this procedure annually; despite the fact that well-designed clinical trials proved that many are in non-emergency situations and can be treated just as effectively with the multiple drug therapy. These are the same drugs, by the way, that most people will be told to take after they’ve had an angioplasty. The procedure, done in non-emergency situations, has a death rate of at least 0.63%.

Lown Cardiovascular Center, Brookline, Massachusetts is the place to go if you want a second opinion about the necessity of angioplasty or coronary bypass surgery. Long-time readers may recognize the name of cardiologist Thomas Graboys, MD, of the Lown Cardiovascular Center, who was frequently quoted in HealthFacts over the years, expressing concern that angioplasty had become a cash cow for many hospitals. In one memorable interview, he said that many symptomless people are scared into undergoing angioplasty after “failing” a stress test and told they are sitting on a “time bomb.” Such people, he said, could have been safely treated with daily aspirin and avoided the procedure.

Dr. Graboys, professor of medicine at Harvard Medical School, first came to our attention in 1992 when he co-authored a seminal study showing that angioplasty can be safely deferred in many people who have been told that the procedure is urgently needed. This and many other studies he co-authored over the years led him to recommend a second opinion when a cardiac catheterization is advised because this diagnostic procedure puts people on the proverbial conveyer belt to having an angioplasty or coronary bypass surgery. Sadly, Dr. Graboys is no longer with the Lown Cardiovascular Center. He was forced into premature retirement in 2006 due to Parkinson’s disease and dementia. He wrote a book about the experience called Life in the Balance.

Visit the Lown Cardiovascular Center Web site to see what a second opinion involves and to read the bios of the six cardiologists on the staff and no cardiovascular surgeons. Let us know if there’s a similar center in your area.

Maryann Napoli,Center for Medical Consumers(c)

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Angioplasty: No Effect on Future Heart Attack

Dramatic Rise in Cardiac Procedures, But Heart Attack Rate Stays Constant

Over the last 10 to 15 years there has been a dramatic increase in cardiac procedures in the U.S. and Canada. Coronary artery bypass surgery and artery-opening procedures are intended to restore blood flow to the heart in order to prevent heart attacks. One might reasonably expect each country’s rate of heart attack to show an equally dramatic decline. But the heart attack rate stayed relatively constant in both countries. The findings came from two studies, one in the U.S. and one in Canada, published in the January 24 issue of the journal Circulation. They appear to validate the longstanding, but widely ignored, research indicating that today’s cardiac surgeons are still operating on an outmoded understanding of heart disease.

Each country’s study drew on claims data from its publicly funded Medicare program to determine the cardiac procedure rate. Medicare in the U.S. primarily covers people age 65 and over, while Medicare in Canada covers everyone, though the study looked solely at adults in Ontario. At the start of the study period, Canada’s rate of cardiac procedures was lower than that of the U.S., but both countries showed similar massive increases. The researchers determined the heart attack rate by looking at the claims submitted by people hospitalized for a heart attack during a 15-year period in the U.S. study and a 10-year period in the Canadian study.

“There are a couple of different messages for consumers in our study,” said F. Lee Lucas, PhD, Center for Outcomes Research and Evaluation, Maine Medical Center, the lead author of the American study. “The increased rates [of bypass surgery and artery-opening procedures] over time likely mean that doctors are quicker to intervene for milder and milder symptoms, particularly in white men,” she noted in a telephone interview. Dr. Lucas explained that the data collected in her study did not allow conclusions to be drawn regarding the percentage that might have been unnecessary.

David Waters, MD, who was not involved in either study, was less reticent about their implications. “We can assume that that these procedures are not influencing the heart attack rate, and some may be unnecessary,” he said in a telephone interview. Dr. Waters is chief of cardiology at San Francisco General Hospital and professor of medicine at University of California, San Francisco.

The two studies also indicate that an outmoded understanding of heart disease still dominates the way it is treated. According to the so-called new view of heart disease, a major constriction in the coronary artery is not where a future heart attack will occur. “There’s lots of data to show that opening a narrowed artery will not reduce your chances of having a heart attack,” said Dr. Waters, citing the one exception. “If, however, a person is having a heart attack, and that person has an artery-opening procedure while having the heart attack, there is good evidence that this will reduce the risk of dying of that heart attack.” In other words, the procedure will have no effect on future heart attacks.

The old model for the development of a heart attack is based on heart disease as a plumbing problem. The metaphor, which is still served up to the public to explain heart attacks, goes like this: A coronary artery slowly becomes narrowed with plaque in much the same way a pipe becomes corroded with rust and other gunk. In time, the artery becomes so constricted that blood flow to the heart is eventually shut off with a blood clot.

New Mechanism for a Heart Attack

The new understanding of heart disease is far more complex and is based on the observation that the vast majority of heart attacks do not occur in the portion of the artery that is most obstructed. Instead, most heart attacks occur where plaque breaks off and a clot forms over the area that can abruptly stop blood flow to the heart. In this scenario, the plaque is soft, symptomless, and would not be seen as an obstruction to blood flow. Heart disease is an inflammatory process by which the coronary arteries are subjected to a constant cycle of irritation, injury, healing and reinjury that makes the plaque likely to rupture. The solutions are the standard prevention advice: stop smoking, and take drugs to reduce clotting, inflammation, blood pressure and cholesterol.

If the new view of heart disease has been around for more than a dozen years, why hasn’t this changed the way it is treated? Do heart surgeons know about it? “The interventional cardiologists know about it, but they ignore it,” answered cardiologist Thomas Graboys, MD, in a telephone interview. “A new breed of over-trained cardiologists has now flooded into the community,” said Dr. Graboys, professor of medicine at Harvard Medical School and president of the Lown Foundation. It is no longer the large urban-based academic medical centers that come overstocked with interventional cardiologists. They have now come to the community hospital near you. And there is a strong financial incentive for them to look for constricted arteries and open them. “Economics drive the train,” said Dr. Graboys. “The starting salary of an interventional cardiologist is $300,000-400,000 a year, and for one that has been in practice three years, it is $500,000 to $600,000.”

Dr. Waters also sees money as the driving force. “If you have chest pain and the cardiologist you see does coronary angiography (see sidebar below) and that pays for his kids to go to college; well, are you are more likely to wind up with that procedure?” He advises, “Get a second opinion from a cardiologist who is not in the same building, the same group, or the same hospital as the first opinion cardiologist.” Dr. Waters also suggests that people give careful thought to the type of cardiologist chosen for a second opinion. There are, he explained, regular cardiologists who prescribe drugs; interventional cardiologists who do cardiac catheterizations, artery-opening procedures and stenting; and cardiovascular surgeons who perform coronary bypass surgery. The received opinion will likely mirror the doctor’s area of expertise.

The number of people undergoing artery-opening procedures continues to rise not only because they are huge money-makers but they are also very effective at relieving the severe chest pain of angina, which is a common symptom of heart disease. They are virtually useless, however, in stopping the progress of the disease itself. “The public is looking for a magic bullet,” observed Dr. Graboys, who offered this advice to people who are not in an acute situation. “Go to a non-hospital-based doctor in the community. A well-trained internist can take care of the lion’s share of people with coronary heart disease. The vast majority of people do well on medication—cholesterol-lowering drugs, antihypertensives, low-dose aspirin.”

Still, clogged arteries cannot be good. Won’t they eventually close off? “The body performs its own bypass,” explained Dr. Graboys, describing what is often seen during cardiac catheterizations. “The body forms new blood vessels around the constricted area, thus restoring blood flow.”

Dr. Graboys knows whereof he speaks; he is a cardiologist at the Lown Cardiovascular Center in Brookline, Massachusetts, a second opinion consultation center affiliated with Brigham and Women’s Hospital. For over two decades, the Center has helped many people avoid unnecessary surgery. Long before others made this connection, Dr. Graboys began to see the stress test and cardiac catheterization—two diagnostic procedures—as somewhat akin to a conveyer belt that funnels people to an artery-opening procedure or bypass surgery. A constricted artery is discovered, often several (not at all unusual in anyone over age 55), and the person goes on to what doctors call “a cascade of interventions”. In fact, the odds are so high that a cardiac catheterization will set people on to this course of events that Dr. Graboys advises a second opinion before agreeing to it.

A second opinion is all the more important given that Dr. Lucas, the lead author of the American study, said her data suggest that the threshold for deciding who is a candidate for an artery-opening procedure has been lowered over time. “Rates of bypass surgery have leveled off. This is due to the fact that bypass surgery is clearly the more invasive procedure requiring prolonged anesthesia and use of a heart/lung machine, etc., but with artery-opening procedures you’ve got the person in the cath lab, and you’ve got that catheter in there already; it’s tempting to go ahead and do the procedure, so the threshold for performing the procedure might be lower than it would be for bypass surgery,” Dr. Lucas explained. “Many people who have had it done firmly believe that it saved their lives, but the benefit of most procedures is [solely] control of symptoms.”

What does all this mean to the average older person who suspects that one day he or she might wind up in an emergency room with chest pains? To Dr. Waters, the people who show up in the emergency room with severe chest pain are the ones most likely to require an artery-opening procedure. “The person I worry about is the person who goes to the doctor with a vague symptom and finds himself with a doctor who is not skilled at distinguishing the important symptoms of a heart disease from other symptoms.”

Asked for an example of a vague symptom that an unskilled physician might mistakenly identify as heart-related: “I was recently playing catch with my dog and now have shoulder pain,” he responded, suggesting that this could be enough to start the cascade of interventions. It is, in fact, common for symptom-free people to be told to have a stress test and this alone can start the cascade.

The cascade may be worth it, if all these cardiac procedures were lifesaving, but so far proof is lacking. “There is no evidence to show that artery-opening procedures will prolong life,” said Dr. Graboys, citing the exception of a person in the midst of a heart attack. “Although these procedures are good at alleviating the heart-related chest pain called angina, so too are drugs and lifestyle changes.” Dr. Graboys continued, “Data show that people with angina can be treated successfully with medicines and lifestyle changes like stress reduction, regular exercise, smoking cessation, and treatment of risk factors like high cholesterol and high blood pressure.”

For more information on different types of angioplasty, see below.

The U.S. study led by F.L. Lucas, PhD, was supported in part by a grant from the National Institute of Aging. The Canadian study led by David A. Alter, MD, PhD, was supported in part by a grant by the Heart and Stroke Foundation of Canada.

Maryann Napoli, Center for Medical Consumers ©
April, 2006

Cardiac Procedures Explained

Cardiac catheterization is a general term for a group of procedures involving a thin tube (catheter) inserted into a blood vessel in the groin or arm. The catheter is threaded up to the coronary arteries andpositioned either in the chambers of the heart or at the arteries supplying the heart. Once the catheter is in place, the doctor can inject a special dye or fluid that is visible by x-ray. This produces motion x-ray pictures called an angiogram, which are used to diagnosed the health of the coronary arteries. Other names for cardiac catheterization are coronary angiography and coronary arteriography.

This diagnostic technique becomes therapeutic once the doctor decides to widen a constricted artery in another procedure called angioplasty. This can be done in several ways. The plaque can be pressed against the walls of a constricted artery with an inflated balloon at the tip of the catheter. In the currently most popular version of angioplasty, tiny wire cages called stents are used to destroy the obstruction and keep the constricted artery open. In the new study by Dr. Lucas and colleagues, artery-opening procedures were grouped under the name of percutaneous coronary interventions.