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Best health-care system…not (5)

Years ago, I attended a public forum on health care where a local doctor let the cat out of the bag. The most expensive technology in American medicine, he explained, is the pen the doctor uses to write orders with. The great scandal of American medicine is how often there is little or no scientific evidence guiding what the doctor writes.

Today’s example concerns coronary bypass grafts, angioplasties and stents, with Dr. Norton Hadler of the Univ. of North Carolina School of Medicine as our expert resource. In the U.S., more than a million patients undergo some cardiac procedure each year.

Yet four large, randomized controlled trials of typical interventions found that patients who had procedures did not live longer, have less chest pain, or suffer fewer heart attacks than they would have without the procedure. “NO ONE was advantaged by submitting to the intervention,” Dr. Hadler declares.

So of course, cardiologists all share this news with their patients when they discuss treatment options. Not exactly, according to Dr. Hadler.

Here’s the story he shared on abc.com and Healthbeat blog.

Not long ago, I attended “Grand Rounds” at a prominent medical school where the professor and director of the Cardiac Catheterization Laboratory was holding forth on the mechanisms by which newer stents can stay open longer. I asked him how he explains the stent option to a patient with chest pain in view of the results of [the four controlled trials].

He, of course, was aware of all these trials. Even though the trials recruited patients with four very typical patterns of disease, he suggested many patients do not quite fit these categories. He was willing to rely on his clinical judgment to infer that a particular patient would be advantaged because he is endowed with a special level of expertise.

I asked him if he told the patient that his judgment was superseding a compelling science and that his judgment had not been subjected to testing. He ducked the question.

Too many patients have a “lottery mentality,” Dr. Hadler adds — even if there’s only one chance in a thousand this will work, I could be that one. But according to the actual scientific evidence on interventional cardiology, you don’t have to buy a lottery ticket to win. The patients who didn’t have procedures did as well as the ones who did.

Bill Sez: How much do you suppose those million procedures cost each year? How much do hospitals get paid for the patients in their operating rooms? How much do doctors get paid for doing the procedures? How many of them tell patients what the evidence actually shows?

Considering this example, is it any wonder how the U.S. spends so much more per capita than any other country while getting such mediocre results? (H/t to Maggie Maher for introducing Dr. Hadler.)

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