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Doctors Disagree About Effectiveness, Cost Of Stents

In the current hunt for savings in the health care system, one idea sounds simple: Just get doctors to quit ordering unnecessary procedures and tests. Evidence suggests that some doctors dole out more treatment, and yet their patients don't fare better.

If you talk to doctors, though, the idea of cutting back starts to sound more complicated. Take, for example, Drs. Paul Teirstein and Eric Topol. Both are interventional cardiologists practicing at Scripps Health in San Diego. Yet the two physicians see their field, and health care in general, from opposite poles. Teirstein calls Topol a good friend, but says, "We disagree a lot. I find him challenging."

One of their biggest disagreements concerns stents, tiny metal tubes that cardiologists use to open clogged arteries and relieve chest pain. Studies show that cardiologists sometimes use stents in scenarios where research would indicate they are unnecessary.

Topol says he believes as many as 20 percent of all stents aren't really needed. He notes that annually, 1.2 million patients undergo a stent procedure. "Undoubtedly, that's more than we need to do," he says.

Sitting in the same California hospital, Teirstein says he's not convinced by the research Topol leans on. Teirstein is an ardent believer in the technology and puts in an average of seven stents a day. "I definitely have a bias towards stents," he says. "I have a lot of experience with stents. I've seen patients do so much better."

Conflicting Research, Competing Motives

It's clear that many patients with serious blockages in their arteries have benefited greatly from stents. But a lot depends on the exact type of treatment involved. A trial called COURAGE — short for Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation — found that for patients with "stable angina," stents are no better than drugs at preventing heart attacks or death.

Drugs take a while to work, Teirstein argues, while stents offer an "instant fix." After surgery to receive a stent, patients tend to go home quickly and feel better almost immediately.

Topol counters that cardiologists, like most doctors, get paid on a fee-for-service basis. The more stent procedures they do, the more money they make. Topol says that dynamic has to drive up the number of stent procedures. "Some of it is financially motivated, but at a subconscious level," he says.

Teirstein says income is not the driving factor. "The physicians I know do what I do, which is say, 'If this was my mother or father, what would I do?' Financial incentive is the last thing you think about," he says. "What is inspiring is trying to help a patient."

If policymakers are to uncover health care savings in curbing unnecessary procedures, they'll need doctors to believe that at least some of what they do is wasteful. As the ongoing conversation between Teirstein and Topol shows, individual doctors make sense of the available research differently, as each makes choices for individual patients.

The one thing Topol and Teirstein agree on is that they want to be able to make those choices. They're fine with telling each other what to do, even when they don't agree. They just don't want the government or insurers telling them what to do.

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