Hundreds of thousands of times each year, doctors install stents (tiny wire cages) in blocked heart arteries, not only to provide better blood flow to the body’s most important muscle but also ostensibly to provide pain relief to patients. Surgeons also perform tens of thousands of different, minimally invasive procedures with the help of elaborate and expensive robot devices.
All these surgeries, which cost patients tens of thousands of dollars and carry real risks, are evidence-based and well-supported in their outcomes, right?
Wrong. And here’s hoping, not dead wrong.
Yet more evidence has emerged that stenting may offer little more than a placebo or sham benefit to patients, while robotic surgeries cost more, last longer, and are no more effective than standard laparoscopic operations.
It’s disturbing to see the medical establishment’s reactions to the latest research, which builds on a growing number of studies that provide evidence about both stenting and robotic surgery.
Cardiologists quoted in the New York Times about the stent study—yes, it’s small and care must be taken in interpreting its meaning and potential impacts—used terms like humbling and unbelievable to discuss the findings. They said the data call into question doctors’ readiness to stent patients with heart woes, which still are a leading killer of Americans, who suffer almost 800,000 heart attacks annually.
More than 500,000 patients globally get stents, operations that can cost, with the device price included, anywhere from $11,000 to $41,000 at U.S. hospitals.
British researchers, however, sowed deep doubt about stents with a startling clinical trial,with 200 well-informed volunteers. They were treated with aspirin, statins, and drugs that reduce blood pressure and those that slow the heart or open blood vessels. Then, all of them had a catheter snaked in their veins as if they would be tested for arterial blockage, and for possible stenting. Some got stents, while others did not. Neither the patients nor their doctors knew which did or didn’t. All of them got extensive, standard post-op care, including with check-ups and continued drug regimens.
The patients with stents had greater blood flow in their once-blocked arteries, and they reported after six weeks that they felt much less pain. The patients who didn’t get stents also had much less pain—and they were faring as well as those who got the devices. So if a key objective of the stent was to relieve chest pain, it alone may not have accomplished that goal. It may just have made patients feel better on their own or due to less invasive care, such as with the drugs they were taking.
Yes, the patients were evaluated after just six weeks and there were only 200 of them. But doctors long have known that cardiac procedures and their outcomes, as one analogy draws them, aren’t as simple as just fixing one pipe and unplugging a kitchen sink.
Further, it isn’t as if patient advocates haven’t been pounding doctors and hospitals about their questionable reliance on stenting: Vinay Prasad and Adam Cifu—both physicians, researchers, and professors—published “Ending Medical Reversal,” their work on the challenges of unwinding medical myth making, two years ago. That popular book received tons of press coverage, and it delves deeply into the rise of stenting and the absence of evidence to support its huge and widespread adoption. David Epstein, a reporter with Pro Publica, the Pulitzer Prize-winning investigative site, in February also wrote in detail about stents and other medical services that doctors and hospitals persist in performing, despite a dearth of fact-based evidence to support them.
Which bring us to robotic surgery. It’s a booming and growing business, used in tens of thousands or procedures. Doctors say the devices help them a lot—this may be especially true for younger and older practitioners. They have asserted the mechanical assistance improves patient outcomes, justifying the big costs for each robot. The devices cost $1.5 million to $2.3 million each, not including maintenance, upkeep, and other associated costs. Intuitive Surgical and its da Vinci system dominates the field.
Despite surgeons and hospitals trumpeting robotic surgery as a technological boon for patient care, medical researchers have kept building evidence that the pricey systems may be tough to justify. They don’t pencil out in rectal cancer and kidney removal procedures, the Wall Street Journal has reported, based on new information published in the Journal of the American Medical Association.
The rectal cancer study examined data on hundreds of patients, while the kidney research looked at data on thousands. Both found that, compared with standard laparoscopic procedures, robot surgeries lasted longer and cost more, without showing significant differences. The cost difference for both exceeded $1,000. This research, by the way, echoes findings—now four years old—that robotic hysterectomies, based on data on procedures performed on hundreds of thousands of women, had higher costs with little added benefit.
In my practice, I see not only the significant harms that patients suffer while seeking medical services but also their terrible struggles to afford medical care. It’s wrong and unacceptable for modern medicine to fail to adopt evidence-based practices, and to subject patients to procedures lacking demonstrable benefit, especially when many of these may carry added and crushing costs.
There’s clearly a need for constant, smart evaluation of medical practices. The new stent study, experts say, likely could not have been conducted in this country due to ethical and legal concerns about human experimentation, especially if it provides patients with a proven therapy to the possible harm. But that does not mean that researchers can’t or shouldn’t figure innovative ways to reexamine orthodoxies, and to force reconsideration as to whether drugs and devices already in use are safe and effective.
Doctors who keep going along to get along, neglecting the homework they need to stay up to date, are practicing a contemporary version of voodoo medicine. Over-testing and over-treating adds hundreds of billions in wasteful costs—and American patients need to revolt against their harms and gouging expense.
