Greed in Medicine Turns to Semantics for Help in Fooling the Unwary — the Culprit in this Case Is the American College of Cardiology — Its Intentionally Blatant Misuse of Language further Conceals Hundreds of Thousands of Medically Inappropriate Stent Placement Procedures — a Good Example of Professional Scumbaggery in Action

© 2013 Peter Free

 

30 October 2013

 

 

As a medically trained lawyer, I got a cynical laugh out of this latest example of the Medical Establishment gone completely awry

 

The Hippocratric Oath has apparently been turned into greedy hypocrisy.

 

If truth-telling is taking big chunks out of your profit margin, get rid of it — even if tens of thousands of medical patients will then be at risk.  Right?

 

Bloomberg reports that the American College of Cardiology was upset by state regulators and insurers taking a profit-evaporating view of its members’ marked propensity to do potentially harmful and unwarranted stent-placements.

 

As a result, the ACC decided to change the medical procedure guidelines language that had previously classified stent-placement procedures as “appropriate”, “inappropriate”, and “uncertain”.

 

The evidentiarily straightforward term “inappropriate” has been replaced with the wiggle-room phrase, “rarely appropriate.”

 

And “uncertain” — meaning that you better have a good evidence-based reason to do the procedure — opens up into the broader and more profitable land of, “may be appropriate” — meaning, why not take a flyer and do it anyway?

 

 

To understand the malpractice-concealing implications of this underhanded scheme — recall the following medical background about stenting

 

Stents are mesh tubes that can be placed in blood vessels, most usually the heart’s arteries, to keep them open against the blockages, which can cause heart attacks.

 

As with almost all medical interventions, these tubes (and the procedures that insert them) can cause problems larger than those they are supposedly going to fix.

 

The medical literature demonstrates that there are often more effective and/or safer ways of dealing with the health problems that the stent-placements are aimed at:

 

 

With 700,000 procedures in the U.S. annually -- at an estimated cost of $14 billion -- appropriate use of the devices has become one of the hottest issues in cardiology.

 

Eight studies have found stents are no better than drug-based therapy in preventing heart attacks and death in patients with stable heart disease.

 

As many as 12 percent of such elective stent cases were “inappropriate” under the ACC’s guidelines, according to a 2011 study in the Journal of the American Medical Association, while 38 percent were “uncertain,” leaving about half that were “appropriate.”

 

Unnecessary stents cost the U.S. health care system $2.4 billion a year, said Sanjay Kaul, a cardiologist and researcher at Cedars-Sinai Medical Center in Los Angeles.

 

About 7 million Americans received coronary stents over the past decade.

 

Roughly half of them had a heart attack or other acute syndrome. Stents are beneficial in such cases, most cardiologists agree.

 

Among the other half -- elective-surgery patients in stable condition -- at least a million didn’t need the implants, according to estimates by William Boden, the chief of medicine at a Veterans Administration hospital in Albany, New York, and three other researchers.

 

“They’re gilding the lily to justify what’s being done too frequently and shouldn’t be done at all.”

 

Patients who get unnecessary stents live with foreign objects in their arteries that pose potentially fatal risks of blood clots, bleeding and new blockages from scar tissue, Boden said.

 

To discourage overuse, the ACC, along with the American Heart Association and six other medical societies, initiated its appropriate-use criteria for stents in 2009. The guidelines rated the evidence for stenting and bypass surgery for some 180 different patient scenarios.

 

© 2013 Peter Waldman, Doctors Use Euphemism for $2.4 Billion in Needless Stents, Bloomberg (29 October 2013) (extracts) (underline added)

 

 

Semantic manipulations that go against the evidence

 

The statistical effect of the new semantics is to grossly and unwarrantedly narrow the area in which physicians and surgeons can be criticized for doing something that the evidence already indicates is a bad thing.

 

Where once something was clearly inappropriate, now it “may be” appropriate.

 

How’s that for changing the burden of proof in medical cases?  Now the arguably malpracticing provider can argue that it “might” have been appropriate and furthermore:

 

“Y’alls gonna have to prove it t’wern’t.”

 

If you are statistically inclined, you immediately recognize that a 1 in a 1,000,000,000 chance of success qualifies as a “might have been appropriate.”  The College’s medically unwarranted new guideline language effectively opens up hundreds of thousands of patients to the College’s now approved misuse of stent procedures.

 

From the ACC’s implied perspective, when at least $2.4 billion (USD) each year is a stake for its members, what has medical evidence got to do with it?

 

 

If the American College of Cardiology were a lobbying group, we might look the other way — but in the light of professional ethics, it should be held to a much higher standard

 

Medical doctors like to pretend that they can police themselves.  The result has been the proliferation of quasi-advocacy groups that sidelight in issuing clinical guidelines.

 

This has always been structurally problematic.  And with the practically unopposed intrusion of undisguised greed into the entire medical field, these guideline-setting organizations have been prolifically infiltrated by self-interested, evidence-ignoring profit-seekers.

 

This is a socially troublesome issue that I have previously addressed:

 

 

here — British Medical Journal study found that conflicts of interests sabotaged the reliability of medical guidelines issued in the US and Canada

 

and

 

here — Harvard professor of medicine, Jerry Avorn, warned that guidelines issued by the American Association of Clinical Endocrinologists — for the treatment of diabetes — had probably been influenced by pharmaceutical financial interests sitting on the issuing panel

 

Organizations that only pretend objectivity — like the American College of Cardiology in its alleged distortion of language — should not have a dominating say in what we recognize to be evidence-based.

 

The ACC, in this instance, is a good example of why Greed is incapable of policing itself.

 

 

The ACC’s response to Bloomberg’s article?

 

The American College of Cardiology ignored Bloomberg’s statement of facts regarding the changes to its "appropriateness" guidelines language.

 

It settled, instead, for implying that doctors are competent, well-intended, and only rarely mislead their patients.  And it closed by throwing in the incontrovertible and contextually irrelevant fact — given that no one disputes it — that stent placements often save lives.

 

In other words, the ACC completely missed the fundamental point to having clinical guidelines at all — namely, the ability to enforce them in light of the situationally appropriate medical evidence:

 

 

Today Bloomberg published an article highlighting overuse of stenting procedures, and deaths linked to stenting.

 

While we cannot comment on specific patients or cases, we do not condone any situation where patients are put at risk for personal gain.

 

However, as I said in the article, it is important to remember that the majority of physicians are doing the right thing for their patients, and cardiologists who’ve been accused of fraud or are serving prison time are outliers who don’t represent the overwhelming majority.

 

The ACC currently has several tools in place to assist with decision-making about percutaneous coronary intervention (PCI) procedures including AUC for coronary revascularization and clinical practice guidelines for PCI and coronary artery bypass graft (CABG) surgery.

 

It is important to remember that PCI procedures are life-saving in appropriate situations.

 

© 2013 John Gordon Harold and David May, The ACC’s Response to the Spotlight on Stenting, American College of Cardiology (26 October 2013) (extracts)

 

Dr. Harold is President of the American College of Cardiology.  That he signed his name to this intellectually inane response shows just how far his organization is removed from the concept of enforceable medical ethics.

 

 

The moral? — When profit and ethics collide in the same body, avarice wins

 

The American College of Cardiology’s underhanded revision of procedural “appropriateness” is a shining example of professional scumbaggery in action.