More than a fifth of all coronary stents given to Medicare patients at hospitals nationwide from 2019 to 2021 are medically unnecessary, driving more than $2.4 billion in unnecessary program spending during those same years and exposing those patients to potential complications, according to a new Lown Institute analysis.
By reviewing Medicare claims for 1,773 hospitals and outpatient facilities capable of performing two types of percutaneous coronary interventions—coronary stent and balloon angioplasty—the think tank found more than 229,000 procedures that met the criteria for overuse.
This translated to an unnecessary stent every seven minutes, Lown said in its report, with Medicare paying about $9,000 of each procedure’s $10,600 price tag.
“When physicians continue a practice despite the evidence against it, it becomes more dangerous than useful,” Vikas Saini, M.D., a cardiologist and president of the Lown Institute, said in a statement. “The overuse of stents is incredibly wasteful and puts hundreds of thousands of patients in harm’s way.”
The group also found a wide range of overuse across the nation’s general hospitals with higher stent volumes.
Those on the highest end of the spectrum’s stent overuse represented over 40% or 50% of their overall total. Northwest Texas Hospital (Texas) and Riverview Regional Medical Center (Alabama) were named as the worst offenders with 52.6% and 50% of their total stent procedures meeting overuse criteria, respectively.
Meanwhile, the 10 high-volume hospitals with the lowest rates of unnecessary use had proportions all below 8%, Lown wrote. Magnolia Regional Health Center (Mississippi) and Kaiser Permanente San Francisco Medical Center (California) received top marks with 1.2% and 1.6% of their total stents meeting the criteria.
Lown’s report included a state-by-state breakdown of hospitals with the highest and lowest rates of overuse. These facilities’ rates could vary broadly, with the widest gulf found between South Carolina’s MUSC Health Columbia Medical Center Downtown’s 42% and Grand Strand Medical Center’s 6%.
Human anatomy is 'more complicated' than unclogging a pipe
Lown defined overuse as when a stent was given to patients with a diagnosis of ischemic heart disease at least six months prior to the procedure. That criteria excluded those with a diagnosis of unstable angina or heart attack during the two weeks prior to a procedure as well as those who had visited the ED within two weeks.
Study data published in the past several years suggest that stents for stable or chronic coronary disease—not acute heart attacks or threatened acute heart attacks—bring no benefits compared to medication-based treatment and come with a rare risk of complications such as coronary artery perforation or hospital-acquired infections, cardiologists explained in a Tuesday virtual webinar hosted by Lown.
The challenge, explained David Brown, M.D., clinical professor of medicine in the division of cardiovascular medicine at Keck School of Medicine of USC, is that it’s hard to break the intuitive interpretation that stents are similar to a plumber unblocking a clogged pipe.
“We’re stuck using a 19th and 20th-century model that … the only way to fix your bathroom is to completely unclog your pipe and let the water flow freely again,” he said during the webinar. “Unfortunately, human anatomy is much more complicated than that, and the science really doesn’t support that model.”
Thomas Power, M.D., senior medical director of cardiology and sleep programs at Elevance Health subsidiary Carelon Medical Benefits Management and a fellow of the American College of Cardiology, agreed and added that a combination of the industry’s fee-for-service payment structure and pressure from patients could also be keeping practitioners from shifting away from stents.
“There may be some medical-legal concerns, because if a patient who has a stable chronic coronary disease does not undergo a PCI and has an adverse outcome that we know is not due to failure to open the stable lesion, but it can be difficult to carry that opinion [to] a jury who sort of buys into that hypothesis.”
Saini, who moderated the webinar, noted that his group’s estimate of $2.4 billion in unnecessary Medicare spending should be viewed as a conservative estimate—while the analysis used Medicare Advantage and fee-for-service claims for 2019 and 2020, only fee-for-service claims were available at the time for 2021.
Still, the money put into this and other so-called “low-value” procedures is substantial and could be put to better use to ensure better health and well-being across the country, Saini and the other panelists said.
“Maybe improving access to care for those who have difficulty accessing care, maybe more focus on prevention and lifestyle choices rather than cure—I mean, there’s so much that could be done with that amount of money,” Power said. “I think it behooves us to wake up and admit that we’re in a resource-constrained system, and to think more globally, to think outside of the patient sitting in front of you and … think more about the whole.”