When Less Is More In Coronary Care

As America's No.1 killer, heart attacks have been a top target of the nation's high-tech medical arsenal. Threading tiny catheters into blood vessels around a stricken heart, cardiologists can pinpoint blockages in an artery and dislodge the clots, or bypass them entirely by grafting veins. Costly yet commonplace, heart surgery symbolizes the heroic treatments that make U.S. medicine the envy of the world.

It may also symbolize something else for which the nation's health system is famous: waste. A groundbreaking new study from the Harvard Medical School concludes that 25% of the invasive procedures performed on elderly heart-attack victims--catheterizations, balloon angioplasties, and coronary bypasses--could be eliminated with no effect on patients' survival. The best way to reduce heart-attack deaths, researchers say, would be to transfer the $600 million wasted on unnecessary procedures to better care within the first 24 hours after an attack. Such treatments range from clot-busting drugs to better emergency response and CPR training.

The new study, published in the Sept. 21 Journal of the American Medical Assn., adds to a raging debate over how much of America's $900 billion health-care tab is squandered on inappropriate care. Researchers have documented overuse of dozens of procedures, from angioplasties to hysterectomies (table). More surgery often doesn't extend life: The Harvard team found that elderly heart-attack victims had lower mortality rates in New York, where 15% were catheterized, than in California and Texas, where 27% underwent the procedure. Such research shows that "we could cut medical costs by one-third in this country without any measurable effects on quality," says David M. Eddy, a Duke University physician and health economist.

Drawing on such studies, the Clinton Administration claimed its reform plan could expand coverage and brake the rise in health spending. Given the demise of President Clinton's universal-care bill, that claim won't soon be tested--but private insurers and health-maintenance organizations are pushing hard to realize similar savings. Their efforts are supporting a growing industry of "outcomes research" aimed at codifying the tests and practices that produce the best results for patients at the lowest cost. "It's time for medicine to figure out the value of treatment, instead of just what we charge for it," says David B. Nash, medical editor at the new Journal of Outcomes Management.

The Harvard researchers tracked 205,021 Medicare patients, 65 years and older, who suffered a first heart attack in 1987. The results depended on how far patients lived from a hospital with extensive cardiac facilities. They found that the "close" patients were 34% more likely to be catheterized and 25% more likely to get bypass operations. But over the next four years, the two groups' death rates didn't vary significantly, except in the first 24 hours after the heart attack: In that time, 7.5% of the patients who lived near a cardiac hospital died, vs. 8.9% of the other group. The difference was attributed to cardiac hospitals' greater experience, not to high-tech procedures.

The study's drawback: It doesn't tell doctors how to identify the one candidate in four who shouldn't undergo surgery. But cardiologists "know which patients are on the line--they can adjust," says co-author Mark McClellan. "If you've got $100,000 to spend, think hard about investing it in intensive response rather than a new cath lab."

PATIENTS INSIST. Skeptics contend such changes won't have much impact on medical costs. Tallying up all the feasible gains between now and the year 2000, economist Daniel N. Mendelson of consultants Lewin-VHI Inc. estimates that health spending would still grow five percentage points faster than inflation. "Identifying unnecessary procedures is one thing; eliminating them is another," Mendelson says. "If Mrs. Smith believes a bypass will relieve her pain, she's going to find a way to get it."

So far, the Mr. and Mrs. Smiths of America are getting what they want: From 1987 to 1990, catheterization rates among the elderly increased 42%, bypass rates rose 41%, and balloon angioplasty use doubled. But with the spread of managed care, medicine's focus is shifting. Advocates insist that eliminating wasteful care will actually boost quality. But judging from America's demand for high-tech miracles, the public remains to be convinced that medicine and economics are a healthy mix.

      Share of medical procedures of doubtful value
      CORONARY ARTERY BYPASS  up to 44%*
      CORONARY ANGIOPLASTY          42%
      HYSTERECTOMY                  41%
      CORONARY ANGIOGRAPHY   24% to 26%*
      *Range of findings from multiple postoperative studies  DATA: RAND CORP.
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