March 3rd, 2011
Pennsylvania Hospital: 141 Patients Received Unnecessary Stents
Larry Husten, PHD
A hospital in western Pennsylvania says that at least 141 heart patients received coronary stents that weren’t needed, according to an article by Luis Fabregas in the Pittsburgh Tribune-Review. Westmoreland Hospital in Greensburg, PA has informed the patients, and the two interventional cardiologists who performed the procedures have resigned. The hospital says that it will cooperate with the Office of the Inspector General.
The episode had its origins early in 2010 when “several unidentified physicians alerted hospital officials about a pattern of excessive stent use in the cardiac catheterization laboratory,” according to the news report. The hospital then initiated an external review of the seven cardiologists and two interventional radiologists who implanted stents at the hospital. The first preliminary review was completed in December and raised concerns about excessive stent implantation by two cardiologists, Ehab Morcos and George Bousamra. They resigned their privileges at the hospital on January 12th when they were asked about the results of the review.
The hospital then began a thorough review of all 753 cases performed in 2010 by the 2 cardiologists. The review by 8 independent cardiologists found that 149 stents had been implanted unnecessarily in 141 people. The hospital has now hired an “internationally recognized university” to provide quality control for the cath lab.
“The fact that we investigated this quickly, in an in-depth and professional manner, in a transparent way, should signal that we’re committed to having a transparent organization,” said the hospital’s CEO.
The incident is reminiscent of a similar case in Maryland, where the formerly prominent interventional cardiologist Mark Midei has been accused of implanting hundreds of unnecessary stents. Many observers have wondered whether the Midei incident would spark similar investigations in other communities. It appears that the concerns about the Pennsylvania case were first raised when the Midei case began to receive public attention.
8 Responses to “Pennsylvania Hospital: 141 Patients Received Unnecessary Stents”
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The tip of the proverbial iceberg. Hospitals & interventionalists should be very nervous. The problem (as we all know) is that hospitals & cardiologists have a symbiosis whereby each feed off the other’s greed. More whistleblowers are lurking. Not every patient who has 5 seconds of fleeting chest pain needs a contrived abnormal nuc, cath, and stent.
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nada
this is of importance and concern all over the world. each of interventionalist should be vigilant.
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none
The essence of this issue relates to the qualified selection and training of interventional cardiologists with the transference and maintenance of the standards of care and appropriateness criteria for application of such a treatment stratagem in the realm of community practice. Of course, embedded within is the remuneration component which drives overuse. The trigger for such expose’s is usually an adversarial competitive practice environment.
There are blatant transgressions…like stenting obviously less than severe lesions in asymptomatic patients. This sounds criminal to me. Then there are a wide range of inappropriate interventions…whose legal implications are unclear to me. Stenting an asymptomatic patient with a severe prox LAD stenosis (and maybe add a NST normal or with minimal abnormality)? I am curious about the nature of the claims above.
I predict legislated FFR in elective cases and 3rd party review before approval. Those dudes slaughtered the fatted calf and left nothing by their unethical practice. Maybe they can get a job on Wall Street.
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none
I find the battering of interventional cardiologists in various blogs by other physicians, particularly fellow non-interventional cardiologists, quite disconcerting and almost wonder if the sentiment is derived from personal bias rather than concern and science.
Interventional cardiologists all over the world work day in and day out APPROPRIATELY fixing STEMI and NSTEMI/ACS lesions, often at ungodly hours. The “grey” areas are the elective patients where MOST are truly symptomatic and hence benefit from PCI but yes, some are truly borderline calls who, in general, fall into one of these categories:
1. Bogus sounding chest pain referred directly to the cath lab almost always by the internist or primary cardiologist (not the interventionalist), end up with with an unequivocally tight lesion that is occulostented because from that point onwards no one’s comfortable leaving it
2. Bogus sounding chest pain that’s recurrent despite negative stress test, referred for cath by internist or cardiologist – lesion found –> after a “now what?” discussion with patient and referring MD, stented (again because no one’s comfortable leaving it).
3. Nonlimiting anginal chest pain, perhaps even a positive (but not high risk) functional study, currently not on optimal beta blockade etc, referred to the lab by the internist or cardiologist. Lesion found – stented.
4. Asymptomatic patient, screening cardiac CT done disease found – referred for cath without any stress testing to document burden of ischemia. Lesions found – stented.
5. Asymptomatic patient, screening nukes done – mild ischemia – referred for cath. Lesions found – stented.
6. Bogus (or even real) sounding chest pain, clearly non-critical moderate disease, stented without any further evaluation (stress test or FFR).
Scenarios #1-5 are cases where the problem is with the referral. It’s not that the referring doctors are doing a bad job (or are unintelligent) – in the real world such patients are difficult to deal with and repeated symptoms prompt them to ask their doctor to “do something”. Or when screening tests are done the physician feels the need to “do something”. Arguably one may decline to do the case but it doesn’t always work like that (I do refuse to cath asymptomatic patients unless demonstrable large areas of ischemia). Since the patient is referred to the lab there is almost by definition an implication that the referrer feels that there may be significant disease which, if found, needs fixing. As an interventionalist I’ve found that in Western countries (especially the US) referring doctors get very uncomfortable with the knowledge that their patient has a critical lesion and it’s treated medically. In Asia, things are mixed and I find patients are much more willing to try medical therapy.
Scenario #6 is truly malpractice and I’m sure there are a few bad apples everywhere doing that kind of stuff but please …….. to imply all interventional cardiologists are out there skimming the world is really inaccurate and inappropriate, and is a reflection of how fragmented the medical community is.
Cheers.
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I’m an interventional cardiologist who works long hours for a FIXED salary.
– Seems like yet another reason to move from fee-for-service medicine to some version of capitation. Under the curent system of reimbursement there is tremendous incentive to perform the marginal procedure not just in cardiology but in all aspects of healthcare.
– If we received no additional $ for incremental imaging, procedures, etc, the world might look very different.
-Alternatively, if there is no incentive to perform these procedures (capitation, one might imagine even greater difficulty in obtaining weekend/evening coverage.
what about CEO?
Unfortunatly the journalist did not tell us or did not invastigate toward the CEO. It would be interseting to know if the two collegues were (or not) congratulated in 2009 and 2010, before their friends (?)alerted hospital officials about their excessive stent use.
I would personnally think that the increased activity of cath lab was first considered as a good opportunity by the financial team of the hospital!
Am I wright?
dr Usdin, non invasive cardiologist.
Paris
France.
April 17, 2011.
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no conflicts of interest