In this case, it's the tiny metal mesh tubes called stents that keep narrowed heart arteries open after angioplasty. In a study published online Monday in the journal Archives of Internal Medicine, the researchers found that overwhelmingly, doctors are giving even the lowest-risk patients costly drug-coated stents when they would likely get the same benefit -- and possibly fewer side effects -- from less-expensive bare-metal stents.
The estimated added cost of these debatable drug-eluting stents: $409 million per year.
"We use an awful lot of drug-eluting stents. From the perspective of doctors, they're giving the best thing to their patients. It's an emotional drive," said researcher John Spertus of St. Luke's Hospital in Kansas City.
Spertus, a cardiologist, collaborated on the study with other researchers at the University of Missouri-Kansas City, the University of Kansas Medical Center, Washington University, Harvard University and the University of Colorado.
America's fascination with health care technology has promoted the use of such devices as $1 million surgical robots and $100 million proton cancer therapy centers long before their value has been proven.
Drug-eluting stents were hailed as a major innovation when they were introduced a decade ago. Arteries with conventional bare-metal stents can narrow again as scar tissue grows in the blood vessel. The new stents release drugs that stop the tissue growth. Drug-eluting stents now account for more than 75 percent of all the stents implanted in the U.S.
Calling drug-eluting stents a "huge advance," Spertus said they have been shown to reduce the likelihood that patients will need a second angioplasty to keep their arteries open. But drug-eluting stents have serious drawbacks, too.
Priced at about $1,600 each, they cost about $1,000 more than a bare-metal stent. And heart patients typically need two or three at a time.
And drug-eluting stents are more prone to develop blood clots, so patients are required to take blood-thinning drugs for a year or longer. The drugs mean out-of-pocket costs to patients and the risk of easy bruising and prolonged bleeding from even small cuts. Patients also must postpone elective surgery while they take the drugs.
And while drug-eluting stents may keep patients from needing additional procedures, they offer no advantage in preventing heart attacks or prolonging lives.
In the new study, the researchers analyzed more than 1.5 million procedures contained in a national data registry. They found that 83 percent of patients at highest risk of having their arteries reclose received drug-eluting stents. However, 74 percent of those at lowest risk also got the costlier stents.
The way individual doctors used stents varied dramatically, with some doctors using drug-eluting stents for just 2 percent of procedures and others using them on all their patients.
"Treatment is being dictated more by who patients see rather than by who the patients are," Spertus said.
Eliminating the use of drug-eluting stents on low-risk patients "should be a societal 'no brainer,'" said Peter Groeneveld, a physician and health economist at the University of Pennsylvania.
In the United Kingdom, for example, fewer than half of angioplasty patients receive drug-eluting stents with no evidence that they are receiving poor treatment, Groeneveld wrote in an editorial that accompanied the study.
"New medical technologies are the primary drivers of rising health care costs, but the U.S. health care system has generally performed poorly in incorporating new drugs, devices, imaging techniques and invasive procedures in a manner that maximizes the value," Groeneveld wrote.
Spertus said he would not advocate denying drug-eluting stents to all low-risk patients. Instead, he and the other researchers proposed that doctors develop strategies for reducing their use in these patients by half. That would save more than $200 million annually yet still offer physicians leeway in how they treat patients.
Patients also should get a greater say in what kind of stent they receive, whether to choose a slightly higher risk of a second angioplasty or the trials of a year of drug therapy, Spertus said.
"Patients aren't being given the alternatives. They don't feel they participate in the decision," he said. "We should be very transparent about the costs and benefits and consider their preferences."
Spertus said he didn't know whether patients would choose bare-metal stents if given that option. He is planning a research study that would look at ways doctors and patients can share in that decision.
"We want to respect patients' values," Spertus said.
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