Tuesday, July 1, 2008

Bad medicine?

The New York Times has a pretty interesting article up about CT angiography and whether or not it's completely useless. Actually not really, it's a fairly balanced article, to my eyes, that seems to examine all the angles. I should note that while it's relatively close to my field, I don't know the cardiac imaging literature at all, so I can't really comment on whether it's any good... though we did work with a Doc who wanted to do them on everybody... whatever population or intervention we were thinking of doing had to somehow include a CT, but that probably had more to do with his personal obsession than the technology itself. Certainly if you look at the video with the article, you gotta admit it's really cool looking... so it's gotta be good, right?

My impression is that they're overselling the cancer risk, but the fact that it's expensive and possibly worthless clinically and causing asymptomatic people to get stents which might also be useless... seems fairly troubling. And paragraphs like these make you wonder whether we incentivize this stuff exactly wrong:
Fees from imaging have become a significant part of cardiologists’ income — accounting for half or more of the $400,000 or so that cardiologists typically make in this country, said Jean M. Mitchell, an economist at Georgetown University who studies the way financial incentives influence doctors.

Besides generating profits themselves, the scans enable cardiologists to find blockages in patients who have no symptoms of heart problems. Doctors can then place stents in patients who would not otherwise have received them, generating additional revenue of $7,500 to $20,000 per patient.

I also like the "I don't need no stinkin' evidence" doctor.
Cardiologists like Dr. Brindis hurt their patients by being overly conservative and setting unrealistic standards for the use of new technology, Dr. Hecht said.

“It’s incumbent on the community to dispense with the need for evidence-based medicine,” he said. “Thousands of people are dying unnecessarily.”

That's right, Dr. Hecht has a hunch that this is really helping people and you should just trust him. He actually might have a point if the situation is that trials are currently underway to determine the benefit and just haven't been completed... I can see how you might want to use the new technology, if the risk was minimal, based on your judgment... but if it's actually the case that studies have already been done that have found no benefit, then he's talking crazy. I don't know the answer to that, but it certainly is an issue that waiting for solid evidence of efficacy might delay new technologies to market... but given the downsides of unintended consequences, I'm not sure there is a better way to go.

UPDATE: Looks like I missed a paragraph or two that indicate studies have never really been done, and now that Medicare is going to pay for it regardless, it doesn't appear there will be any.