Tuesday, March 12, 2013

The Bypass/Angioplasty Fad

Wonderful article at Harvard Magazine on Dr. David S. Jones, who has spent the past decade documenting how little benefit patients actually receive from coronary bypass surgery or angioplasty:
Each intervention, promising lifesaving relief, was embraced with enthusiasm by cardiologists and cardiac surgeons—and both techniques often do provide rapid, dramatic reduction of the alarming pain associated with angina. Yet, as Jones painstakingly explains, it took years to show whether the procedures prolonged lives; in both cases, subsequent research deflated those early hopes. The interventions—major procedures, with potentially significant side effects—provided little or no improvement in survival rates over standard medical and lifestyle treatment except in the very sickest patients. From his detailed study, Jones draws broader conclusions about the culture and practice of modern medicine. . . .

Like bypass surgery, angioplasty went from zero to 100,000 procedures annually with no clinical trial to assess long-term outcomes—based on the logic of the procedure and patients’ reports of how much better they felt. Yet the first clinical trials, which appeared in the early 1990s, showed no survival benefit of elective angioplasty as compared with medication. . . .

“Patients are wildly enthusiastic about these treatments. There’ve been focus groups with prospective patients who have stunningly exaggerated expectations of efficacy. Some believed that angioplasty would extend their life expectancy by 10 years! Angioplasty can save the lives of heart-attack patients. But for patients with stable coronary disease, who comprise a large share of angioplasty patients? It has not been shown to extend life expectancy by a day, let alone 10 years—and it’s done a million times a year in this country.” Jones adds wryly, “If anyone does come up with a treatment that can extend anyone’s life expectancy by 10 years, let me know where I can invest.”

“The gap between what patients and doctors expect from these procedures, and the benefit that they actually provide, shows the profound impact of a certain kind of mechanical logic in medicine,” he explains. “Even though doctors value randomized clinical trials and evidence-based medicine, they are powerfully influenced by ideas about how diseases and treatments work. If doctors think a treatment should work, they come to believe that it does work, even when the clinical evidence isn’t there.”
As Jones explains, part of the problem is that doctors focus on the benefits of what they do and tend to ignore the risks. Successful heart surgery may help some patients, but as the overall survival numbers show, that benefit is balanced out by all the people who are hurt. Hospitals are as dangerous as war zones, killing, by some estimates, 100,000 Americans every year. If you value your own life, stay out of them as much as you can.

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