Overdosed America (27 page)

Spring came, and Mr. and Mrs. Wilkins returned north about six weeks after his surgery. He needed to see me every two or three days to
change the drain in his chest
so that the infection would not close over and become an abscess again. This procedure caused some discomfort, though over time we worked out a method of partially numbing the sensitive area by washing it with a local anesthetic, before reinserting the gauze wick. Mr. Wilkins remained good-natured with me throughout his ordeal.

His relationship with his wife of over 60 years was another story. Mr. Wilkins’ wife would usually come with him to his office visits. Virtually every time I walked into the exam room, I would find them arguing. They argued constantly. Previous to this, they had seemed a happy enough couple, and I had certainly never witnessed this kind of discord. Every time Mrs. Wilkins could talk to me out of her husband’s earshot, she would register the same complaints: “He asks me the same thing over and over again” and “He just isn’t himself anymore.”

One day Mr. Wilkins came to his visit without his wife. As I was working on him, concentrating on being as gentle as possible while I reinserted the drain, Mr. Wilkins said to me, “You know, Doc, I finally figured out the secret to a happy marriage.” With great interest, I stopped what I was doing and asked him what it was. “When we disagree,” he explained, “I just let my wife think she’s right.” I was impressed and humbled by his newfound wisdom. Two days later Mr. Wilkins returned to the office, again unaccompanied by his wife. At about the same point in the visit he said, “Doc, remember what I said last time about a happy marriage?” I certainly did. He said, “Well, just forget it.” I confess that I felt relieved.

The infection improved gradually over several months. Sadly, almost as soon as Mr. Wilkins’ infection resolved, his prostate cancer began to spread to his bones, causing him increasing pain. Radiation therapy did not help. When it became clear that the spread of his cancer could not be stopped, I arranged for hospice to become involved in Mr. Wilkins’ care, and he died peacefully without further hospitalization.

Despite the postoperative infection, Mr. Wilkins and his wife remained confident that he had received the best possible care after his heart attack—immediate access to the latest diagnostic procedures and heart surgery to protect him from another heart attack. Given what I have subsequently learned, I am not so sure.

There is no doubt that Americans have the best access to the latest and most expensive medical treatments. For example, heart attack patients in the United States who have reached the age of 65 are
five times more likely
to have a diagnostic cardiac catheterization looking for blocked arteries than are similar patients in Canada. And senior citizens in the United States are seven and a half times more likely to undergo balloon angioplasty or coronary artery bypass surgery. Obviously, this kind of care is very expensive. Overall health care costs are
75 percent higher per person
in the United States than in Canada and rose much more quickly during the 1980s and 1990s as these cardiac procedures were becoming standard therapy for heart attack patients in the United States. This is the price that Americans have to pay for unimpeded access to the most advanced medical care. But there is more to the story.

Despite the fact that we treat senior citizens with so many more heart procedures after heart attacks than are given in Canada, it turns out that one year after their heart attacks, patients treated in the United States are no more likely to be alive than those treated in Canada. Still, survival rates alone may not be a sensitive enough measure to detect more subtle clinical benefits. Perhaps the extra procedures done in the United States leave patients with better exercise capacity or an improved quality of life, medical outcomes that weren’t measured in this study.

This is unlikely, as we learn from a study published in NEJM that capitalized on the “natural experiment” created by the difference in post–heart attack care
between Texas and New York state
. Medicare patients in Texas were 50 percent more likely than similar patients in New York to have a cardiac catheterization within 90 days after a heart attack. Surprisingly, patient outcomes in Texas were actually
worse
over the following two years: The death rate was significantly higher in Texas (15 percent). Also, the patients in Texas reported about 40 percent more angina (heart pain), and 62 percent more of the patients in Texas were unable to do tasks that required moderate exertion compared with the patients in New York. The authors concluded that there appeared to be no benefit to the greater number of post–heart attack cardiac procedures being done in Texas.

Post–heart attack care has changed dramatically since the early 1980s, when only about 10 percent of heart attack patients in the United States underwent diagnostic cardiac catheterization. By
1998, more than half of our heart attack patients
were receiving this diagnostic test, with more than half of these going on to angioplasty or coronary artery bypass surgery. The increased number of procedures added about $10,000 (adjusted for inflation) to the care of each heart attack patient between 1984 and 1998. During this same time, the life expectancy of the average heart attack patient in the United States increased by about one year. An article in the health policy journal
Health Affairs
used these facts to argue that the increased number of procedures being done on heart attack patients in the United States was extremely cost-effective—$10,000 is a very small amount in terms of medical interventions for an additional year of life.

The story, however, gets a lot more complicated when we compare the situation regarding death rates due to heart disease and the cardiac care provided in the United States with that of the other industrialized countries. On a per-person basis for patients of all ages, the
United States does three and a half times as many coronary angioplasties and coronary artery bypass surgeries
as the other industrialized countries. One might conclude that this investment in the treatment of heart disease in the United States and increased longevity for heart attack victims is proof positive of the superiority of our treatment of heart disease, end of story.

Not so, according to data from the National Heart, Lung, and Blood Institute of the National Institutes of Health. The
United States has the third highest death rate from coronary artery disease
among 10 wealthy industrialized countries. Despite the greater number of invasive cardiac procedures being performed and all the cholesterol-lowering statin drugs being taken, not only is the death toll from coronary heart disease higher in the United States, but the United States is losing ground to most of these wealthy industrialized countries as well. Even more disappointing, despite the increased use of invasive cardiac procedures after heart attacks, the
in-hospital death rate for heart attack
patients in the United States remained virtually unchanged between 1993 and 2000.

Doing too many cardiac procedures can waste more than money. A study published in NEJM in 2001, two years after Mr. Wilkins died, showed that more than half of the people who go through coronary artery bypass surgery
experience a significant decrease in mental capacity
postoperatively, and the risk is even higher for older patients. In retrospect Mrs. Wilkins’ frustration with her husband (“he’s not himself”) was almost certainly a reaction to mental impairment he had suffered as a result of his surgery.

There is no way we can know whether Mr. Wilkins was the one American patient out of seven and a half who would really benefit from heart surgery. But given his age and prostate cancer, there is a pretty good chance that the coronary artery bypass surgery that looked like the best care for him at the time of his heart attack may not have been.

Perhaps the use of invasive cardiac procedures for older patients in the United States is an isolated instance of providing more care than appears to be necessary or beneficial. Not so, as we see from medical care at the other end of the life cycle.

Neonatology is the highly specialized field of caring for sick newborns. My colleagues and I were pleased when a full-time neonatologist was added to the staff of our community hospital. Typically, community physicians request a consultation from the neonatologist when there is anything more than a minor concern about a newborn’s health. The neonatologist then plays the key role in deciding whether to transfer the baby to the special care nursery.

In 2002, a study done by researchers from Dartmouth Medical School’s Center for Evaluative Clinical Sciences, published in NEJM, showed that the concentration of intensive care
neonatology services varies widely
in different regions of the United States, by a factor of four or more. The researchers found that the distribution of these services was not, however, based on the number of low-birth-weight babies being born in an area. Nor was neonatal mortality further reduced after a basic level of intensive care was available for sick newborns. Much of the country, it turns out, has about twice as many of these services as necessary to achieve optimal survival rates.

The point is driven home by a study that compared neonatal care in the United States, Canada, Australia, and the United Kingdom. There are
almost twice as many neonatologists and neonatal intensive care beds
for each baby born in the United States as for babies born in the other countries. Nonetheless, survival rates for equivalent birth-weight babies are no better in the United States. And because of the greater frequency of low-birth-weight babies, the
United States has the highest infant mortality
rate of the four countries. Part of this problem is the consequence of social issues that go beyond the health care system (such as poverty and racial disparities). Still, part of the problem is that the United States commits far more resources to expensive hospital-based treatment after birth than the other countries, but it offers fewer public health services before conception and during pregnancy. As with post–heart attack cardiology procedures, the oversupply of neonatologists and neonatal intensive care facilities appears to be driven more by financial incentives than documented health needs—and even less by an effective strategy for achieving better health.

If American medicine is really guided by scientific evidence, how has our pattern of cardiac care evolved so that, on a per-person basis, the United States is doing three and half times as many invasive cardiac procedures, but has one of the highest death rates from heart disease of 10 industrialized nations, and is losing ground to most of them? Similarly, how is it that we invest about twice as much as other countries in the care of sick newborns, yet our infant mortality rate ranks poorly and, like our cardiac death rate, is losing ground? Is it our science that is failing us?

Three editorials from the
New England Journal of Medicine
shed some light on this issue. In 1997, an editorial mused about why so many more cardiac surgeries were being done on American heart attack patients aged 65 and over compared with similar patients in Canada, when there was no evidence of better outcomes from the extra surgery. The author, Dr. Harlan Krumholz, suggested that at least part of the answer had to do with the prestige and
the billions of dollars these procedures generate
each year for “hospitals, physicians, and vendors of medical equipment.” One year later, Drs. Richard Lange and L. David Hillis wrote an editorial addressing the same subject.
A major study (VANQWISH)
had shown, once again, that there was no advantage to performing cardiac catheterizations routinely on clinically stable post–heart attack patients with no warning signs of further heart problems. The editorial underscored the fact that this was the fourth such major study that had come to the same conclusion, noting that the previous studies had had little effect in slowing the growth in the number of post–heart attack cardiac procedures being done in the United States. Commenting on the widespread disregard for the scientific evidence, the editorial concluded, like the one a year before, that the reason for the greater number of cardiac procedures in the United States as compared with Canada and Europe was “monetary remuneration to the facilities and physicians.”

It’s no wonder that hospitals aggressively market their “state-of-the-art” procedures, trying to attract “customers.” At first glance, this may seem like the health care market working well, with hospitals competing to provide the best service to sick patients. The reality is that financial incentives motivate the medical industry to expand the supply of profitable procedures, and then maximize demand for those services. The
fees paid by Medicare
for coronary artery bypass surgery, for instance, range from about $26,000 for nonteaching hospitals to between $30,000 and $40,000 for academic medical centers. According to an article in the
Boston Globe,
the profit margin on these procedures is more than 40 percent. Despite the aura of medical progress and public service, this is business, pure and simple.

Finally, Dr. Kevin Grumbach wrote an editorial that accompanied the article documenting the oversupply of neonatologists and neonatal intensive care beds in many parts of the United States. Searching for an explanation of this apparently irrational use of health care resources, he concluded: “
One important explanation is money
. Neonatal intensive care units are profit-making centers for hospitals, commanding high payments from private and public insurance plans.” The editorial reported that an investor-owned group of 600 neonatologists had earned more than $30 million in 2001.

Why don’t the findings of studies like those documenting the overuse of costly cardiology procedures and neonatology services play more of a role in shaping the American health care system? The truth is that American medical practice today is based on scientific evidence as long as the evidence supports commercial interests; but all too often when the science conflicts with commercial interests, science gets nudged aside.