HJNO Mar/Apr 2023

CHANGING THE CARE: HEART DISEASE & CHOLESTEROL 20 MAR / APR 2023 I  HEALTHCARE JOURNAL OF NEW ORLEANS   understand the data themselves, their decision would be to choose between the following two options: 1) If they chose stent placement, then the majority of the time, they would experience neither harm nor benefit from the procedure versus medications alone; but they would be weighing a small risk of death or heart attack from the procedure itself versus the chance of quicker relief from chest discomfort; 2) If they were to choose medical therapy alone, they may not get better as quickly, but they would not be exposed to the risk of the procedure, and, in time, their symptoms would be the same as if they underwent the procedure. I certainly know which option I would choose for myself. Our profession needs to remem- ber the guiding adage of “primum non no- cere,” otherwise known as “first, do no harm.” In an article published in JAMA Internal Med- icine in 2014, Schwartz et al. identified that 42% of Medicare beneficiaries received at least one of 26 useless services that have been labeled low-value care or overtreatment. Low-value care occurs whenever a care delivery intervention is delivered where the scientific evidence shows that the care does not result in clinical benefit for the patient. In that article, 26 commonly provided services or procedures were included under the category of low-value care. The list included cardiac stress testing in asymptomatic patients or stable angina, as well as PCI with an- gioplasty and stent placement for stable coro- nary artery disease. It has been estimated that between $75 and $101 billion is wasted every year on such low-value care or overtreatment with total waste costing us between $760 and $935 billion. And when it comes to dollars, one person’s waste can be another person’s income. More recent evidence confirms that invasive strategies to manage stable atherosclerotic coronary artery disease do not provide sig- nificant mortality benefits over optimal medi- cal therapy alone. The ISCHEMIA trial — which stands for Initial Invasive or Conservative Strat- egy for Stable Coronary Artery Disease — was published in the New England Journal of Medi- cine in 2020. The authors of this study conclud- ed that “among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conserva- tive strategy, reduced the risk of ischemic car- diovascular events or death from any cause.” De-adopting low-value care: evidence, eminence, and economics Despite the scientific evidence demonstrat- ing the failure of stent placement in stable coronary artery disease to provide mortality benefits over optimal medical therapy, and de- spite the admonishments of respected experts like Nissan from the Cleveland Clinic advising against such practices, the majority of stents placed in this country are still in patients with stable coronary artery disease. Why is that? Unfortunately, clinician practice pattern varia- tion and economics both play a role. As the forward-thinking healthcare systems transition away from being a traditional health system and toward a system that delivers health, they find themselves on a path that conflicts with deriving their profitability solely from volume- driven, transaction-based economic models and instead toward new business models that are value-driven and outcomes-based. Along this journey, these systems find themselves contending with the reality of deliberately stop- ping performing procedures or services that have traditionally been financially lucrative, like coronary stent placement in patients not ex- periencing acute heart attacks. It places them in a difficult position that has been described as balancing precariously with one foot placed side-by-side in each of two floating canoes. The challenge is in attempting to transfer both feet from the traditional, “volume-driven canoe” into the “value-driven canoe” without falling into the water. Systems that deliver health are willing to take this risk because it is the right thing to do for the patients they serve. But the more traditional providers and health systems have been painfully slow to embrace change. Why has the U.S. healthcare system been so slow to move away from delivering care that has been scientifically proven to be wasteful? In their JAMA article published in 2020, “De- adopting Low-value Care,” Powers et al. cited three common reasons for the failure to stop delivering care that has not been shown to result in clinical benefit: evidence, eminence, and economics. Care that provides little or no value cannot be de-adopted until evidence becomes available that demonstrates the lack of benefit. However, such evidence often does not become available until after the practice is widespread. Such failure may be due to inad- equate evidence prior to the service becoming widespread or to more rigorously conducted trials after the service is already widespread. However, even evidence alone rarely leads to widespread de-adoption. Broad acceptance of an intervention’s ineffectiveness needs to occur first, and sometimes there is cultural resistance among clinicians to stop performing or deliv- ering services that they are convinced remain useful. Such clinician resistance has led to ex- perts and professional societies (i.e., eminence) issuing broad sets of recommendations or evidence-based guidelines to try to expedite de-adoption. The American Board of Internal Medicine’s “Choosing Wisely” campaign is one such initiative. Lastly, even evidence and eminence may be insufficient to drive de-adop- tion if economics create strong financial pres- sures to continue delivering low-value care. However, financial incentives can be used to catalyze de-adoption. When payers stop cover- ing a low-value service, use often drops precipi- tously. Let’s look at an example outside of car- diovascular care for a moment. A randomized, controlled trial in 2002 showed that arthroscop- ic knee surgery for patients with osteoarthritis showed no benefit over placebo. Evidence alone did not lead to de-adoption as only a mild decrease in number of cases occurred over the next few years. It wasn’t until the Center for Medicare and Medicaid Services (CMS) issued a formal non-coverage decision three years later that a 25% decrease in the number of ar- throscopic surgeries for osteoarthritis was seen. And it was only after the CMS decision that the American Academy of Orthopaedic Surgeons issued a recommendation against the proce- dure. This example illustrates the inadequacy of relying solely on evidence or the eminence of a professional society, as well as the power of economic forces. However, the stakes of life and death are much higher for cardiovascular care, and so CMS has continued to pay for stent