President Bush's stent: inappropriate screening and care for the rich, nothing for the poor

One of the recurrent themes of this blog has been the importance of everyone having access to necessary medical care, and how the US compares poorly to other developed countries in that it does not cover everyone. Another recurrent theme has been that many medical procedures are unnecessary, sometimes even harmful, but are nonetheless provided to people who have the money or insurance to pay for them. This is not to say that greed is always the motivator; there is a powerful, if often incorrect, belief that to do something is better than to do nothing.

In this context, it is interesting to read “President Bush’s unnecessary heart surgery”, a Washington Post “Viewpoint” by Vinay Prasad and Adam Cifu published August 9, 2013. As part of his “annual physical”, the former President  (who is “…widely regarded as a model of physical fitness”), received, in addition to (presumably) the screening tests and immunizations recommended by the evidence, a cardiac stress test. Discovering an abnormality on that test led to his having a CT angiogram and finally placement of a cardiac stent.

One interpretation of this story might be “he’s lucky they did the test; they found something wrong and fixed it”. I’m afraid, along with Prasad and Cifu, that this might be the lesson taken from it by many people, and the result could be more people requesting such a test because, “hey, they found something wrong with President Bush – could I also have such a problem?” This would be unfortunate, because it is incorrect. President Bush – based on the information provided – should not have had the stress test and not have had the stent placed.

The key point is in understanding that he was (by all reports) asymptomatic. “Before he underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the opposite: His exercise tolerance was astonishing for his age, 67. He rode more than 30 miles in the heat on a bike ride for veterans injured in the wars in Iraq and Afghanistan.” While the definition of screening tests is that they are done on asymptomatic people, there are a number of criteria that have to also be present, among them that the test should detect a condition before it is symptomatic, and there should be an intervention that will prevent progression if disease is discovered. So, isn’t that true in this case? He did have the disease, a narrowing in one of his coronary arteries, right? So isn’t it good that it was discovered.

As Prasad and Cifu discuss, however, there is no evidence that stenting a coronary artery prolongs life.  “It is worth noting that at least two large randomized trials show that stenting these sorts of lesions does not improve survival.” Even for higher risk patients than Mr. Bush, survival is not increased. However, if people have symptoms of chest pain that appears cardiac in origin, for whom stress testing may be indicated (not a screening test now; they are symptomatic), treatment by angioplasty, stenting, or even bypass surgery can ease or relieve the pain. That is a good thing. But for Mr. Bush, who had no pain, there can, by definition, be no pain relief. There was some additional risk, however; in addition to the inherent low risk of doing the procedure (such as bleeding and stroke, and even, rarely, death), he now has to take anti-platelet drugs, which also confer some risk. And a stent only holds open the spot it is in; it does not prevent progression of coronary artery disease elsewhere.

The larger issue of the “annual physical” (which I have addressed previously in “ The "Annual Physical": Screening, equity, and evidence”, July 4, 2012, citing Elizabeth Rosenthal’s NY Times article “Let’s (not) get physicals”) was again the subject of a popular article, “The case against the annual checkup” by Brian Palmer on Slate.com on August 20, 2013, which states: “There are two kinds of arguments against the adult annual health checkup. The first has to do with the health care system overall, and the second has to do with you personally.” Palmer does add that

“It’s important to separate preventive care from annual checkups. Only one-half of annual checkups actually include a preventive health procedure such as a mammogram, cholesterol testing, or a check for prostate cancer. (Annual gynecological visits are excluded from these numbers, although the evidence supporting those is not particularly overwhelming either.) More importantly, only 20 percent of the preventive health services provided in the United States are delivered at annual checkups.”

He has a pretty good point, although he includes prostate cancer screening, which is not recommended or beneficial, in his list, something Prasad and Cifu do not. But I would take issue with his suggestion that you only visit the doctor when you are sick, which is in fact when doctors tend to work in the preventive services the other 80% of the time.

There are a couple of reasons for this, but the main one is that there are a lot of people (even older people at higher risk) who do not get sick, or at least sick enough to decide to come to the doctor, or at least sick enough to decide to take off from work and maybe lose income to come to the doctor. And they could benefit from preventive care as well. The list of preventive services changes from time to time, which it should as new evidence emerges, but includes immunizations, screening, and education. The list of conditions for which screening is effective and recommended by the evidence is relatively short (despite our natural desire to have more, more effective, tests) and does not include prostate cancer or ovarian cancer (thus, no reason for an asymptomatic woman to have a “routine” bimanual pelvic exam), but does include Pap smear for cervical cancer, colorectal cancer screening (which can be done with colonoscopy or regular stool screening for occult blood), bone density screening for certain age groups, and mammography. There are also recommended screening for other conditions: hyperlipidemia (mainly cholesterol), abdominal aortic aneurysm (once, in men over 60 who have smoked), HIV and Hepatitis C, as well as some screens for people who are themselves asymptomatic but whose family history places them at higher risk for a condition (e.g., diabetes). (See the Guide to Preventive Services 2012, Recommendations of the US Preventive Services Task Force, on the website of the Agency for Healthcare Research and Policy.)

Immunizations include not only annual influenza shots, but also less-frequent pneumococcal vaccine and tetanus/diphtheria/pertussis boosters, which are often not up-to-date in adults. Education may be the most important: counseling on diet, exercise, smoking, alcohol, drugs, and risk behaviors, as well as identifying victims of violence (domestic or otherwise) should not wait until these conditions have resulted in symptomatic disease.

Perhaps these preventive services should not be “annual”; there is no magic to this number, but it was chosen because it is easy to remember. Certainly many of these preventive services (now including Pap smears, bone density and mammograms) are recommended less frequently than yearly. Perhaps they can be as well delivered by other health professionals as by physicians. But there is benefit to preventive care even for asymptomatic people, and not the least is noted by Palmer: “They build relationships between doctor and patient, and open lines of communication are important in medicine.”  Yes, there are certainly many risks, which I have often pointed out, to over-testing and over-medicalization. But there are also risks to not having preventive care. And, of course, the key point here is equity: those most at risk of “too much” care and too many interventions are the more well-to-do, well-educated, and well-insured. Those most at risk of too little care, too little screening and immunization and education about how to reduce their risks and early identification of disease are the poorer, less educated, and uninsured.

The fact is that health care, like most things in our society, is very different for different socioeconomic classes. Cautioning against overuse by the privileged is one thing; being sure that this does not bleed into justifications for limiting access to necessary care for the less privileged is quite another.