Matters of the heart

New study on stents highlights need for adherence to clinical protocols, caution in decision-making.

Written by Meeta Rajivlochan | Published: June 11, 2018 12:49:59 am

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Heart disease, according to 2016 data, is the leading cause of disability in India today and accounts for 28 per cent of all deaths in the country. Providing optimal and cost-effective care to patients, then, must be a serious concern for public policy. (Representational Image)

A recent Indian study on health outcomes of angioplasty, a procedure performed on heart patients, has shown that stenting all blockages in the heart can reduce survival and increase chances of death. The study covered 4,595 patients treated in a government insurance scheme over a four-year period. It highlights the need for closer observance of clinical protocols and calls for more caution in decision-making.

It also points to the need to collate data on clinical performance indicators at hospitals and also at state level, and to regularly provide such data to doctors so it could be used to improve survival and recovery rates of patients treated. Given that the recently announced Ayushman Bharat scheme is a major intervention in the healthcare market, the study suggests that patient outcome indicators need to be integrated with the functioning of the scheme, for it to truly reduce death and disease in the country.

In the study that has been published in international journal PLOS One in May, 4.5 per cent of patients died within one year of the procedure. These deaths were related to high numbers of stents implanted and to greater stent length. Greater age of patient was also directly related to death. The lead author of the study, Dr Bhanu Duggal, a cardiologist from AIIMS Rishikesh, suggests that only those blockages in the heart that are shown to be responsible for heart disease, should be stented, for better health outcomes.

Yet, the current discourse on public health is almost entirely dominated by financing issues rather than possible strategies to improve the health status of patients. No doubt it is important to provide financial support to needy patients. But, surely, it is even more important to see that the maximum number of patients treated recover fully. The only way to ensure that healthcare becomes more patient-centric is if research studies come out of rarefied clinical discourse into public spaces.

These findings suggest two things. One, that better decision-making can improve chances of patient survival in angioplasty cases. Ideally, a cardiac surgeon should also be involved in the treatment decision and not just cardiologists alone. Today there are no norms of this kind in India.

The second implication of the study is that better decision-making can cut costs significantly. After all, given the high cost of stents, the issue of appropriate use becomes critical. Moreover, heart procedures constitute a very large percentage in monetary terms, of monies allocated in public insurance schemes.

The Indian healthcare scenario is characterised by the relative absence of appropriate use criteria for surgical procedures. Appropriate use criteria mean that in any health care scheme, before proceeding for a surgery, the doctors concerned affirm that the case in question conforms to pre-defined norms. The norms are hard-wired into the scheme. So in the case of angioplasty, the use of such criteria would mean that for all elective procedures, the physicians would need to state explicitly on paper that only those blockages that are shown to be responsible for heart disease are proposed to be treated.

Currently, to our knowledge, there is only one health scheme in India, namely the Maharashtra health insurance scheme, that funds secondary and tertiary care, that formally links appropriate use criteria to incurring expenditure in the scheme. The Maharashtra scheme requires treating physicians to fill out a form designed by the topmost experts in the field for each clinical indication that is being treated. Only after that is permission given to proceed. In case of any difference of opinion, the physician is required to record his reasons.

Another study, by Dr G Karthikeyan, cardiologist at AIIMS New Delhi and lead author, showed that in one year after the introduction of these criteria in the Maharashtra scheme, the incidence of angioplasty as a proportion of all treatments, was reduced by 12.3 per cent. Given that angioplasty accounted for roughly Rs 90 crore annual expenditure at the time and a major share of all claims, this was a significant saving.

Interestingly, both studies show no difference in outcomes between public and private sector hospitals.

For nearly a hundred years now, Western countries have developed a convention of patient registries. Such a register is specific for a disease and means that participating hospitals record patient information in the register. The information, recorded over time, can provide extremely valuable inputs for improving treatment protocols. In the US, using data from the National Cardiovascular Data Registry, a study of over 5,00,000 patients who had undergone angioplasty between 2009-2010 showed that while interventions in emergency situations were appropriate, for elective procedures, only 50 per cent could be categorised as appropriate, 38 per cent were uncertain and 12 per cent were inappropriate.

In India we have no such convention, nor are hospitals required to collate procedure specific data. The government has great market power in the health space today. Such market power could conceivably be used to improve the practice of medicine. We have any number of highly qualified doctors who are willing to help and who have devised appropriate use criteria. If only such criteria could be structured into group insurance schemes, they could do a great deal of good. In a knowledge society, the use of evidence-based criteria can save many lives.

The writer is an IAS officer. She was Secretary, Health, Government of Maharashtra, when the study was initiated. Views are personal.

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