Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Timely fillip for Practice Based Commissioning.
- Michael R Chester, James Kingsland, GP & Chairman NAPC (14 March 2007)
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The silence is deafening
- M Justin S Zaman (29 March 2007)
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Full BCIS response is on the website
- Martyn R Thomas (25 April 2007)
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Michael R Chester, Consultant cardiologist & Director National Refractory Angina Centre, Liverpool, James Kingsland, GP & Chairman NAPC
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In March 2006 the Secretary of State for Health identified £400M wasted annually in the NHS that could be avoided through Practice Based Commissioning reforms (1). NHS waste comes in a number of forms and this real-life observational study by Griffin et al (2), is a timely reminder that lessons from the past have still to be learned in the era of evidence-based medicine. Angioplasty is one of a long line of 'intuition-based' costly palliative interventions: tonsillectomy, grommets, knee washouts, spinal fusion, transmyocardial laser revascularisation and hysterectomy that do not stand up under scientific and cost-effectiveness scrutiny. It is not properly understood amongst commissioners and non-cardiologists that for stable angina patients, angioplasty (with or without stents) is a palliative pain controlling intervention. The current European Society of Cardiology guidelines state, “Contrary to the case of bypass surgery, on the available evidence, PCI compared to medical therapy does not seem to confer substantial survival benefit in stable angina” (3). The ‘available evidence’ actually showed a 78% relative increase in risk in the PCI treated group compared to the medically treated patients (4). It is doubtful that patients fully understand this when they give consent to undergo angioplasty (5). The seminal studies by Dimond (6) and Cobb (7) demonstrated that sham cardiac procedures can result in dramatic and sustained improvements in symptoms. Given that PCI in stable angina is primarily a pain relieving intervention it is remarkable that there has been no attempt to examine the placebo effect. Having attacked the interventional cardiologists’ holy cow the authors perhaps understandably shy away from this second significant weakness in the case for angioplasty. The pharmaceutical industry would certainly not be allowed to get away with promoting a palliative drug without demonstrating the benefits were superior to placebo. Cash releasing service redesign through Practice Based Commissioning, with improved services delivered in the community setting is central to the NHS reform agenda. However, the process is stalling because Primary Care Trusts are focussing on financial balance through rationing rather than investing to save, and therefore claim to have no money to fund the initial start up costs. Even a small percentage of the estimated £200 million spent annually on angioplasty in the UK would go a long way to pump priming the reforms. References 1. www.dh.gov.uk smart code 2006/0104 2. BMJ, doi:10.1136/bmj.39129.442164.55 (published 5 March 2007) 3. European Heart Journal, doi.10.1093/eurheartj/ehl002 4. RITA-2 Trial Participants. Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. Lancet 1997;350:461–468 5. Bridson J, Hammond C, Leach A, Chester MR. Making consent patient centred BMJ 2003;327;1159-1161 6. Dimond E G, Kittle C F, Crockett J E. Evaluation of internal mammary ligation and sham procedure in angina pectoris. Circulation 1958 18:712- 713 7. Cobb L A, Thomas G I, Dillard D H, Merendino K A, Bruce R A. An evaluation of internal mammary artery ligation by a double blind technique. New England Journal of Medicine 1959 20:1115-1118 Competing interests: None declared |
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M Justin S Zaman, Research Fellow in Epidemiology and Specialist Registrar in Cardiology University College London
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Considering the front page of this week's BMJ and the three articles devoted to the stent vs surgery debate, I am surprised - or am I? - at the lack of response from interventional cardiologists. These articles and the handful of other rapid responses to each of them has highlighted the lack of true informed consent prior to intervention, the lack of a multi-disciplinary team in decision-making and the fact that stents are effectively palliation for symptoms, a fact somewhat lost as investigators study outcomes such as MACE* rather than symptom improvement and quality of life. As a trainee cardiologist with no 'vested interest' in intervention bar the interests of the patient in front of me and of the society I serve, it would be nice to hear from some of my seniors. *'MACE', or major adverse cardiac event - which can be comprised of whatever you want it to be...: e.g. MACE - number of in-hospital deaths, Q wave MI, emergency CABG surgery, and cerebrovascular accident Grayson AD et al. Heart. 2006;92:658-63. MACE - cardiac death or non-fatal myocardial infarction Harm H H Feringa et al. Heart 2007;93:226-231 MACE - cardiac death, myocardial infarction, stent thrombosis or target vessel revascularisation Nordic Bifurcation Stent Technique Study Competing interests: None declared |
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Martyn R Thomas, President of the British Cardiovascular Society SE5 9RS
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The full British Cardiovascular Intervention Society response to the 3 articles and to Professor Taggart's editorial is posted on the website.[1] The article is in the rapid response section of Professor Taggart's editorial. Dr Zaman will learn that sometimes the delay of a considered response is worthwhile. I hope Dr Zaman will understand the issues more clearly after he has read the response. 1 http://www.bmj.com/cgi/eletters/334/7594/593?ck=nck#163651 Competing interests: None declared |
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