AIR spotlight summary on “Unnecessary Stent Implants”.

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AIR spotlight summary on “Unnecessary Stent Implants”.


 

Introduction

  • Several senior cardiologists in India have raised concern over the rise in the cases of unnecessary implant of stents in India. They say if an audit of stent implant cases was done, over a third of the elective procedures could turn out to be needless.
  • It depends on the patient also like where he goes to treat his heart diseases. If he chooses an academic hospital which is run by the government or semi government organisation he would face a different list of charges. If you go to hospitals in the private sector they have lots of overheads and they have their own charges and the patient pays for the procedure and the comfort he gets in the hospital also.
  • A few years ago in the US, studies had found that only half the non-emergency cardiac stenting procedures were appropriate. In the same study the patients insist on angioplasty because they have a feeling that angioplasty will improve their long-term survival.

Stenting in India

  • There is no regulation of hospitals in India, especially in the private sector where a majority of urban Indians seek healthcare. At least 25-30% of the stenting done in this country is inappropriate. There are cases of stents being used in absolutely normal patients.
  • In our country the major gap is in the counselling which the doctor provides. Normally the patients go by the doctor’s advice. In the absence of any monitoring, patients in India have no protection from unnecessary use of stent.
  • In the last 5 years the implant of stenting in India has increased by 5 times. There is not only a boom in the domestic market, bust also foreign patients are coming to India as part of medical tourism to get stenting done because the cost of stenting in India is low. This is because there is increased awareness, increased diagnosis, increased availability of the angiograms and increased availability of doctors.

Concerns / challenges

  • In India there are instances where angioplasty is done for patients having chest pain due to Vitamin D deficiency which is wrong.
  • The bypass is done by the surgeon and the stenting is done by the cardiologists. The poor victim of the heart attack or the Coronary artery disease lands up with cardiologist. It is the integrity, honesty and the righteousness of the cardiologists to decide whether the patient really needs stenting or not.
  • The stents are very costly. There is no regulation and the Drug Controller is not capable of regulating domestic stent manufacturers. There have been cases where the stent manufacturers have been found making stents in garages.
  • In India the coronary artery disease is seen in young age, people do not exercise, do not have adequate sleep, do not have stress free life and do not eat balanced diet to keep their coronaries healthy.

Providing guidelines for Stenting 

  • Dr Devi Shetty, chairman of Narayana Health says that a significant percentage of angioplasties are inappropriate. The Cardiology Society of India should bring out guidelines which the public can access and decide whether stenting or open heart surgery is required. He also said Cardiology Society of India should create a mechanism to audit themselves rather than giving a chance for an external body to be created. Such an audit is needed as society has lost trust in doctors because of such inappropriate use.
  • It would be difficult to audit during an emergency with acute heart attack with very low chances of surviving if the intervention is not done. Despite making guidelines there can be aberrations. So making guidelines is not the solution. We have to follow the footsteps of our elders like B.C Roy. Loosing reputation at the cost of earning money should not be the part of medical treatment.

Way Forward

  • We have to treat the accompanying illnesses; stenting alone is not the answer to the problem. Normally patients have diabetes and hyper tension which has to be controlled and treated simultaneously. Then we can have the optimal benefit of stenting.
  • Everyone is not doing this profession as a service; people are in the service to make money. The best way is that decision has to be taken in the best interest of the patients and go for stenting if it is required.