One in 3 stent implants in India is possibly unnecessary

Several senior cardiologists in India have raised concern over 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.

A few years ago in the US, which has better monitoring and oversight of medical procedures than India, studies had found that only half the non-emergency cardiac stenting procedures were appropriate. Several cardiologists and hospitals were forced to cough up millions of dollars in penalties for unnecessary stenting. Stent companies too paid heavy penalties to settle charges of giving kickbacks to doctors.

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. External audit of every cath lab and all cardiac procedures is urgently needed. Every state government ought to have doctors with calibre and integrity comprising an audit committee. And doctors caught doing inappropriate stenting ought to be jailed for fraud to set an example,” said Dr T S Kler, head of the department of cardiology in Fortis Escorts Heart Institute.

In 2007 a study in the US that tracked patients over five years showed that in people with stable coronary artery disease, stents were no better than drug therapy. Until this finding, doctors had claimed that stenting in such cases showed excellent results.

In India, there are hospitals that boast of conducting up to 25,000 angioplasties a year and several cardiologists are too close to stent makers and suppliers for comfort. In the absence of any monitoring or oversight, patients in India have no protection from unnecessary use of stent.

“I agree that a significant percentage of angioplasties are inappropriate. I think the Cardiology Society of India should bring out guidelines and 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,” says Dr Devi Shetty, chairman of Narayana Health.

In 2009, an expert panel of cardiologists in the US published criteria for appropriate use of stents. A study preceding the publication looked at 2.7 million stenting procedures in 766 hospitals. It showed that inappropriate stenting in non-acute cases, fell from 25% in 2009 to 13% by 2014. Equally significantly, the total number of stenting in non-acute cases fell by about a third. As a result, the total number of cases of inappropriate stenting fell from 21,000 to just 8,000.

While there is broad consensus among cardiologists that stents can save the life of a patient with symptoms of heart attack, the decision to use stents on an elective basis is far more complicated. With the National Pharmaceutical Pricing Authority revealing that hospitals make the highest profit on stents, it seems obvious why hospitals are not pushing for audits to curb inappropriate use.


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