VIDEO: Our October 31, 2023 launch event featuring David L Brown, MD, clinical professor of medicine in the Division of Cardiovascular Medicine at Keck Medicine of USC; Betty Rambur, PhD, RN, FAAN, Routhier Endowed Chair for Practice, professor of nursing at the University of Rhode Island; Thomas Power, MD, senior medical director of cardiology and sleep programs at Carelon Medical Benefits Management; and Dr.Vikas Saini, president of the Lown Institute.
The Lown Institute Hospitals Index is the first to evaluate how well individual hospitals avoid overuse of common low-value tests and procedures. The Institute measured overuse of coronary stents at 1,773 hospitals with the capacity to perform the procedure using Medicare claims data from 2019-2021. (press release | methodology)
These hospitals have the highest rates of stent overuse in the nation from 2019-2021. All had rates over 40 percent.
Only general hospitals with above-average volume of total stents were included in this study.
Northwest Texas Hospital
Riverview Regional Medical Center
Kansas Medical Center Llc
UW Medical Center – Montlake
Riverside Medical Center
UT Southwestern – William P. Clements Jr. University Hospital
Terrebonne General Health System
Keck Hospital of USC
The Medical Center of Southeast Texas
MUSC Health Columbia Medical Center Downtown
These hospitals have the lowest rates of stent overuse in the nation from 2019-2021. All had rates under 8 percent.
Magnolia Regional Health Center
Kaiser Permanente San Francisco Medical Center
Kaiser Permanente Santa Clara Medical Center
HCA Florida Northwest Hospital
Strong Memorial Hospital
Centra Lynchburg General Hospital
Grand Strand Medical Center
Rhode Island Hospital
Mount Carmel East
South Shore Hospital
These hospitals have the highest and lowest rates of stent overuse in each state.
In some states, rates of overuse varied widely. In South Carolina, for example, 42 percent of stent procedures at MUSC Health Columbia Medical Center Downtown met criteria for overuse, while at Grand Strand Medical Center the rate was only 6 percent.
Only general hospitals with above-average volume of total stents were included in this study. The “n/a” label indicates that a state had fewer than two hospitals with adequate volume to be included.
Number of stents meeting overuse criteria
Number of total stents performed
Best in state
Shelby Baptist Medical Center
Worst in state
Northwest Medical Center-Springdale
Baxter Regional Medical Center
Banner Del E. Webb Medical Center
Yuma Regional Medical Center
Centura – Penrose Hospital
UCHealth Memorial Hospital Central
Beebe Medical Center
UF Health Leesburg Hospital
South Georgia Medical Center
St. Joseph’s Hospital
MercyOne Des Moines Medical Center
Genesis Medical Center, Davenport, East Rusholme Street
St. Luke’s Boise Medical Center
Eastern Idaho Regional Medical Center
Northwestern Medicine Mchenry Hospital
Franciscan Health Lafayette East
St. Mary Medical Center
Stormont Vail Hospital
Owensboro Health Regional Hospital
Our Lady of the Lake Regional Medical Center
Terrebonne General Health SystemMedical Center
Massachusetts General Hospital
UM Upper Chesapeake Medical Center
Adventist HealthCare White Oak Medical Center
Maine Medical Center
Northern Light Eastern Maine Medical Center
Bronson Methodist Hospital
McLaren Bay Region
M Health Fairview University of Minnesota Medical Center – West Bank East
Mercy Hospital South
St. Luke’s Hospital of Kansas City
Anderson Regional Medical Center
Logan Health Medical Center
St. Vincent Healthcare
Frye Regional Medical Center
UNC Medical Center
Essentia Health – Fargo
Bryan East Campus
Great Plains Health
Catholic Medical Center
Virtua Our Lady of Lourdes Hospital
Robert Wood Johnson University Hospital
Lovelace Medical Center
Renown Regional Medical Center
Mount Sinai Hospital
Mount Carmel West
Cleveland Clinic Main Campus
Ascension St. John Medical Center
Integris Baptist Medical Center
Providence St. Vincent Medical Center
OHSU Hospital and Clinics
Wilkes-Barre General Hospital
Best in US
The Miriam Hospital
Monument Health Rapid City Hospital
Sanford USD Medical Center
Holston Valley Medical Center
Parkridge Medical Center
Texas Health Fort Worth
Intermountain Medical Center
Mckay Dee Hospital
Southwest Medical Center
Gundersen Lutheran Medical Center
Aurora St. Lukes Medical Center
Mon Health Medical Center
*Fewer than two hospitals had enough volume to include in comparison
The Lown Institute examined overuse of percutaneous coronary interventions (coronary stent or balloon angioplasty) for 1,773 hospitals with the capacity to perform the procedure. Medicare Advantage and fee-for-service claims were used for 2019 and 2020; only fee-for-service claims were included for 2021 as Medicare Advantage claims were not available.
Stents were defined as meeting overuse criteria for patients with a diagnosis of ischemic heart disease at least six months prior to the procedure, excluding patients with a diagnosis of unstable angina or heart attack within the past two weeks, and excluding patients who visited the emergency department over the past two weeks.
Total Medicare spending on low-value stents was calculated using Medicare’s per-procedure cost of $10,615, the most frequent procedure code used for PCI in our analysis. Of this cost, $9,015 is paid by Medicare and $1,600 is paid by beneficiaries. Our cost estimate assumes that the cost of stents for Medicare Advantage patients is similar to beneficiaries in traditional Medicare.
Only hospitals performing above the national average volume of total stents were considered for the top and bottom lists.
As early as 1983, the Coronary Artery Surgery Study (CASS) showed no mortality benefit of coronary artery bypass surgery (a precursor to PCI) compared to medical treatment, putting in question the “clogged pipe” theory of heart disease.
Eleven randomized trials including 2,950 patients are done between 1987 and 2001, evaluating PCI compared to medical therapy. A 2005 meta-analysis of these trials showed no mortality benefit or difference in cardiac events for PCI, except for patients who recently had a heart attack. At this time, PCI was still seen to be effective for reducing angina (chest pain).
This large randomized trial of 2287 patients found that PCI in addition to medical therapy did not reduce all-cause mortality, heart attack, or hospitalization for heart disease compared to medical therapy alone. Prior to COURAGE, PCI trials had not incorporated modern stents and medication management standards.
This randomized controlled trial of 2,368 patients with heart disease and diabetes found no significant difference in mortality or major cardiovascular events with PCI and intensive medical therapy compared to medical therapy alone after 5 years.
The benefits of PCI over medical therapy remain controversial, with competing studies finding different results. While one meta-analysis found a long-term mortality benefit to PCI and another study found a benefit for patients with reduced blood flow to the heart, other trials once again found no benefit to PCI particularly when compared to modern medical therapies.
The ORBITA trial tested PCI for the first time with a “sham” procedure, in which patients on already on medical therapy believed they were getting a stent but nothing was inserted. The results showed not only that PCI did not have a mortality benefit but also that it did not even improve chest pain. The authors experienced backlash from cardiologists contesting their findings.
ISCHEMIA is the largest study to date (n=5179) measuring the effect of stents and bypass surgery on patients with stable coronary artery disease. Given that previous studies showed a hypothetical PCI benefit for the subgroup of people with reduced blood flow, this trial looked at the impact of PCI in that group. The results showed no difference in risk of heart attack or death compared to drug therapy, even for patients in this higher-risk subgroup. This study was hailed as “extraordinarily important” by doctors and the results also made waves on social media.
The REVIVED trial enrolled 700 patients with conditions thought to be most helped by stents: those with a severe coronary disease and left ventricle dysfunction, but also viable heart muscle. They randomized patients to optimal medical therapy or medical therapy plus PCI.The results showed no difference in the rates of the primary outcome (death or heart failure hospitalization) between the two groups after 3.5 years. There was also no difference in heart function or patient-reported quality of life. No subgroups saw an additional benefit from PCI.The REVIVED results were shocking even to to many cardiologists who were already skeptical about stents. “This was the best chance for PCI to win (they really cued it up for PCI), and it still came up short,” wrote Dr. Sanjay Kaul on social media in reaction to the results.
Any surgical procedure has the potential for harm. Complications of percutaneous coronary interventions (coronary stent or balloon angioplasty) are rare, but can include:
Additionally, inpatient stent procedures expose patients to risks of hospital-acquired infections and patient safety events. A 2021 study from Lown Institute researchers shows that for every 1000 low-value inpatient PCIs, there are an estimated 1.5 hospital-acquired infections and 8 patient safety indicators.
Unnecessary stents can also incur financial harm for patients. The total Medicare cost for outpatient PCI is $10,615 per procedure, with $1,600 paid by the patient. For patients with private insurance, the cost may be even higher. A 2022 study of commercial prices for cardiac procedures found that median payer-negotiated prices for PCI were higher than $20,000 at some academic medical centers.
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BECKER’S HOSPITAL REVIEW
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Media inquiries should be directed to Aaron Toleos, vice president of communications for the Lown Institute, at email@example.com.