Avoiding Overuse: Coronary Stents

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.

Key Takeaways

U.S. hospitals performed over 229,000 unnecessary coronary stents from 2019-2021. That’s a rate of one every seven minutes.
Of the approximately 1 million stents placed by hospitals, 22 percent met criteria for overuse.
Medicare wasted as much as $2.44 billion on unnecessary stents from 2019-2021.
Rates of overuse varied widely: at some hospitals, more than 50 percent of all stents met criteria for overuse, while at others, fewer than 5 percent were unnecessary.

Hospitals with the highest rates of stent overuse

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.

NAME	STATE	# stent procedures meeting overuse criteria	# total stent procedures	proportion of all stents meeting overuse criteria
Northwest Texas Hospital	TX	733	1394	52.58%
Riverview Regional Medical Center	AL	401	802	50.00%
Kansas Medical Center Llc	KS	415	849	48.88%
UW Medical Center – Montlake	WA	713	1544	46.18%
Riverside Medical Center	IL	299	653	45.79%
UT Southwestern – William P. Clements Jr. University Hospital	TX	277	622	44.53%
Terrebonne General Health System	LA	321	725	44.28%
Keck Hospital of USC	CA	260	603	43.12%
The Medical Center of Southeast Texas	TX	261	608	42.93%
MUSC Health Columbia Medical Center Downtown	SC	484	1156	41.87%

Hospitals with the lowest rates of stent overuse

These hospitals have the lowest rates of stent overuse in the nation from 2019-2021. All had rates under 8 percent.

Only general hospitals with above-average volume of total stents were included in this study.

NAME	STATE	# stent procedures meeting overuse criteria	# total stent procedures	Proportion of all stents meeting overuse criteria
Magnolia Regional Health Center	MS	8	647	1.24%
Kaiser Permanente San Francisco Medical Center	CA	14	884	1.58%
Kaiser Permanente Santa Clara Medical Center	CA	42	1131	3.71%
HCA Florida Northwest Hospital	FL	26	668	3.89%
Strong Memorial Hospital	NY	67	1238	5.41%
Centra Lynchburg General Hospital	VA	68	1196	5.69%
Grand Strand Medical Center	SC	113	1853	6.10%
Rhode Island Hospital	RI	51	818	6.23%
Mount Carmel East	OH	80	1135	7.05%
South Shore Hospital	MA	66	852	7.75%

Hospitals with the highest and lowest overuse rates IN EACH STATE

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.

State	Category	Name	Number of stents meeting overuse criteria	Number of total stents performed	Overuse rate
AK	n/a*
AL	Best in state	Shelby Baptist Medical Center	144	693	20.8%
AL	Worst in state	Riverview Regional Medical Center	401	802	50.0%
AR	Best in state	Northwest Medical Center-Springdale	67	700	9.6%
AR	Worst in state	Baxter Regional Medical Center	356	1092	32.6%
AZ	Best in state	Banner Del E. Webb Medical Center	98	747	13.1%
AZ	Worst in state	Yuma Regional Medical Center	473	1155	41.0%
CA	Best in state	Kaiser Permanente San Francisco Medical Center	14	884	1.6%
CA	Worst in state	Keck Hospital of USC	260	603	43.1%
CO	Best in state	Centura – Penrose Hospital	106	879	12.1%
CO	Worst in state	UCHealth Memorial Hospital Central	261	1170	22.3%
CT	Best in state	Hartford Hospital	141	1133	12.4%
CT	Worst in state	Bridgeport Hospital	175	688	25.4%
DC	n/a*
DE	Best in state	Christiana Hospital	356	1555	22.9%
DE	Worst in state	Beebe Medical Center	314	933	33.7%
FL	Best in state	HCA Florida Northwest Hospital	26	668	3.9%
FL	Worst in state	UF Health Leesburg Hospital	931	2443	38.1%
GA	Best in state	South Georgia Medical Center	69	644	10.7%
GA	Worst in state	St. Joseph’s Hospital	333	1098	30.3%
HI	n/a*
IA	Best in state	MercyOne Des Moines Medical Center	192	1164	16.5%
IA	Worst in state	Genesis Medical Center, Davenport, East Rusholme Street	753	1956	38.5%
ID	Best in state	St. Luke’s Boise Medical Center	75	771	9.7%
ID	Worst in state	Eastern Idaho Regional Medical Center	158	714	22.1%
IL	Best in state	Northwestern Medicine Mchenry Hospital	92	754	12.2%
IL	Worst in state	Riverside Medical Center	299	653	45.8%
IN	Best in state	Franciscan Health Lafayette East	69	623	11.1%
IN	Worst in state	St. Mary Medical Center	313	863	36.3%
KS	Best in state	Stormont Vail Hospital	174	804	21.6%
KS	Worst in state	Kansas Medical Center Llc	415	849	48.9%
KY	Best in state	Norton Hospital	226	2026	11.2%
KY	Worst in state	Owensboro Health Regional Hospital	420	1135	37.0%
LA	Best in state	Our Lady of the Lake Regional Medical Center	73	587	12.4%
LA	Worst in state	Terrebonne General Health SystemMedical Center	321	725	44.3%
MA	Best in state	South Shore Hospital	66	852	7.7%
MA	Worst in state	Massachusetts General Hospital	434	1462	29.7%
MD	Best in state	UM Upper Chesapeake Medical Center	68	605	11.2%
MD	Worst in state	Adventist HealthCare White Oak Medical Center	330	952	34.7%
ME	Best in state	Maine Medical Center	211	1654	12.8%
ME	Worst in state	Northern Light Eastern Maine Medical Center	215	1429	15.0%
MI	Best in state	Bronson Methodist Hospital	68	810	8.4%
MI	Worst in state	McLaren Bay Region	811	2200	36.9%
MN	Best in state	Mercy Hospital	173	1550	11.2%
MN	Worst in state	M Health Fairview University of Minnesota Medical Center – West Bank East	185	606	30.5%
MO	Best in state	Mercy Hospital South	168	1087	15.5%
MO	Worst in state	St. Luke’s Hospital of Kansas City	493	1268	38.9%
MS	Best in state	Magnolia Regional Health Center	8	647	1.2%
MS	Worst in state	Anderson Regional Medical Center	259	735	35.2%
MT	Best in state	Logan Health Medical Center	120	607	19.8%
MT	Worst in state	St. Vincent Healthcare	211	714	29.6%
NC	Best in state	Frye Regional Medical Center	81	1021	7.9%
NC	Worst in state	UNC Medical Center	363	1150	31.6%
ND	Best in state	Essentia Health – Fargo	125	635	19.7%
ND	Worst in state	Altru Hospital	257	784	32.8%
NE	Best in state	Bryan East Campus	219	1089	20.1%
NE	Worst in state	Great Plains Health	233	605	38.5%
NH	Best in state	Concord Hospital	77	652	11.8%
NH	Worst in state	Catholic Medical Center	281	1191	23.6%
NJ	Best in state	Virtua Our Lady of Lourdes Hospital	276	1315	21.0%
NJ	Worst in state	Robert Wood Johnson University Hospital	1063	2836	37.5%
NM	Best in state	Presbyterian Hospital	82	965	8.5%
NM	Worst in state	Lovelace Medical Center	288	1510	19.1%
NV	Best in state	Renown Regional Medical Center	131	950	13.8%
NV	Worst in state	Mountainview Hospital	246	915	26.9%
NY	Best in state	Strong Memorial Hospital	67	1238	5.4%
NY	Worst in state	Mount Sinai Hospital	1719	4251	40.4%
OH	Best in state	Mount Carmel West	80	1135	7.0%
OH	Worst in state	Cleveland Clinic Main Campus	809	2299	35.2%
OK	Best in state	Ascension St. John Medical Center	152	1004	15.1%
OK	Worst in state	Integris Baptist Medical Center	501	1652	30.3%
OR	Best in state	Providence St. Vincent Medical Center	188	1179	15.9%
OR	Worst in state	OHSU Hospital and Clinics	180	609	29.6%
PA	Best in state	Jefferson Hospital	48	619	7.8%
PA	Worst in state	Wilkes-Barre General Hospital	350	884	39.6%
RI	Best in US	Rhode Island Hospital	51	818	6.2%
RI	Worst in state	The Miriam Hospital	125	1392	9.0%
SC	Best in state	Grand Strand Medical Center	113	1853	6.1%
SC	Worst in state	MUSC Health Columbia Medical Center Downtown	484	1156	41.9%
SD	Best in state	Monument Health Rapid City Hospital	171	986	17.3%
SD	Worst in state	Sanford USD Medical Center	934	2424	38.5%
TN	Best in state	Holston Valley Medical Center	75	848	8.8%
TN	Worst in state	Parkridge Medical Center	359	1233	29.1%
TX	Best in state	Texas Health Fort Worth	131	1015	12.9%
TX	Worst in state	Northwest Texas Hospital	733	1394	52.6%
UT	Best in state	Intermountain Medical Center	166	1243	13.4%
UT	Worst in state	Mckay Dee Hospital	166	619	26.8%
VA	Best in state	Centra Lynchburg General Hospital	68	1196	5.7%
VA	Worst in state	University Hospital	355	950	37.4%
VT	n/a*
WA	Best in state	Southwest Medical Center	77	793	9.7%
WA	Worst in state	UW Medical Center – Montlake	713	1544	46.2%
WI	Best in state	Gundersen Lutheran Medical Center	95	665	14.3%
WI	Worst in state	Aurora St. Lukes Medical Center	500	2168	23.1%
WV	Best in state	Wheeling Hospital	74	647	11.4%
WV	Worst in state	Mon Health Medical Center	416	1117	37.2%
WY	n/a*

*Fewer than two hospitals had enough volume to include in comparison

methodology

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.

STent research timeline

1983: CASS Trial

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.

1987-2001: Early trials show no mortality benefit for PCI

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).

2007: COURAGE study puts PCI to the test

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.

2009: BARI 2D finds no stent benefit for diabetes patients

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.

2008-2016: Dueling meta-analyses

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.

2017: ORBITA Trial breaks new ground

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.

2019: ISCHEMIA trial validates conservative approach

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.

2022: REVIVED gives stents “best chance to win” but still fails

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.

HARMS of coronary stent overuse

Any surgical procedure has the potential for harm. Complications of percutaneous coronary interventions (coronary stent or balloon angioplasty) are rare, but can include:

Perforation (piercing) of the coronary artery, which can lead to heart attack or death. Incidence of perforation ranges from 0.19% to 1.46% (Source).
Dissection (tearing) of the coronary artery, which can lead to heart attack or death. A 2023 study of coronary artery dissection after PCI found an incidence of 1.4% (Source)
Stent embolization (loss of device) occurs when the stent unintentionally dislodges from the balloon and can result in heart attack or death. Incidence of embolization ranges from 0.29% to 0.32% (Source).
Stent thrombosis (blood clots) that can lead to heart attack or death. Incidence ranges from 0.3% to 0.5% (Source).
Bleeding, bruising, or fistula at the catheter site, which can lead to prolonged hospital stay, increased patient morbidity and mortality and higher treatment costs. A 2021 study of access site complications found an incidence of 1.6% (Source)
Bleeding into the abdomen (retroperitoneal hemorrhage) which is associated with an increased risk of mortality and adverse events. Incidence rate is 0.06% (Source).
Kidney damage from the contrast used, which can lead to acute kidney injury. Incidence of contrast-induced nephropathy is 1-2% (Source)

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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