The St. Joseph Medical Center cardiologist accused of performing hundreds of unnecessary and potentially dangerous procedures was able to slip through the hospital's safety net of peer reviews partly because, as a department chairman, he could select which cases to evaluate, according to government records.
Dr. Mark Midei coordinated all of the peer review at St. Joseph's cardiac catheterization laboratory, which he ran until May 12, 2009, when he was removed on suspicion of placing unnecessary stents in patients' arteries. His duties also included selecting which of his own cases would be scrutinized by other physicians, according to a report from the state Office of Health Care Quality.
Midei has since lost privileges to practice medicine at the Towson hospital, which sent letters to 585 patients telling them they received what might have been unnecessary stent implants from the veteran cardiologist during his last two years at the hospital.
St. Joseph officials say they implemented new procedures in January, including a random, computer-assigned selection of cases for review.
But the report, which details the findings of two regulatory inspections at St. Joseph in February and March, describes an oversight process that was far more relaxed under Midei, whom it identifies as "physician #1."
"The practice of only reviewing physician #1's hand picked cases failed to identify any cases that fell outside of the standards of practice for quality," it says.
Alan Levine, a former Medicare inspector who has worked to strengthen peer-review procedures around the country, called such "self-policing" a conflict of interest.
"One hopes, for the sake of patient safety, that hospitals are taking a more serious approach to peer review than that," he said.
Designed as a safety check of medical practices, peer review involves the post-treatment evaluation of patient records with an eye toward ensuring that accepted standards were followed. It is a requirement for hospitals that accept Medicare payments.
The state report also offers new insight into the events that led to Midei's departure from the hospital, where he was the most productive physician in the cardiac lab.
The hospital conducted a survey of Midei's cases after receiving a complaint from a patient — someone, according to the report, who was also an employee of the hospital.
That survey led to a systematic review, conducted by an independent company, of all of Midei's catheterization procedures over two years. During such a procedure, a device is threaded into a patient's arteries through an incision in the leg or wrist, and if a blockage is detected the doctor can insert a mesh tube known as a stent to prop the artery open.
After reviewing "nearly 2,000" of Midei's cases — a number that hospital officials had not disclosed — reviewers found questionable stents in 585 patients, or about every third or fourth case.
The peer review system at St. Joseph, which hospital officials called "consistent with other hospitals performing interventional cardiology procedures," also flagged cases whenever a death or unexplained complication occurred, the report said.
But Midei, long regarded as one of the Baltimore region's more skilled cardiac-care clinicians, did not have any questionable deaths or complications that would have automatically triggered an evaluation, the report said. The document did not indicate the number of cardiac cases at St. Joseph's reviewed by peer doctors, or how many of them were Midei's.
Dr. Gerald N. Rogan, a California emergency physician who works as a health care consultant and specializes in peer review, said a system that double-checks only cases where problems occur is unlikely to uncover a physician providing unnecessary treatment.
"If the patients being treated are healthier than average, and have fewer complications, you might not find any problem cases," he said.
In addition, the report says the hospital's oversight policies "did not identify concerns with the number of cases completed or rates of cardiac stents placed," by Midei. St. Joseph says it now will conduct regular audits of all its "most active" physicians.
Rogan said "star" physicians like Midei are often subjected to relaxed peer review because they assume positions of authority within a hospital.
"The guys that bring in a lot of business for the hospital, the guys that make a lot of money, these doctors end up being appointed the head of their departments," Rogan said. "And then they can thwart peer review by controlling the mechanisms."
In a statement, St. Joseph officials called the new procedures implemented at the hospital in January a "state-of-the-art" system of checks and balances "to assure such a situation cannot occur again."
Cardiac surgery cases at the hospital are also subject to the enhanced review procedures, which will eventually be implemented at every department, the statement said.
Since investigating a case in California in the early 2000s in which a doctor was found to have directed hundreds of patients to unnecessary cardiac bypass surgeries, Rogan has advocated independent peer review processes that do more than just investigate mistakes, but also explore whether medical procedures were appropriate.
"Maybe you don't have to do that for appendicitis, or tonsillitis, something like that," he said. "But maybe for Cesarean section you do. Or cardiac surgery. Certainly for something like cardiac catheterization and stent placement, where the person diagnosing the injury is the same person recommending and performing the [treatment.]"