Sun exclusive: Officials broaden stent investigation

State health officials investigating claims that a Towson cardiologist performed hundreds of unnecessary medical procedures have identified other doctors in Maryland with similarly questionable practices, The Baltimore Sun has learned.

Several cardiologists in the state have performed a suspiciously high number of the same invasive cardiac stent procedures that Dr. Mark G. Midei is accused of over-performing at St. Joseph Medical Center, according to an analysis of data from the state's Health Services Cost Review Commission.

The discovery was made as part of a broader statewide investigation of hospitals that was triggered by the allegations at St. Joseph, and is raising concerns that the accusations against Midei might not be isolated.

Investigators plan to review the work of the other cardiologists — who were not identified to The Baltimore Sun — going back five years. Sources also said they expect the investigation to eventually expand to include inquiries into other medical specialties and procedures.

Del. Peter A. Hammen, who asked the state agencies to investigate, cautioned against jumping to conclusions about what the higher rates of stent placement indicate.

"Once we have [all] the numbers in front of us, we'll be able to make, obviously, better sense as to what they mean and what actions we should take," said Hammen, who was briefed on the initial data. "It's early in the state's investigation."

State investigators, after interviewing medical specialists and analyzing billing data reported by hospitals, have determined that doctors who perform a diagnostic test called a cardiac catheterization typically find blockage requiring treatment with a stent about 30 percent of the time.

But Hammen and other sources say the regulatory data suggests Midei performed stent procedures nearly twice as often, and that other Maryland doctors are high enough above the 30 percent benchmark to warrant a closer look.

Still, a spokeswoman for the American College of Cardiology said there was no reason for stent patients to panic. The devices, which can't be removed, are relatively safe once they're implanted. She suggested that people with questions or concerns about the validity of their own stent placement either talk to their doctors, or to an outside physician.

Arthur Caplan, chairman of the Department of Medical Ethics within the University of Pennsylvania, said differences in the rate of procedures can be caused by a variety of benign reasons, including variations in medical training and the types of patients being seen.

But wide differences demand investigation, he said.

"There are the occasional outliers that are so far out that red flags should be going off," Caplan said, adding that "for most of the things that are overused, there is an amazing relationship to profit."

Stents, which are designed to prop open arteries and improve blood flow around the heart, are a multimillion-dollar industry, bringing in $222 million in business to Maryland hospitals during the past fiscal year alone. They're relatively simple to insert and bring in $10,000 or more per procedure.

And patients often prefer them as an alternative to heart surgery. Stents can offer quick relief from symptoms like chest pain, though recipients often have to take blood-thinning drugs for life.

Clinical guidelines generally suggest that an artery be at least 70 percent blocked before a stent is placed, and St. Joseph's rules consider anything less than 50 percent blockage to be "insignificant." But court documents allege that some of Midei's patients were told they had blockages in the 90 percent range, while a subsequent review of their records shows blockages closer to 10 percent or less.

Midei left St. Joseph last year amid accusations that he falsified records to make it appear that patients needed stents when they did not. St. Joseph reviewed Midei's records over a two-year period and identified 585 people who may have received unneeded stents from the well-regarded cardiologist. Hospital officials, who recently concluded their investigation, said they were tipped off by a patient complaint in April 2009.

Since then, local malpractice attorneys say they have been approached by hundreds of Midei's patients, and a handful of lawsuits against him and St. Joseph have been filed.

In a statement e-mailed to The Sun Friday, St. Joseph officials said the hospital "is a cardiac referral center and frequently receives more complicated cases from referring physicians and other hospitals, so the hospital's volume would be higher than some other hospitals. However, St. Joseph has acknowledged that Dr. Midei appears to have performed stent procedures that may have been medically unnecessary."

After that finding, the hospital withdrew Midei's practice privileges at the hospital and implemented "an enhanced state-of-the-art peer review process" for its cardiac catheterization lab. The hospital has said it reviewed the records of other St. Joseph cardiologists, as well, but found no problems.

Midei did not respond to a list of questions forwarded to him by his spokesman Friday.

Court papers filed on Midei's behalf suggest that the allegations against him have been inflated by malpractice attorneys. And he has many fans who remain loyal, describing him online as a "brilliant cardiologist" who saved many lives. His friends have created the Web site,, to support him, and a Facebook page titled "Dr Mark Midei Saved a Loved One" has 195 members.

Still, he and St. Joseph are facing civil lawsuits, a U.S. Senate investigation, and, most recently, the state's examination.

In February, Hammen asked state health agencies to investigate the situation at St. Joseph along with patient care at other hospitals to determine whether Maryland residents are — or were — at risk for receiving "unnecessary invasive procedures that could jeopardize their health."

The agencies — which include various divisions within the Department of Health and Mental Hygiene, the Maryland Patient Safety Center and the Board of Physicians, among other groups — plan to hold their first coordinated group meeting this week to discuss strategy and preliminary data.

Members are expected to focus on developing policy and legislative changes to prevent future physician abuses across disciplines.

"One of the things we're thinking about, if you're looking at patient safety, is looking beyond what's already been in the news," said Wendy Kronmiller, the DHMH chief of staff.

Investigators are expected to report their findings to the legislature by September.

"Obviously, there were a number of procedures that the state has in place, and, for whatever reason, they failed to detect what happened at St. Joe's," Hammen said. "I think it's time we reviewed those processes and procedures to make sure that this doesn't occur in the future."

Baltimore Sun reporter Robert Little contributed to this article.

St. Joseph Timeline

January 2008: Dr. Mark Midei leaves MidAtlantic Cardiovascular Associates to become a full-time employee of St. Joseph Medical Center, scuttling MidAtlantic's $25 million merger deal with MedStar Health and prompting MidAtlantic's then-CEO to tell him, "I will spend the rest of my life trying to destroy you personally and professionally."

June 2008: St. Joseph, MidAtlantic and MedStar's Union Memorial Hospital receive subpoenas from the federal agency that investigates Medicare fraud.

February 2009: St. Joseph CEO John K. Tolmie and two other hospital executives step aside to "avoid a conflict of interest" during the federal investigation. They later resign.

May 2009: A patient of Midei's, later identified as a hospital employee, lodges a complaint alleging that Midei performed inappropriate medical procedures, sparking an internal review at the hospital. Midei is suspended and later loses his privileges to practice medicine at St. Joseph.

July 2009: St. Joseph reaches an undisclosed agreement with the federal government to settle any potential claims related to its dealings with MidAtlantic, and later says the agreement is with the U.S. Department of Justice.

December 2009: St. Joseph begins sending letters to 585 of Midei's patients telling them they might have had unneeded stents implanted in their coronary arteries.

January 2010: Hospital officials acknowledge the issues related to Midei after inquiries from The Baltimore Sun, and note that they are no longer claiming that the federal investigation is not focused on patient care.

May 2010: State regulatory documents indicate that Midei was able to avoid St. Joseph's peer-review process because, as a department head, he chose which cases would be reviewed.

June 2010: State regulators reviewing billing records determine that other doctors in Maryland have suspiciously high rates of placing stents.

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