The use of heart bypass surgery on patients who are not seriously ill causes about 6,300 avoidable deaths a year and costs the U.S. economy about $9 billion a year, according to a study by a Baltimore research firm.
Researchers with HCIA Inc., a health economics research firm, said in a report yesterday that the patients' lives might have been spared if doctors had opted for a less traumatic procedure known as angioplasty.
The study found that bypass surgery had a lower death rate in only one group: the most seriously ill patients, or those with complete blockages in one or more coronary arteries.
But it said that doctors frequently recommended bypass for patients with partial blockages, subjecting them needlessly to the risks of surgery.
Some doctors reacted skeptically to the report, saying that it failed to examine subtle differences among patients that might have influenced the decision to give them one treatment rather than another.
Also, they said, it failed to consider that bypass does a much better job of relieving patients of their chest pains, freeing them to lead more active lives.
J. D. Kleinke, an HCIA official, said the study was purely statistical and did not examine the reasons patients died. Instead, it compared death and complication rates of heart patients given different types of treatment.
But, he said, experience has shown that the most frequent surgical risk is the formation of clots that can go on to cause heart attacks. The clots sometimes form around surgical stitches.
He cautioned that the report does not offer prescriptions for individual patients. Rather, he said, it gives a "big picture": America's over-reliance on a costly procedure that carries risks that can be fatal.
"Obviously, treatments are always decided on a case-by-case basis," Mr. Kleinke said. "You can't say you should always do angioplasty. But when you have borderline patients, doctors have been trained to say, 'I'm going to put my hands on this and fix it.' "
The firm analyzed data on 100,000 heart-disease patients recorded by the Health Care Finance Administration, the federal agency that runs Medicare. All of the patients were 65 or older.
Findings were published in a special report by the Bureau of National Affairs, a private publisher of news and information.
Bypass and angioplasty are both done to clear blocked arteries, the principal cause of heart attacks.
In a bypass operation, surgeons reroute blood flow around a blockage by grafting a small vessel from another part of the body onto the blocked vessel.
In angioplasty, the surgeon threads a narrow tube into the diseased artery, then inflates a tiny balloon to flatten the blockage.
About 435,000 angioplasties are done each year in the United States, compared to 550,000 bypass operations, Mr. Kleinke said.
Angioplasty costs an average of $18,000, compared with $46,000 for bypass surgery.
Dr. Michael Fisher, a cardiologist with the University of Maryland Medical Center, said that other studies hadn't shown major survival differences between angioplasty and bypass operations except in seriously ill patients, who fared much better with bypass surgery.
But he said that bypass was much more likely to relieve chest pains even in patients who are less seriously ill. This can mean a much better quality of life -- the difference between leading an active life and feeling severely restricted.
Dr. Thomas J. Ryan, former president of the American Heart Association, questioned the validity of the study, noting that it hadn't been reviewed by an independent panel of medical authorities.
He also said that angioplasty patients are much more likely to have a recurrence of symptoms, often forcing them to have another procedure just months after the original one.
HCIA Inc. analyzes medical data that can be used by individual hospitals, doctors and insurance companies to compare and reduce costs. Although its clients are most often hospitals, Mr. Kleinke said the heart study was not done for any client.
He said the study was done to focus attention on an important issue and to attract potential customers.
Mr. Kleinke said the data could be most useful to hospitals as they look for ways to cut costs. As hospitals take more financial risks by participating in managed care plans, he said, "the last thing a hospital wants to do is invasive surgery. They can save $20,000 to $30,000."
Insurance companies reacted cautiously to the study, saying that it probably wouldn't affect their medical policies.
"We always look at what is medical necessary and what is proven safe and effective. It's kind of an individual thing, and one study is not going to change our policy," said Dennis Milewski of The Travelers Cos. in Hartford, Conn.