Increased stent use could increase mortality: Study

At least 203 patients were recorded dead in a year after they underwent procedure to insert stent due to various medical reasons. (Representational Image)

A multi-centre study initiated by the Maharashtra government to analyse the use of stents under its insurance scheme — Mahatma Jyotiba Phule Jan Arogya Yojana (MPJAY) — over a period of three years found that increased use of stents has raised the chances of death among patients. The study found that hospitals, empanelled under MPJAY, on an average used 1.55 stents in a patient and called for “conservative use of stents in coronary angioplasty”.

Under the study, published on May 24 in Public Library of Science (PLOS), 4,595 coronary heart patients were surveyed between August 2012 and November 2016 from 110 hospitals. At least 203 patients were recorded dead in a year after they underwent procedure to insert stent due to various medical reasons. “We noted that average death rate is 4.5 per cent under the insurance scheme. In USA, a similar analysis showed death ranged below 1.7 per cent,” said Dr Jyothi Subramanian, attached with Maharashtra Department of Health Services. In addition, death rates stood at 5 per cent when bare-metal stents were used and at 3.8 per cent when drug-eluting stents, considered superior and more expensive, were used.

“There is a need to increase awareness about conservative stent use. A doctor must analyse whether the decrease in blood flow caused by blockage is significant or not,” said lead author Dr Bhanu Duggal, head of cardiology department in AIIMS, Rishikesh. She explains that stent is a piece of metal that can lead to clotting when fixed in arteries. A patient has to remain on blood thinners. This can lead to an increased risk of mortality.

The MPJAY scheme, that covers 971 procedures, currently has 212 hospitals empanelled for cardiology procedures. The report has recommended that policy makers must conduct an annual audit of hospitals to assess use of stents under insurance procedure. “In USA, hospitals are ranked based on their use of stents and its necessity. A similar model should be replicated in India,” said Dr Mona Duggal, from department of community medicine in PGIMER, Chandigarh. Duggal, also part of the research, said while private hospitals may use more stents than public hospitals, limiting the insurance scheme for the procedure to public hospitals may disrupt patients’ access to healthcare.

The research had 30 per cent private and 70 per cent public hospitals, however, results in use of stents by doctors were same in both sectors. Doctors part of the research said cardiologists need to switch from visual examination of arteries to newer technologies such as stress test, nuclear testing and fractional flow reserve (FFR) for accurate analysis of blockage in arteries. “It is more expensive, but it will eliminate unnecessary use of stents,” added Dr Bhanu. The research paper, a first to examine patients under the insurance coverage, also calls for conservative use of stents.

Dr Anil Sharma, cardiologist attached with Bombay hospital, said western countries use more stents on an average on patients than Indian doctors. “We visually observe the blockage in artery and then use computerised calculations. If block is over 70 per cent, stent is prescribed. In situation where blockage is between 50-70 percent, we use FFR and then based on analysis, a patient may be put on medicines,” Sharma said. Dr Pradeep Vyas, principal secretary (health), said, “We have not gone through the research, so I cannot comment on it.”

A senior government official attached with MPJAY said that stent usage is a larger issue that government needs to address. “Under MPJAY, we can only monitor implementation of scheme, not why a doctor takes decision to use the number of stents that he uses,” the official said.