東京日和＠元勤務医の日々

　アメリカでは保険会社側の審査も厳しく、合併症などの種類(術後縫合不全、カテーテル感染など)によっては保険請求しても償還されないなど厳しいのが現状です。そのうえ、Medical Boardによる審査もあり、「不必要」な医療について非常に厳しい処分がなされます。

　去年WSJで「Abbott Hired Barred Doctor」という記事があったようですが、その続報です。今回は「Heart Treatment Overused　Study Finds Doctors Often Too Quick to Try Costly Procedures to Clear Arteries」だそうです。

　アメリカのボルチモアで有名な循環器内科医師が４人の患者さんに不要なステントを入れたかどで、Marylandの医師委員会が２年間の医師免許の停止処分を決定したそうです。
罪状は：concluded that Midei acted dishonestly, committed unprofessional conduct, overutilized healthcare services, made intentional false reports, and violated the standard of care when he used two anti-coagulants in patients.
ってところで、不誠実、プロとしてあるまじき行為、医療保険の無駄遣い、レポートねつ造、診療基準を犯した件・・・ですが、調査委員会によると

「the committee released a report in December 2010 that found Midei performed many more medically unnecessary stent implants -- nearly 600 total -- at a cost of $3.8 million to Medicare. The Finance Committee report alleged that between 2007 and 2009, Midei implanted 585 unneeded stents, all made by Abbott Labs.」
不要な600件ものステンと留置で、380万ドル(３億円弱！)の公的医療であるメディケアへの損害、さらに

「 Abbott paid Midei nearly $31,000, put him on its list of top stent volume cardiologists, and paid for a barbecue and a crab dinner at his home, according to the Finance Committee report. After St. Joseph barred him from practicing in 2009, Abbott hired him to prepare safety reports in China and Japan..」

　アボット社から３万ドル受け取っていたり、バーベキューやらカニディナーにそんでもって中国と日本で安全性報告の準備のために雇われていたり・・・グレーな感じがします。

　アメリカでもstable patients who are suffering mild symptoms or no symptoms at all. Of those, 50% are deemed appropriate, 38% uncertain and 12% inappropriate, という指摘があります。

　医師が必要性があると判断して行う医療内容について裁量権が日本でも認められますが、治療ガイドラインを逸脱して手術をしすぎていたりするのは日本でも稀ではありますが、たまに耳にします(下肢へのPTAなどです)

　また、利益相反の観点からも、高額なデバイスを使う医師への支払いも非常に考えさせられます。

　今後、この業界が厳しくなると見ています。もちろん、海の向こうの話ですからすぐにではないのですが、例の「ゴルフ、カラオケ、観劇は禁止　製薬会社の医師接待「上限2万円」もアメリカの方で問題視されてからこっちにやってきたのです。間違いなく、デバイス関連も厳しくなっていくと感じています。

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Doc's License Pulled for Implanting Unneeded Stents
MedPage Today July 15, 2011

  The Maryland Board of Physicians has revoked a cardiologist's medical license, finding that he implanted unnecessary stents in four patients.
  Mark Midei, MD, formerly a cardiologist at St. Joseph Medical Center in Towson, Md., can apply to the board for reinstatement of his license in two years.
  An administrative law judge with the Maryland Board of Physicians concluded that Midei unnecessarily implanted stents in four of the five patients investigated by the board, in each case greatly exaggerating the extent of arterial blockage. In three of the cases, Midei also said that the patients had unstable angina, when, in fact, they did not.
  In all five patients, he did not achieve the active coagulation time and instead administered heparin while inserting the catheter, according to a 77-page decision which was issued after a seven-day hearing.
 The judge, Mary R. Craig, concluded that Midei acted dishonestly, committed unprofessional conduct, overutilized healthcare services, made intentional false reports, and violated the standard of care when he used two anti-coagulants in patients.
  The issue was first brought to the public's attention in late 2009, when St. Joseph Medical Center sent letters to Midei's stenting patients, explaining that their stents may have been implanted unnecessarily. The letters became the subject of an article in the Baltimore Sun.
  That article prompted the Senate Finance Committee to investigate; the committee released a report in December 2010 that found Midei performed many more medically unnecessary stent implants -- nearly 600 total -- at a cost of $3.8 million to Medicare. The Finance Committee report alleged that between 2007 and 2009, Midei implanted 585 unneeded stents, all made by Abbott Labs.
  "This report sets forth alarming evidence that patients at St. Joseph Medical Center received unnecessary and potentially harmful stent implants time and again -– a pattern that is shocking, disturbing and shameful," wrote Sen. Max Baucus (D-Mont.), chairman of the committee.
  Abbott paid Midei nearly $31,000, put him on its list of top stent volume cardiologists, and paid for a barbecue and a crab dinner at his home, according to the Finance Committee report. After St. Joseph barred him from practicing in 2009, Abbott hired him to prepare safety reports in China and Japan.
  According to the report from the administrative law judge, the Maryland Board of Physicians was sent several letters in 2008 from a person who wished to remain anonymous who worked at St. Joseph Medical Center accusing Midei of fraud and saying he had needlessly implanted stents in at least 41 patients.
  Midei testified before the board that he saw his hospital's stent business slipping away as a rival hospital's stent implants increased. He was appointed head of his hospital's cardiac cauterization laboratory and paid triple his previous salary.
  Midei is reportedly being sued by hundreds of his patients, and he himself is suing St. Joseph Medical Center.
  In its decision, the board wasn't sympathetic to Midei's claims that pressure from the hospitals caused him to implant so many stents.

  "Dr Midei's violations were repeated and serious," the decision read. "They unnecessarily exposed his patients to the risk of harm. They increased the cost of the patients' medical care. Dr Midei's willful creation of false percentage numbers for the degree of occlusion of coronary arteries is indefensible and amounts to a deliberate and willful fabrication of medical records."
  Attempts to reach Midei's lawyers for comment were not successful.
  William O'Neill, MD, a cardiologist at the University of Miami, testified on behalf of Midei, defending the doctor as a seasoned cardiologist who has participated in many clinical trials.
  "I'm appalled by the decision [of the board]," he told MedPage Today. "I think it's a disgrace. I think in the light of day that Dr. Midei will, I hope, be vindicated."
He denied that any of the stenting examined by the board was unnecessary.

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Heart Treatment Overused
Study Finds Doctors Often Too Quick to Try Costly Procedures to Clear Arteries
WSJ 2011/7/6

 Outside of heart attacks, doctors are often too quick to use a common $20,000 procedure to treat patients suffering from coronary artery disease, a new study suggests.
 About 600,000 angioplasty procedures, which almost always involve placement of a tiny metal tube called a stent, are done in the U.S. each year. Roughly 70% of these procedures are performed on patients suffering symptoms of a heart attack and aren't medically controversial. But the remainder are done on stable patients who are suffering mild symptoms or no symptoms at all. Of those, 50% are deemed appropriate, 38% uncertain and 12% inappropriate, the report says.
 "One in eight is probably higher than we would like," said Paul Chan, a cardiologist at Saint Luke's Mid America Heart and Vascular Institute, Kansas City, Mo., and the study's lead author.
 The results, published in the Journal of the American Medical Association Tuesday, come amid rising concern about the overuse of big ticket medical technology. Such concerns are rising not only in cardiology, but in other major specialties as state and federal governments and health insurers seek to contain health-care costs.
 "This tends to confirm concerns that many people have expressed—that there are many thousands of patients who undergo coronary interventions for very questionable indications," said Steven Nissen, head of cardiovascular medicine at the Cleveland Clinic.
 Researchers cautioned that the findings are complicated and include some results that are reassuring and others that are troubling. The study is part of an unusual initiative by the American College of Cardiology to examine the extent of unnecessary procedures in part because of growing concerns in recent years that angioplasty and especially stents are overused.

 （以下略）

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