Years ago doctors in USA were regularly undertaking procedures that seemed unnecessary. The insurance companies who were being conned woke up to this malpractice and started clamping down on anything that appeared unnecessary. What happened in USA is now being repeated in India. I wasn’t surprised when I read a report in the Times of India that several senior cardiologists have raised concern over the increased number of unnecessary stents being implanted in India. They say if an audit of stent implant cases was done, over a third of the elective procedures could turn out to be needless.

According to the report by Rema Natarajan, Dr T S Kler, head of the department of cardiology in Fortis Escorts Heart Institute indicated that there is no regulation of hospitals in India, especially in the private sector where a majority of urban Indians seek healthcare. At least 25-30% of the stenting done in this country was inappropriate. There were cases of stents being used in absolutely normal patients. External audit of every cath lab and all cardiac procedures was needed urgently. Every state government ought to have doctors with calibre and integrity comprising an audit committee. Doctors caught doing inappropriate stenting ought to be jailed for fraud to set an example, he said.

In 2007 a study in the US that tracked patients over five years showed that in people with stable coronary artery disease, stents were no better than drug therapy. Until this finding, doctors had claimed that stenting in such cases showed excellent results. In India, there were hospitals that boasted of conducting up to 25,000 angioplasties a year and several cardiologists were too close to stent makers and suppliers for comfort. In the absence of any monitoring or oversight, patients in India had no protection from unnecessary use of stent. Dr Devi Shetty, chairman of Narayana Health said that a significant percentage of angioplasties were inappropriate. He thinks the Cardiology Society of India should bring out guidelines and create a mechanism to audit themselves rather than giving a chance for an external body to be created. Such an audit was needed as society had lost trust in doctors because of such inappropriate use.

In 2009, an expert panel of cardiologists in the US published criteria for appropriate use of stents. A study preceding the publication looked at 2.7 million stenting procedures in 766 hospitals. It showed that inappropriate stenting in non-acute cases, fell from 25% in 2009 to 13% by 2014. Equally significantly, the total number of stenting in non-acute cases fell by about a third. As a result, the total number of cases of inappropriate stenting fell from 21,000 to just 8,000.

While there is broad consensus among cardiologists that stents can save the life of a patient with symptoms of heart attack, the decision to use stents on an elective basis is far more complicated. With the National Pharmaceutical Pricing Authority revealing that hospitals make the highest profit on stents, it seems obvious why hospitals are not pushing for audits to curb inappropriate use.