Do physicians have the courage to implement comparative effectiveness?

Comparative effectiveness outcome studies have shown that while percutaneous coronary intervention (PCI) may be more effective than optimal medical therapy (OMT) for treatment of acute coronary syndrome, it is not more effective for treatment of stable ischemic heart disease.

Results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, published in 2007 and 2008 in the NEJM, demonstrated that PCI did not improve survival or prevent myocardial infarctions more than OMT, and had a limited role in symptom relief.

Dr. Raymond Gibbons, professor of medicine at Mayo, in December 2007 in a Webcast Video Interview in the Medscape Journal, stated that physicians should replace PCI with OMT in these patients.

Dr. David Maron, professor of medicine and emergency medicine at Vanderbilt, in December 2008 in a Webcast Video Editorial in the Medscape Journal, urged that physicians convert their practice from PCI to OMT in these patients.

Both Gibbons and Maron cautioned that the strong financial incentives to continue usual use of PCI would be a substantial barrier.

What actually happened? Borden, et al., utilizing a massive database, reported in JAMA in May 2011, that physician practices re: OMT and PCI in these patients changed almost NOT AT ALL after these reports and numerous commentaries.

Why did American primary care physicians and cardiologists continue the old, high-tech, institutional, expensive, invasive, not-better PCI treatment for stable coronary artery disease (CAD) once diagnosed, and not convert to the better, safer, faster, cheaper OMT?

There was massive dissemination of the results of the COURAGE trial and major changes in guidelines. The OMT combination of aspirin, beta-blockers, and statins can be prescribed by any licensed physician in America and found at any American pharmacy, 24/7.

Why did the use of OMT rather than PCI not quickly become the dominant mode of therapy for stable CAD?

American physicians are not stupid. They know where the money is.

Established referral patterns, collegial medical relationships, flashy glitz for the patient to experience and describe versus ordinary pills, no pesky lawyers, country club shoulder rubbing, the payroll, and marketing of the local hospital. All these factors, and more.

Wanted in 2011: American physicians with the COURAGE to implement the results of comparative effectiveness research and evidence-based medicine to benefit their patients, their professionalism, and their country, even if it may hurt the pocketbooks of themselves and their institutions.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.