When retired pharmacist Hakim Khambati, 59, had a heart attack because of a 99% blockage in one of his arteries, he opted for an angioplasty at a reputed Mumbai hospital. “The doctor treating my father had informed me about another 45% blockage in the same artery, which was not serious and did not require an angioplasty,” recalls Hozaifa Khambati, 25, Hakim’s son.
Khambati had a surgery that fitted his blocked artery with a stent, (a metal scaffold that would keep the artery open). But three months later, he developed similar symptoms of uneasiness and breathlessness again. This time, the doctor said that his second blockage had increased to 99% and he needed an emergency angioplasty once more. “We were taken aback, wondering how things had escalated so fast,” says Hozaifa. “But since we did not want to take any risks we went ahead with the procedure for a second time.”
It was later, when they consulted Dr Kirti Punamiya, senior interventional cardiologist at Breach Candy hospital, did they realise that both the stents could have been placed at the same time. “When I took a look at his reports I realised that what was considered a 45% blockage was at least 80% three months ago, and the trauma caused by the first angioplasty had affected the second blockage,” says Dr Punamiya.
The two-stent procedure would have saved the Khambatis additional expenses and a great deal of stress. They spent almost Rs 6 lakh for each angioplasty, which included hospitalisation charges. “We had to go through the ordeal twice, which could have easily been avoided,” says Hozaifa.
He believes that the setting up of a board of experts to study cases like his father’s will minimise the hassle and expense for patients in the future. Even Dr Punamiya stresses on the need for additional assessments and imaging after an angiography to ensure better diagnosis.
“When I took a look at his reports, I realised that what was considered a 45% blockage was at least 80% three months ago, and the trauma caused by the first angioplasty had affected the second blockage.” – Dr Kirti Punamiya
ALL IN AGREEMENT?
The concept is already popular in the US, where heart surgeons and cardiologists collaborate to help manage a range of heart diseases from coronary artery problems to structural heart issues. The team effort is aimed at improving patient care.
It’s now happening in India too. To ensure that heart patients get the best possible options, a Heart Team has been set up at Medanta-The Medicity in Gurgaon. The board brings together experts from preventive, interventional and surgery cardiology to review each case within the hospital (much like a cancer board or ethics committee for organ donation). They then reach a consensus to ensure the patient gets the best possible treatment.
“Sometimes, there’s a lack of trust between patient and doctor,” says cardiac surgeon Dr Naresh Trehan, chairman, Medanta. “Patients end up thinking that surgeons will only recommend surgery and interventional cardiologists will recommend stents.” It sets up a zone for potential abuse, in which stents or surgery may be overused or recommended without looking at other options. Trehan believes the solution lies in a heart team.
“There is a section of heart patients that do better with medicines,” he says. “Another clear cut category needs either stents or bypass surgery. But 50%-60% of the patients fall in the middle category, which could be interpreted either way. It’s for this section that the team approach will prove beneficial.”
The need for more transparency was one reason that India’s drug-pricing watchdog, the National Pharmaceutical Pricing Authority (NPPA), capped the price for coronary stents last week. Data from the National List of Essential Medicines (NLEM) shows the price of bare-metal stents ranges between Rs 25,000 and Rs 75,000. More advanced drug-eluting stents cost between Rs 40,000 and Rs 2 lakh.
The new price of basic bare-metal stents has been fixed at Rs 7,260, exclusive of VAT. The drug-eluting stents now cost Rs 29,600. The inclusion of life-saving stents in the NLEM was prompted by a petition filed before the Delhi High Court by advocate Birender Sangwan, who moved court after a friend’s brother was charged Rs 1,26,000 in a private hospital in 2014.
The NPPA’s data shows that hospitals increase margins up to 2,000%, creating opportunities for misuse if an interventionist recommended more stents than a patient needed.
“The box that carried the stent had no maximum retail price on it. We checked and were told stent prices weren’t regulated, so hospitals could charge at will,” said Sangwan.
The NPPA’s data shows that hospitals increase margins up to 2,000%, creating opportunities for misuse if an interventionist recommended more stents than a patient needed. The fixed price and the concept of Heart Teams are part of the bonanza for patients, who for years have been confused about whether they are getting the best advice for their cardiologist or surgeon.
CONSENSUS IS KEY
While heart experts across superspecialities tend to agree that having a heart board works, emergency cases remain a grey area. “It’s a concept that originated in the US to let the patient make an informed choice. But this is feasible only in stable patients and not serious patients who require an emergency procedure,” said Dr VK Bahl, head of cardiology department, AIIMS. “It is a good idea only if implemented properly.”
Dr Amit Sharma, interventional cardiologist at Holy Spirit hospital, Mumbai, has reservations and believes that the concept of a board of experts may not work too well in India.
The US has an insurance-based healthcare system,” he points out. “Here, consulting a board and then going ahead with the procedures might be a long-drawn process that may be risky when it comes to emergency situations.”