I was traveling yesterday so didn't get to comment on an important and depressing study that appeared in the Journal of the American Medical Association on Wednesday. Researchers who poured over Medicare records found that less than half of seniors (44.5 percent) with stable coronary artery disease who complained of symptoms like angina were whisked off to the catherization lab for percutaneous coronary interventions (PCI) like balloon angioplasty and stenting without first confirming by a stress test that they were indeed suffering from reduced blood flow to the heart (ischemia). Guidelines published by American College of Cardiology, the American Heart Association and, significantly, the Society for Cardiology Angiography and Intervention call for the tests.

Previous studies among the commercially-insured population are even worse. Only a third of patients in the under-65 crowd with stable heart disease but having symptoms are likely to have gotten a stress test before getting PCI.

Why is this important? Let us count the ways:

* PCIs have increased 300 percent over the past decade and accounted for at least 10 percent of the increase in Medicare spending since the mid-1990s.

* Medicare spends $10,000 to $15,000 per PCI.

* While PCI may reduce ischemia and angina more effectively than drugs, more than a half dozen studies conducted over the past decade have established that in terms of reducing deaths or heart attacks, PCI is no better than drugs alone.

* Patients who fail a stress test and then get PCI do better and have shorter hospital stays; and

* Patients who get PCI with minimal symptoms, with or without the stress test, are at increased risk of repeat procedures and may experience a deterioration in their overall quality of life going forward.

So who is responsible for this mass defection from established clinical practice guidelines? According to the study, which reviewed the records of 23,887 Medicare patients, younger physicians and those who conducted lots of PCIs were more likely to eschew ordering the stress test before moving straight to PCI. The study also found huge geographic differences. Those areas with the fewest facilities and cardiologists who perform the PCI procedures ordered the required test in as much as 70 percent of cases, while those with more labs and intervention cardiologists fell well below the 44.5 percent average.

"Physician decision making regarding PCI was influenced less by presence of ischemia, as PCI guidelines suggest, and more by physicians' own biases and community practice patterns," the study authors suggested.

Despite its own guidelines, the Society for Cardiovascular Angiography and Interventions, which represents the cardiologists who do the PCIs, immediately issued a press release attacking the study. “The guidelines are important, but they are meant to guide physicians based on the data available at the time of their development, not serve as a substitute for clinical judgment,” said Dr. Bonnie H. Weiner, SCAI immediate past president. “The message from the interventional cardiology community is that for these patients, who may not be able to walk across a parking lot without pain, angioplasty and stents improve health and quality of life substantially.”

Here in a nutshell is the heart of the health care cost crisis. Physicians, in this case intervention cardiologists, claim their personal judgments, which are obviously clouded by their financial interests, are superior to and must hold sway over the statistical evidence gathered by impartial researchers.

It would appear that we can lead the horses to evidence-based medicine, but we can't make them drink. If the crisis caused by rising medical bills reaches the point where frustrated payers impose payment guidelines that require adherence to guidelines, the physicians, who will complain bitterly about "cook book medicine" and insurer straightjackets, will have no one to blame but themselves.