Health News Review

On the New York Times’ online opinion page, Dr. Zeke Emanuel wrote, “In Medicine, Falling for Fake Innovation.”  Excerpt:

“The sleek, four-armed “da Vinci” robot has been called a breakthrough technology for procedures like prostate surgery. “Imagine,” the manufacturer says, “having the benefits of a definitive treatment but with the potential for significantly less pain, a shorter hospital stay, faster return to normal daily activities.”

That’s just the kind of impressive-sounding innovation that critics of the health care reform act say will be stifled by the new law, with its emphasis on cost control and the comparative effectiveness of new pills and devices. “Instead of encouraging innovation,” wrote Senator Ron Johnson, Republican of Wisconsin, in The Wall Street Journal, “it stifles creativity.”

The critics are right — if they’re talking about innovations like the da Vinci robot, which costs more than a million dollars and yet has never been shown by a randomized trial to improve the outcomes of prostate surgery. Indeed, a 2009 study showed that while patients had shorter hospital stays and fewer surgical complications like blood loss when they underwent this kind of robotic surgery, they later “experienced more … incontinence and erectile dysfunction.” Similar problems are occurring with robotic surgery for other cancers.

In other words, this is a pseudo-innovation — a technology that increases costs without improving patients’ health.”

Recently, MedPageToday reported on a paper presented at the American Urological Association annual meeting:

“Robotic-assisted radical prostatectomy (RARP) cost 60% more than an open procedure, a difference driven primarily by higher operating-room costs, according to data from one large medical center.

On average, robotic procedures cost $6,000 more than open procedures, and the hospital lost approximately $4,000 on each robotic procedure.

The robotic technique accounted for 60% of the total cost of each RARP, Jeffrey Tomaszewski, MD, reported here at the American Urological Association meeting.

“We asked our finance department to see how many more robotic procedures we would have to make a difference [in the disparity], and we would almost have to increase our volume by a factor of 10 just to break even,” said Tomaszewski, of the University of Pittsburgh.

Radical prostatectomy accounts for about half of all costs associated with treating prostate cancer, currently estimated at $1.7 billion annually. Use of RARP has increased rapidly since its introduction and has become the predominant technique for prostate removal (J Urol 2012:187:1392-1398).

RARP volume has grown in the absence of data to demonstrate the cost-effectiveness of the surgery, said Tomaszewski.

“Given that medical devices are not subject to the same level of scrutiny, compared to pharmaceuticals, in demonstrating clinical effectiveness, the rapid adoption of new medical technologies significantly contributes to spiraling healthcare costs,” he added.”

Comments

matt posted on May 30, 2012 at 10:33 am

OK, but you’re talking about surgical costs only when you refer to it being more expensive – but in the first paragraph it says they have shorter hospital stays and fewer transfusion. Both of these are very expensive, so does it cancel out the additional expense of the robot? That is important info to know if you’re claiming it “increases costs.” Because if patients leave the hospital days earlier then that is worth the extra 1 to 2,000, isn’t it?

And does the data that Dr Tomaszeski refers to only refer to operating room costs? Or is it all hospital costs? I am not a urologist so I have no idea.

Anthony posted on May 30, 2012 at 11:56 am

Sounds like a load of nonsense. Everything I have read about the Da Vinci written by doctors or patients have been overwhelmingly positive. So basically besides the minimal scarring, quicker recoveries, shorter hospital times, less pain, better precision, and improved situational awareness these things are awful? Well I guess we should go back to patients being hacked away at by hand tools again…

    Gary Schwitzer posted on May 30, 2012 at 12:08 pm

    Anthony,

    You may wish to expand your reading sources.

    Many articles in recent months have raised questions about:

    • Patient expectations and the conclusion that “Medicare-age men should not expect fewer adverse effects following robotic prostatectomy.”
    • The reasons for the rapid spread of robotic prostatectomy are unclear, given the lack of randomized trials and few comparative studies, given that it’s more expensive and appears to have a long learning curve to achieve optimal outcomes.
    • Unsubstantiated claims in hospitals’ marketing of their robotic surgical systems.

    You may choose to ignore the mounting questions, but caveat emptor.

Greg Pawelski posted on May 30, 2012 at 1:11 pm

Touche Gary!

David Penson posted on June 3, 2012 at 4:12 pm

This is 100% correct and we have only ourselves to blame for it. However, I don’t think the reasons for the rapid spread of robotic prostatectomy are so unclear- here are a few possible explanations: a device manufacturer who fanned the flames with questionable marketing campaigns and used cutthroat methods to encourage uptake of the technology by hospitals; hospital administrators worried about keeping their operating room volumes up; urologists worried about losing patients to other urologists and other doctors and; perhaps most importantly, the public’s insatiable appetite for new technology, even when it has not been proven to be superior (or even equivalent to existing technologies). The robot is an example of the “Apple-fication” of medicine…if there is a sexy new technology involved, everyone wants it- and, of course, if it is on the internet and there are a few strangers in a chat room or forum who underwent the procedure and have positive things to say about it, it must be better. As a practicing urologist at a major academic medical center, I have been a skeptic of the robot’s for years but now have no choice but to use it as my patients demand it. While there is a real need to rethink the way prostate cancer is treated in general in the US, it strikes me as unlikely that we will force this genie back in the bottle… perhaps we need to change the way we approach new technologies and disease management in general and only provide coverage for interventions that have evidence documenting their effectiveness. If there is no evidence, we can still offer the treatments, but patients will be financially responsible for more, if not all, of the costs. A variation on this way proposed by Pearson and Bach in Health Affairs in 2010

Rob Midwest posted on June 5, 2012 at 9:47 pm

Regarding Matt’s comment about early discharges saving money. Keep in mind, under DRG payment methodology, which is the system Medicare pays under, a hospital is paid a fixed amount per stay, regardless of how many days one stays. So, getting discharged a day or two early does not reduce the price paid for the inpatient stay. It only adds to the profit of the hospital.