Comparative effectiveness research -- which looks at which tests and treatments work best -- should ideally improve the quality of medical care while reducing, or at least holding down, costs. The new healthcare-reform law strongly supports comparative effectiveness, but as the case of surgical robots suggests, unproven technologies that capture the fancy of doctors and hospitals may well grow in popularity anyway.
Robotic surgery systems, which cost between $1 million and $2.5 million each, have spread across the U.S. and Europe in the past four years, according to a paper in the New England Journal of Medicine. Between 2007 and 2009, the number of robotic surgery systems installed in U.S. hospitals jumped 75 percent to about 1,400, and the number purchased in other countries doubled to 400. Since 2007, the number of robot-assisted procedures has soared from 80,000 to 205,000 per year.
The main argument in favor of robot-assisted surgery is that they make it easier to perform complicated laparascopic surgeries -- minimally invasive procedures in which surgeons thread their instruments into the body via a small incision. Compared to "open" procedures -- i.e., those in which the patient is cut open), laparoscopy reduces hospital lengths of stay and recovery times for a number of common operations.
Of course, the same is true when surgeons perform the same kind of minimally invasive procedures manually. Both kinds of minimally invasive procedures are available for some conditions; in other cases, robot-assisted laparoscopy is the only alternative to open surgery.
Either way, there's no solid evidence that patients fare better in the long run when they have robot-assisted surgery than when they undergo conventional procedures. For example, when patients have their prostates removed in an operation known as a radical prostatectomy, their subsequent incidence of incontinence and impotence is about the same whether a surgeon does the procedure directly or via an expensive robot.
But while the incidence of prostate cancer declined between 2005 and 2008, there was a 60 percent rise in the number of hospital discharges for radical prostatectomy. That just happens to be the period when robot-assisted surgery for that condition was becoming widespread. Patients who received a diagnosis of prostate cancer were 14 percent more likely to have the procedure in 2007 than three years earlier.
Why did this happen, and why did the technology spread if it hadn't been shown to improve patient outcomes? Robot-assisted surgery adds about 6 percent to the cost of an operation, and twice that after factoring in the cost of the equipment. But it's not clear that Medicare or private insurers are paying that extra amount, at least not directly. What seems more likely is that surgeons became convinced that robot-assisted surgery was better and persuaded more patients to have these operations. That, of course, meant extra money for doctors. As the physicians began to demand robotic surgery systems, hospitals felt compelled to purchase them.
A couple of years ago, my BNET colleague David Hamilton noted a post on surgical-robot systems by Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston and an early skeptic of the systems. Levy had initially resisted calls to buy the $1 million robot for his hospital -- it was expensive and didn't seem to be more clinically effective than manual laparoscopic or open surgery. But he eventually capitulated. Why? Because nearly all of the other hospitals in the area already had robotic systems, he wrote.
Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places.... Prospective residents who are trying to decide where to have their surgical training look upon our lack of the robot as a deficit in our education program.
Levy's story is typical of the "medical arms race" that's going on all across the country. So regardless of what comparative effectiveness research comes up with, we'll have to nullify those arms races before it can begin to make much of a difference.
Image supplied courtesy of Wikimedia Commons.