Outcomes, shmoutcomes — how much do we make?
Outcomes, shmoutcomes — how much do we make?
“Doctor, I'm still having pain. Those vertebroplasty procedures only helped a little.”
“Mrs. Burns, we have a new $500 million machine that will take care of that. The ‘Leonardo' is a state-of-the-art 7T robotic-vertebroplasty-and-heavy-ion combined-therapy behemoth. It takes up a whole city block!”
“$10,000 per treatment! You'll need at least10.”
“My daughter works at Mercy Hospital and says I should go there because they have the ‘Di Caprio.'”
“They only have a 3T and use a proton beam. Are you willing to trust a technology that's almost three months old?”
“Isn't it cheaper?”
“Yes, but do you really want to gamble with the cheapest? If you do, I have some leeches….”
“What if it doesn't work?”
“We've only done two of your vertebrae. If the next one doesn't work, we have 21 more to try!”
Doctors at Cape Fear Medical Center in North Carolina performed an emergency c-section on a woman after several days of being unable to induce labor when no fetal heart activity could be found on fetal ultrasound. After cutting her open they found she was not pregnant. Whoopsie! The state medical board did not take this lightly, coming down on the doctors like a ton of bricks by issuing a scathing letter saying, “We have some concerns.” Ouch! Brutal! (Just “some concerns”? Whoa! No wonder it's called Cape Fear.)
I thought about this while on hold listening to a recording informing me that the hospital I called had recently acquired the Da Vinci robot and could now offer the highest level of care in the state. This was particularly amusing, since I had just been reading about the higher incidence of complications associated with this robot due to the steep learning curve. The Wall Street Journal had excellent coverage in the May 5 issue in which Dr. Jim Hu of Brigham and Woman's Hospital said that it takes a urologist anywhere from 250 to 1000 cases to master use of the device.
Intuitive Surgical, which makes the robot and which had sales of over a $1 billion last year, markets the robot heavily to hospitals as a strategy for increasing market share and revenue. But the local doctors don't have a chance to do a fellowship with 250 to 1000 cases before going solo like Dr. Hu. They get to do only three or four proctored cases and then start having complications. I feel sorry for patients who are now getting an ostomy as part of an attempt to capture market share. Like Cape Fear, just because you can turn on an ultrasound machine or afford to buy an expensive robot doesn't mean you should—unless you have the necessary training.
Healthcare facilities are racing each other with market share and profits as the prize. Look at the competition to acquire proton beam therapy units, huge 222-ton machines that must be sited in a building the size of a football field with walls up to 18 feet thick that will cost over $100 million. Dr. Theodore S. Lawrence, chair of radiation oncology at the University of Michigan, is quoted in The New York Times (Dec. 26, 2007) as saying there are no solid clinical data that protons are better. And yet everyone wants one of the machines for prestige and profits. Hampton University, a small college in Virginia—that doesn't even have a medical school—is building a $140 million unit.
In the same article Dr. Anthony L. Zietman, a radiation oncologist at Harvard and Massachusetts General Hospital, called this the dark side of American medicine. The article goes on, “Once hospitals have made such a huge investment…doctors will be under pressure to guide patients toward proton therapy when a less costly alternative might suffice.”
Yeah, but proton beam is SOOoooo last month. The new prestige market lure is carbon heavy ion beam therapy. The Mayo clinic is considering such a device costing more than $300 million. Even without any validating research it must be better, since it costs so much more.
Radiology is no different. If you're using a 1.5T magnet, you're medieval now. And if you've just bought a 3T, then the hospital across town is planning to top it with a 7T. But does the oneupmanship actually result in better healthcare? Probably not, but it sure costs more. A million people a year in the U.S. get cardiac stents, but a 1993 Rand study said 42% were of questionable benefit (though quite profitable).
A 2008 study in the Journal of the American Medical Association found that $86 billion was spent on back pain between 1997 and 2005 with little to show for it—except the improved profits for vendors of relevant equipment.
In a time of limited resources we should be looking to credible scientific research to guide our medical decisions rather than to marketing materials provided by salespeople who work on commission.
The demand for cost-effective, evidence-based medicine is focusing a glaring spotlight on radiology since it is the fastest growing medical expenditure. The July 1 issue of the New England Journal of Medicine leads with two articles highly critical of radiology, “Is Computed Tomography Safe?” and “The Uncritical Use of High-Tech Medical Imaging.” These force us to remember the goal is “first, do no harm,” not “grab market share.”
Vertebroplasty is the latest technology under criticism. Its use spread quickly thanks to early reports showing that patients improved afterward. But now two research studies, one in the New England Journal of Medicine (Aug. 9, 2009), could find no difference between patients who had the real procedure and those who had a sham procedure. Subjects in both groups said they felt better afterward. Not surprisingly, many interventionalists have outright rejected this research, saying the studies are not supported by their own experience. But wasn't that the point of the research? To show it's merely a placebo effect? Relying on anecdote instead of science is what politicians do. Do we want to stoop to their level?
Still, we need to be equally critical of the research we choose to aid our decisions. It has become too clear that big industry often co-opts researchers, their studies, and medical journals in the pursuit of equipment sales and profits. Their goal is for everyone to have direct access to every medical technology, no matter the expense or the skill level of its operator. I've even heard a rumor that the upcoming iPhone 5 will have a built-in ultrasound transducer. Why shouldn't everyone get to do ultrasound? Tom Cruise would certainly be the poster child for such a campaign, given his own ultrasound machine. I'd even bet he would be a welcome addition to the staff at Cape Fear...