Our chiefs of service at BIDMC are technically and academically tops. Plus, they are great people. Plus, they have good senses of humor. Every now and then a one-liner pops out that is especially worth memorializing.
Today at Medical Executive Committee, we were voting on approval of procedures and therapies. The topic was adult intraosseus device use. This is a gizmo that screws into a bone that permits the delivery of medication into the marrow. It is for those cases in which access to blood vessels is not possible. I am told that this doesn't happen often, but that it is good to have the devices in reserve for emergency department and ICU situations.
Well, the group got to talking about what these devices look like now and how they compare in functionality and cost to ones used in prior years. Finally, our Chief of Anesthesiology summarized the discussion by saying, "So now we have a new expensive device that is just as good as the old cheap one."
In health care, plus ça change, plus c'est la meme chose.
Speaking of which, I am told of an article in the New England Journal of Medicine by Barbash and Glied, entitled "New technology and health care costs - the case of robot-assisted surgery." Aug. 19, 2010 pp 701-704. A friend sent an excerpt:
"... [R]obotic technology may have contributed to the substitution of surgical for nonsurgical treatments ... increased both the cost per procedure and the volume of cases treated surgically.... The evidence suggests that despite the short term benefits, robotic technology may not have improved patient outcomes or quality of life in the long run."
It's fun, but in the technology field we face that kind of decisions everyday too. Since there's always something new to work with (programming language, mobile phone...) we have to constantly decide wether to take that train or not.
ReplyDeleteThe point is that most of the times the new technology is indeed better than the previous one, but only marginally. At the end we often find that the benefit we'll take from the change is way lower than the cost of the change itself, so we stay put.
Ah, but that's a double-edged sword. From time to time we feel outdated and have to take the leap forward.
I guess it's a matter of timing in the end, but how to determine the precise moment?
As you may recall, I have mixed feelings about this. I see no point hospitals duplicating technology for competitive purposes; it senselessly drives costs through the roof, as you've written, and is one of the best arguments I've heard for centralized control: "No, you don't need one of those, there are only 50 cases a year and somebody else in your city has one. Stop it."
ReplyDeleteOtoh, I kind of object to "despite the short term benefits." If they're talking about much earlier recovery, return to work, etc, to me that's worth paying for.
And finally, as you well know, my surgeon, Drew Wagner, didn't need no steenking robots to take out my kidney mess; he did me laparoscopically with his bare hands. He does use the robot for some cases, particularly tight prostate surgery, he said.
But when it comes to competing for business, much much bigger concern to me is the physicians and surgeons who don't tell the patient that a better option is available elsewhere in town. That is wholesale unethical and even cruel, IMO. I know a guy who had his nephrectomy via the open method (2-3 month recovery) and was never told about the laparoscopic option, with or without robot.
I sure wish docs would write about that in their frickin journals as much as they write about the other valid topics.
And just to reinforce the point, yesterday's NEJM carries a randomized trial of early palliative care coincident with best cancer care. The palliative care group- no surprise- had better quality of life, less depression, and less use of aggressive last ditch chemo and hospitalization. But- surprise- they also lived nearly 3 months LONGER. Turns out adressing and treating patient's misery helps them to live. Plus ca change, indeed. http://www.nejm.org/doi/full/10.1056/NEJMoa1000678
ReplyDeleteWe are living in the age where technology is throwing us a new left curve every day, I post about a lot of that both on the clinical and tech side as they all work together today in some fashion or another and agree it is hard to figure out the value sometimes too.
ReplyDeleteIf it is something that extends life and better outcomes for the patient then certainly worth a look and then there's the cost that comes into play too. Certainly everyone wants to earn back their R and D costs, but how much is that? I think we have a gray area here. Gosh knows we see it with stents, and those folks make a ton of money in court just suing each other over that fact with their patents, so we end up with legally patented stents and whether or not they are better than the competition, only the doctors and patients can be the judge there with their findings and studies. Stent wars are so very costly and we all pay for it in the price of the product.
Its a tough decision today as there's new devices, drugs, etc. rolling out it seems almost every day and with devices we now have more software than before too so it's not just a matter of a mechanical device any longer too.
It's hard to budget for tomorrow when you don't know what tomorrow will bring, that's for sure and yet there's the pressure to keep those efficiency numbers in place as all this meshes together somewhere along the line with new procedures to learn with every new product that comes down the line too.
It's kind of similar to the research environment in China. When I came to the US for graduate school, I was surprised to find that most of the instruments in the lab are so outdated compared to the ones in China. We had a NMR 800Hz (the best in the field) in our lab in Peking University and when I talked about it, nobody believed it... But why is the US research much better than China? In the end, it's all about who use the machines, not the machines themselves.
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