Once again, it appears that “more” medical care is not necessarily the “best” medical care. This time, two medical procedures are at the root of the debate: endovascular therapy following stroke and robotic gynecologic surgery.
Two trials published in a recent issue of the New England Journal of Medicine provide new evidence that sometimes high-tech procedures may not be better than low-tech treatments. Contrary to expectations, there was no difference in clinical outcomes among stroke patients who received just intravenous medication (tissue plasminogen activator [t-PA]) compared with patients who received intra-arterial t-PA, angiography, or clot removal. In fact, one study was stopped early because there was so little difference in outcomes between the two groups.
The same “less might be better” hypothesis was also reported this week in the Journal of the American Medical Association. According to the authors, the use of robotically assisted hysterectomy for benign gynecologic disorders increased substantially between 2007 and 2010. Robotic-assisted hysterectomies rose to 9.5% of hysterectomies in 2010 from 0.5% in 2007. However, the robotic procedure appears to offer little short-term benefit and is accompanied by significantly greater costs.
The researchers examined records from 264,758 women who underwent hysterectomy for benign gynecologic disorders at 441 hospitals across the United States from 2007 to 2010. Among the women, 46.6% underwent an abdominal hysterectomy, 20.7% had a vaginal hysterectomy, 28.6% had a laparoscopic procedure and 4.1% underwent a robotically assisted hysterectomy. The same researchers had already analyzed a subset of these women who had undergone laparoscopic or robotic hysterectomy for endometrial cancer. At that time, they determined that there were no significant differences in patient outcomes, rates of overall complications, or prolonged hospitalization between the procedures, despite a significant cost increase for the robotic procedure.
In this study, patients who underwent a robotic-assisted hysterectomy had slightly shorter hospital stays; however, the overall complication rates were similar for robotic-assisted and laparoscopic hysterectomy (5.5% versus 5.3%). The total costs associated with robotically assisted hysterectomy were $2189 more per case than for laparoscopic hysterectomy.
Because both laparoscopic hysterectomy and robotic-assisted hysterectomy are associated with low complication rates, it is unclear what benefits robotically assisted hysterectomy offers. And unlike robotic prostatectomy, which essentially offers the only minimally invasive surgical approach for the procedure, robotic-assisted hysterectomy has several acceptable alternatives, including both laparoscopic and vaginal approaches.
The bottom line? We don’t have conclusive evidence that angiography, intra-arterial tPA or mechanical thrombectomy improves patient outcomes following a stroke. Nor do we know for sure that robotic hysterectomy offers fewer complications or provides more benefit than less invasive procedures. We do know, however, that these procedures cost more than their lower-tech complements. To what end?
If you read this blog on a regular basis, you’ve probably read posts by Winifred Hayes, our founder, who says that one driver of the skyrocketing healthcare costs in the United States is our penchant for more of everything regardless of the cost—more tests, more medications, and more treatments, without regard to how best use these technologies and in which patient populations. The authors of the studies mentioned above appear to agree. The authors of both stroke studies suggest that their findings do not support the use of the more invasive and expensive endovascular therapy over intravenous treatment; the authors of the hysterectomy study say that their findings “highlight the importance of developing rational strategies to implement new surgical technologies.”
How can we develop strategies to implement these more expensive technologies when the evidence is less than robust?