We’ve blogged several times in the past few weeks about the fact that expensive medical technologies don’t necessarily lead to better patient outcomes. A case in point is robotic surgery—and in particular—robotic hysterectomy for benign gynecologic conditions.
Hayes has been tracking the evidence on robotic hysterectomies for some time; click here for our FREE Pocket Evidence Summary.
JAMA recently reported that the use of robotic hysterectomies has increased from 0.5% in 2007 to 9.5% in 2010; in hospitals that performed robotic procedures, robotically assisted hysterectomy accounted for 22.4% of all hysterectomies within 3 years. However, among a nationwide survey of 264,000 women with benign gynecologic conditions who underwent either type of surgery during the same time frame, there was no difference in complication rates or outcomes. The big difference was cost: each robotic hysterectomy cost about $2200 more than the laparoscopic surgery. What we can’t tell from the study is whether the robotic procedures were done because laparoscopic surgery wasn’t available—an unlikely scenario, however.
Data suggestive of these findings have been available since at least 2010. So what drives the decisions to purchase this equipment if there are no improvements in the end result?
One driver is likely the intense marketing of surgical robots by its manufacturers to consumers, healthcare providers, and hospital administrators. And, in some cases, hospitals are marketing the technology directly to consumers, as well. A 2011 study from Johns Hopkins reported that many hospital websites use industry-provided content to over-state claims of robotic success. Another driver is the competitive mentality that influences one hospital to purchase the equipment because a nearby hospital offers the procedure.
As coverage policies stand today, reimbursement for laparoscopic surgery is the same whether or not the robot is used. Therefore, there is no motivation for the patient, the clinician, or the hospital to pursue the less expensive option. While it is difficult to restrict coverage to an expensive technology that is clearly superior to a less expensive one, does it make sense to reimburse a more expensive technology that is no more effective than a current technology? Robotic hysterectomy for benign gynecologic disease would likely fall into this latter category, with an exception made for subgroups of patients with select comorbidities or challenging anatomy that could be identified by a nationally recognized registry.
The U.S. Government is currently pursuing an aggressive agenda of comparative effectiveness research (CER); along with evidence-based medicine, CER should help ensure the optimal treatment for a given group of patients by reducing the influence of nonclinical factors such as clinician bias, marking strategy, or manufacturers’ profit. This should lead to improved patient outcomes and lower costs. But this endeavor will be worthwhile only if the results are readily disseminated to stakeholders in the debate: payers, physicians, hospitals, and patients.