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Robot-Assisted Surgery Has Poorer Outcomes And Is More Expensive – But Because It’s Cool, We’ll Use It Anyway?

July 27th, 2009 by DrWes in Better Health Network, Health Policy, News

Tags: Cardiology, Cardiothoracic Surgery, Cleveland Clinic, Costs, Finance, MedPAC, Robotics, Surgery

Yesterday in our cath conference, we discussed the substudy from the prospective randomized trial called PREVENT-IV just published in the New England Journal of Medicine. That study evaluated the major adverse cardiac event rates of minimally invasive vein harvesting compared to open vein harvesting prior to coronary bypass surgery.

I was surprised to see that minimally-invasive vein harvesting had a higher combined complication rate of death, myocardial infarction (heart attack) and need for revascularization in the patients who received vein grafts harvested by the minimally-invasive technique. Following the presentation of the data, our surgeons were asked why this might be the case. While none knew for sure, they postulated that the art of harvesting vein-conduits using endovascular techniques might play a role (it’s more difficult), or the effects of the thrombolytic state induced by on-pump bypass vs. off-pump bypass might create the discrepency in post-surgery vein survival, since patients are less likely to develop clinical thromboses in the post-open chest bypass population.

So this morning, I was surprised that President Obama toured Cleveland Clinic yesterday and had such an up-front experience with minimally-invasive robotic surgical techniques for mitral valve repair that hardly represents mainstream American health care. While the marvels of the technology cannot be disputed, like the endovascular vein harvesting study above, might we find that robotics could be as deleterious to patients compared to open chest techniques? After all, these techniques have yet to be compared in multi-center trials to more conventional open techniques for mitral valve repair. But more concerning as we move forward is this question: will academic centers be granted more funds to test comparative effectiveness research for robotics at the expense of front-line American health care? Surely, this won’t be, will it?

Probably.

But when I see pieces like this I wonder why the article does not question the cost and risks of this technique compared to conventional open-chest procedures, especially in this era of touting the need for health care cost containment. How much is this piece about the marketing of this technique to the community (for financial gain) or to the President (for obtaining grants or political favors)?

Perhaps we should ask ourselves how many of the physicians and surgeons at Cleveland Clinic stand to earn a seat on the proposed MEDPAC board that will determine if Congress will approve payment for robotic techniques even when few data exist to show their superiority over conventional techniques.

Now that might make for some really interesting reading.

*This blog post was originally published at Dr. Wes*

Valerie Jarrett, White House Senior Advisor At BlogHer09

July 25th, 2009 by Emergiblog in News, Opinion

Tags: Bloggers, BlogHer, BlogHer09, Government-run Healthcare, Healthcare reform, Obama, Obamacare, Single Payer, Valerie Jarrett

I was honored to receive an unprecedented opportunity to hear a Senior Advisor to President Obama speak about his health care reform efforts at BlogHer 09.

Valerie Jarrett, Senior Advisor and Assistant to the President for Public Engagement and Intergovernmental Affairs, spoke to an intimate group of bloggers at a luncheon today.

And I was 15 minutes late.

How humiliating! This was definitely not the event where one should be “fashionably late”.

Ms. Jarrett was totally cool though, and said “Come on in and tell us who you are!” Apparently I had just missed intros; the discussion was just starting.

(Photo credit: Wikipedia)

********************

Now I’ve been pretty clear about not wanting a government run health care system, and I attended the luncheon knowing I did not have a clear grasp on the President’s proposal. (I have downloaded the Bill, have not had a chance to finish it.) I wanted to keep an open mind; I wanted to learn as opposed to opine.

The best way to learn is to keep your mouth shut and listen. That is exactly what I did.

It was not easy.

*****

Ms. Jarrett is warm, sincere and truly passionate about the President’s efforts at health care reform;  Ms. Jarrett has full faith in the ability of the President to positively reform our health care system.

Now, if I heard and understood correctly, what the President wants is a public plan as an option; a choice to obtain health care coverage through the government should you find yourself unemployed/without any health care coverage.  Ms. Jarrett was adamant that the goal is not a single-payer government run plan, but there was some group questioning of (1) why the idea of a government plan is perceived as scary and (2) whether or not it would be tantamount to socialism and indeed, what would be wrong with that anyway. One blogger noted that she knew many Canadians who were happy with their health care.

These questions were more rhetorical in nature. Honestly, I don’t think time would have permitted in-depth discussion.

*****

There was discussion on how bloggers can get out the message of health care reform and ideas on how the President can best communicate his ideas to the public.  It was noted that the President is holding press conferences for which he is asking full coverage because he wants the entire story told, not just sound bytes.  (Side note: I found this interesting because just recently ABC News encamped in the White House for an entire day – and the topic was health care reform.)

I actually did have a question enter my mind, as I was intrigued by the idea that the public plan was an option: I wanted to know if one could move in and out of the public plan as desired, or were you stuck in the public plan once it was chosen.

I didn’t get a chance to ask, as the discussion moved forward with two bloggers sharing stories of their personal experiences with the health care system.  Very personal, heart wrenching stories. Their frustration and anguish was palpable. Ms. Jarrett listened with empathy; she truly cared about what my fellow bloggers had/were enduring.

I found out later that both bloggers left with her personal business card with her office number for them to call her directly after the conference.  That was impressive.

*****

So, some final thoughts.

I like Valerie Jarrett.  It was amazing that she took time to come and speak to us, and it was informative. She speaks straight, she is sincere and she seems very passionate and compassionate regarding health care reform.  I’m a bit more informed about what the President is looking for.  This was the advantage shutting up and listening. I don’t necessarily agree but I’m starting to at least get a hold of the concept.

Gratuitous political commentary: I think a little too much time was spent decrying the last administration. It’s over; time to move on.

Now for my totally off-the-cuff observation. I could not help but notice this was the exact opposite of my experience in DC last week. This was a full-on Obamafest, last week seemed like an “anything BUT Obamafest”. This week the “opposition” was putting out misinformation, last week the “opposition” was trying to cram a bill through before Congress could read it.

Is there no middle ground? Does it have to be this contentious? Maybe it’s the way of politics and I’m just now realizing it.

Between the two events, I guess I have now been exposed to a “fair and balanced” view of health care reform by Washington insiders.

So….why does it still feel like I have vertigo?

*****

This post was written from my own notes and memory. It was actually live-blogged in real time and if you would like to read the entire transcript, it is written here: Valerie Jarrett/Health Care Reform Live Blog BlogHer 09.

Valerie Jarrett, White House Senior Advisor Talks to Bloggers at BlogHer09

*This blog post was originally published at Emergiblog*

The Difference Between Short and Long Term Medicare Savings for Health Care Reform

July 22nd, 2009 by SteveSimmonsMD in News, Opinion, Primary Care Wednesdays, Uncategorized

Tags: Primary Care Wednesdays

Robert Blendon, Professor of Health Policy and Political Analysis at the Harvard Kennedy School of Business, speaking on funding for Health Care Reform, July 8, 2009

“Potential sources for this (health care reform) are new taxes on people or businesses, substantial short-term savings from the existing Medicare and Medicaid programs, or increasing the deficit”

After Last week’s passage of Health Care reform plans by committees in the House and Senate, attention has turned to the Senate Finance and House Commerce Committees to see how congress will pay for reform in a deficit neutral way, as mandated by President Obama.  The price tag over ten years–$1.2 Trillion–is paired with the observation that a shortage of $240 billion currently exists.  This assumes that $948 billion already has been found.

The only way to ‘find’ $948 billion without increasing the deficit is to increase taxes on businesses and the wealthy or by reimbursing less for services provided through Medicare and Medicaid.  I will leave the never-ending tax-rate argument for political pundits, and instead focus this post on short and long-term savings from Medicare and Medicaid because I believe paying less for services than it costs to provide them will negatively impact the quality of medical care in this country.

I was surprised to learn of a battle being waged between the executive and legislative branches on the issue of “long-term savings” from Medicare, as it relates to “Medicare Payment Authority”.  White House Chief of Staff, Rahm Emanuel, has called Medicare payment Authority, “the least talked about, most important issue on the table” and clarified its’ importance by stating, “Structures that fundamentally alter the long-term costs are a must for real health-care reform.”   This issue does not follow party lines with a mix of Republicans and Democrats being in opposition or support of the President, irrespective of party affiliation.

Our Congressional Representatives have the power to set Medicare Payments, outside of any pre-set rules or regulations by simply passing legislation.  The Washington Post describes this power as “one of their most valued perks….a powerful tool on the campaign trail”.  President Obama’s administration wants to either transfer payment authority to MedPac (the Medicare payment advisory commission) or create an independent Medicare Advisory Council, reporting to the executive branch so lawmakers can no longer tailor Medicare spending to address local concerns.

Before leaving office, Senator Ted Stevens secured a permanent 35 percent increase in Medicare payments for Alaskan physicians only.  The political benefits to an incumbent running for reelection need not be explained while it is easy to see the inefficiency in such a system.  At a time when politicians are admonishing those working in the Health Care Field to be more efficient, I would urge congress to take a dose of their own efficiency medicine and support the current administration in their efforts to curtail long-term spending by surrendering this power.

According to the White House, $622 of the $948 billion will come from short-term savings squeezed out of existing Medicare and Medicaid programs through one of two ways: by improving efficiency (309 billion) or enacting policy changes (313 billion).  The Medicare Fact Sheet posted on the White House website, states that one policy change will have the added benefit of encouraging efficiency:  “incorporate productivity adjustments into Medicare payment updates”.  This policy change measures the productivity of the entire U.S. economy, as measured by subtracting the hours worked from the amount of product created and extrapolates it to Health Care (a profession which does not produce “products”).  This idea justifies the withholding of 110 billion dollars from “providers” with an unexplained benefit stated in the closing sentence describing this policy, “This adjustment will encourage greater efficiency in health care provisions”.

I found it difficult to believe that anyone could suggest paying less would encourage greater efficiency in caring for the infirm and old until Boston Medical Center, a hospital serving thousands of indigent residents, sued the state of Massachusetts one week ago, charging that the state is now reimbursing only 64 cents for every dollar spent treating those covered under Medicaid or Commonwealth Care (the state subsidized insurance program for low-income residents).  This should be of great concern to us all since the House’s plan adds 11 million people to Medicaid and cuts funding while reformists tout Massachusetts as an example worth following, being the only state with universal coverage today.  Before state wide reform was enacted this hospital had operated for 5 years without a loss.  However, when the hospital showed losses over two years of 138 million dollars, state officials observed the hospital had a 190 million dollar reserve (not for long it appears) and suggested that Boston Medical could reduce costs by operating more efficiently.

The above example demonstrates the willingness of government bureaucrats, inexperienced in providing actual medical care, to give flippant advice while failing to appreciate how fiscal efficiency, doing more with less, impacts medical efficiency, caring for the ill effectively.  To be sure, something must be done to curtail run-away costs in health care and I agree with the president when he says, “The status quo is unsustainable. Reform is not a luxury, but a necessity”.  However, reform needs to focus on sustainable Short-term and Long-term savings in such a way that prevents hospitals and doctors from having to make a choice between providing sub-standard care or going out of business.  Furthermore, I would hope that Congress take an honest look in the mirror regarding long-term savings before only enacting short-term savings which could negatively impact the care available to us all.

Until next week, I remain yours in primary care,

Steve Simmons, MD

A 16-Way Kidney Swap?

July 15th, 2009 by Medgadget in Better Health Network, Expert Interviews, Health Policy, News

Tags: 16 Patients, Johns Hopkins, Kidney, Renal Disease, Surgery, Swap, Transplant

A team at Johns Hopkins has coordinated the world’s largest kidney swap, involving sixteen patients in multiple medical centers across the US. One of the donors was the vice president of human resources at Johns Hopkins Health System, a woman who has promoted organ donation and finally got a chance to do the ultimate charity work herself.

Johns Hopkins reports:

An altruistic donor started the domino effect. Altruistic donors are those willing to donate a kidney to any needy recipient. Just like falling dominoes, the altruistic donor kidney went to a recipient from one of the incompatible pairs, that recipient’s donor’s kidney went to a recipient from a second pair and so on. The last remaining kidney from the final incompatible pair went to a recipient who had been on the United Network for Organ Sharing (UNOS) waiting list.

As part of this complex procedure, Johns Hopkins flew one kidney to Henry Ford, one kidney to INTEGRIS Baptist and one kidney to Barnes-Jewish, In exchange, Henry Ford, INTEGRIS Baptists and Barnes Jewish each flew a kidney to Johns Hopkins.

The 16 surgeries were performed on four different dates, June 15, June 16, June 22 and July 6. The 10 surgeons in charge included four at Johns Hopkins, two at INTEGRIS Baptist, two at Barnes-Jewish and two at Henry Ford.

Johns Hopkins surgeons performed one of the first KPD transplants in the United States in 2001, the first triple-swap in 2003, the first double and triple domino transplant in 2005, the first five-way domino transplant in 2006 and the first six-way domino transplant in 2007. Johns Hopkins also performed the first multihospital, transcontinental three-way swap transplant in 2007 and the first multihospital, transcontinental six-way swap transplant in 2009.

Nearly 100 medical professionals took part in the transplants, including immunogeneticists, anesthesiologists, operating room nurses, nephrologists, transfusion medicine physicians, critical care doctors, nurse coordinators, technicians, social workers, psychologists, pharmacists, financial coordinators and administrative support people.

*This blog post was originally published at Medgadget*

Twitter First Conceived By British Hospital In 1935

July 9th, 2009 by Berci in Better Health Network, News

Tags: Britain, Communication, Hospital, Notificator, Twitter

*This blog post was originally published at ScienceRoll*