Is it time to roll back the robots?
Technological breakthroughs in medicine can have a transformative effect on patient outcomes and health care costs. But in a newly published study, several alumni of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program suggest that such technological changes are not always an improvement.
A group of researchers led by Danil V. Makarov, M.D., M.H.S., an alumnus of the RWJF Clinical Scholars program (2008-2010), examined the impact of hospitals’ acquisition of surgical robots on the treatment of patients with prostate cancer. Such patients are often presented with a number of options, including surgery to remove all or part of the prostate, radiation of the cancerous area or careful monitoring of the often slow-growing tumor.
The researchers found that when hospitals bought a surgical robot, patients were more likely to be treated with surgery than they would have been before the acquisition of the robot. That might not be a good thing, the authors suggest, because it is unclear from existing data whether robotic surgery is a superior treatment option.
They cite recent studies suggesting that robotic surgery might be associated with a higher incidence of post-surgical complications than traditional “open” surgery, raising concerns that patients may be choosing—or being steered toward—robotic surgery on the basis of false assumptions or incomplete information, or because hospitals guided them toward that approach for reasons that might have included helping recoup the costs of buying and maintaining the $1.7 million robot.
Makarov and his colleagues surveyed rates of radical prostatectomy, focusing both on individual hospitals and on geographic regions. They compared treatment data for 2001 with comparable data for 2005, using 2001 data as a benchmark because it was the last year before surgical robots began to come into common use. By 2005, the surgical robots had become fairly common, and Makarov and his team found them in 36 of the 71 regions they studied, and at 67 of the 554 hospitals in their sample.
In comparing the data, the researchers focused on how treatment had changed between 2001 and 2005. They discovered that regions and hospitals with surgical robots and those without the robot technology saw their numbers for radical prostatectomy surgery move in opposite directions. Hospitals with surgical robots had an average of 29 more surgery cases in 2005 than they did in 2001, while those without robots saw their case numbers decline, with an average of five fewer cases in 2005.
On its own, the increase in surgery cases for robot-equipped hospitals does not necessarily indicate that more patients are having surgery. It could simply mean that patients who choose surgery are electing to have it done robotically, and are then seeking treatment from nearby hospitals with robots. But the regional data suggest that the presence in a region of a surgical robot was associated with an increase in patients choosing surgery. In their article on the study, published in the March issue of the journal, Medical Care, the authors write:
This trend suggests that regional adoption of the surgical robot represented either supply-induced demand in local markets or the attraction of patients seeking robot surgery residing in regions without robots to those regions with an abundance of them. The results do not support the idea of a zero-sum game within an HRR [hospital referral region] where hospitals compete for a fixed number of patients without altering regional-level rates of surgery. At the hospital level, hospitals acquiring surgical robots increased their radical prostatectomies very significantly compared with those not acquiring robots, which lost a relatively small volume during the same time.
“Once the hospitals acquire this technology, they’re going to use it,” says Makarov, even though evidence of its superiority to other methods is sketchy. “From a hospital administrator’s point of view, it’s a very difficult issue. Patients demand it, and administrators may feel pressure to acquire the technology in order to keep up with the competition from other hospitals. I’m sure that for administrators, it’d be very useful if the government or some other entity ensured that there had been a rigorous demonstration of the benefits and comparative effectiveness of new devices before they go on the market.”
“There are some real pressures here that have nothing to do with science,” co-author David Penson, M.D., M.P.H., an RWJF Clinical Scholar program alumnus (1997-1999), told the New York Times. “We have this interplay of patients’ fascination with technology coupled with business interests on the part of the hospital and device makers, pushing people to try a new technology perhaps before it’s been fully tested.’’
“Once the hospital has a robot,” Makarov concludes, “all of the incentives created by its purchase lead to more people getting surgery.”
In the nine years since the surgical robot first became available, it has captured a significant share of the market. Approximately 85 percent of all radical prostatectomies in the United States are now conducted robotically. The robots’ rapid growth in market share has continued despite scant evidence of superior patient outcomes, and despite its considerable price tag. Capitalizing on the robots’ popularity, its manufacturer is now marketing it for other types of surgery, including hysterectomies and ear, nose and throat procedures.
In the view of the authors of the study, that makes it all the more important that policy-makers and hospital administrators exercise care. “We don’t argue that we need to ‘roll back the robot,’” Makarov says. “The lesson is that when new technology comes out, society would benefit more if policy-makers understood that, if it’s approved for use, it will be bought and it will be used. It’s not just that it’s going to be out there and may or may not catch on. And, in fact, it might even drive up the use of certain procedures in the absence of evidence that they’re superior. When these tools are so expensive, the matter deserves greater scrutiny. It demands a rational plan to roll out the technology built on some demonstrated benefit or cost savings.”
In the meantime, Makarov says that patients should approach robotic surgery with a critical eye. “If you go to a hospital that has acquired this technology, you’re more likely to get that procedure, and in a situation like prostate cancer where treatment decisions should be very sensitive to patient preference, patients should be very skeptical, ask a lot of questions, and make sure that their preferences are driving the treatment decision.”
The Role of the RWJF Clinical Scholars Program
Makarov and Penson’s co-authors on the study included James B. Yu, M.D., and two co-directors of the Clinical Scholars program at Yale University, Cary P. Gross, M.D., and Rani A. Desai, M.P.H., Ph.D. Gross is also an alumnus of the Clinical Scholars program (1997-1999). Makarov credits the program with helping him develop the skills needed to conduct such research. “With exposure to great mentors like my co-authors on this study, I became fascinated by how care is delivered to men with prostate cancer,” he says. “So watching the robot become so widely adopted without strong evidence to support its use was very troubling to me. I wanted to know what the adoption of the robot meant for patients’ choices and outcomes. Not only did I learn a lot of subject matter during my time in the Clinical Scholars program, but I learned to think critically, to determine which questions were important, and to design and execute research. It was an amazing experience.”
Funding for the study was provided by The Veterans Health Administration and the Robert Wood Johnson Foundation Clinical Scholars® program. For more than three decades, the Robert Wood Johnson Foundation Clinical Scholars program has fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policy-makers on issues important to the health and well-being of all Americans.