Do It Because You Can or Do It Because You Should?

Those of us who practice medicine have been accused of being Luddites, slow to adopt technology and change.  How else can you explain the slow incorporation of electronic medical records (granted there are also cost issues, too).  Heck, washing hands is still a problem even today, centuries after Semmelweis.  And while some of us have jumped on the social media bandwagon, others of us can't differentiate between a tweet and a chirp.

And yet, at other times, we've jumped way ahead of the curve way before science has proven any benefit.  The use of fetal heart monitors is a good example as we still don't have any studies demonstrating outcome benefit.  And as published yesterday in JAMA, the use of robotic hysterectomy has increased dramatically w/o any demonstration of outcome benefit.  In fact, its use has increased cost of surgery w/o meaningful benefit.  

To arrive at their conclusion, the authors performed a cohort study on 264,758 women who had undergone hysterectomy for non-malignant reasons at over 400 hospitals from 2007 to 2010.  The percentage of robot-assisted surgeries jumped from nothing to 1 in 10, in just 3 short years.  If you looked more closely at only the hospitals that were actually equipped to perform robot-assisted surgeries, the climb in use was even steeper, from nothing to 1 in 5, almost 1 in 4, operations.  The good news is that (traditional) abdominal hysterectomies decreased in frequency during this same period of time.

Sure, there is tremendous benefit in shorter recovery times when comparing robot-assisted surgery to open abdominal approach.  But there's no outcome benefit when compared to laparoscopic hysterectomy which is also minimally invasive.  On the other hand, cost of robot-assisted surgery is dramatically higher than either laparoscopic and open surgeries.

In this day & age of cost containment & comparative outcome studies, it would behoove us to determine what benefit any given prescription or procedure provides over its competitors.  Just because something is new doesn't mean it's better.  Just because we can do something doesn't mean we should do so.  Make an active choice to prescribe a medication, order a test, or perform a procedure, not because we can, but because we should.  And if you think about, this post is the surgical analog to yesterday's discussion about prescribing generic statins over brand name medications which have no outcome benefit.  

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