Tuesday, June 17, 2014

Costs and Effects of a Surgial Tool

Today's Wall Stree Journal had a column that definitely attracted my attention.  The title was "Showdown for Surgical Tool."  The article was about the power morcellator.  This is a device used to "slice up" the uterine tissue that is affected by fibroids so that it can be removed through small incisions.  (I'm taking this pretty much from the article at this point.)  This provides an opportunity to perform a very minimally invasive hysterectomy.  I don't know much about this device.  I do know a think or two about abnormal uterine bleeding and hysterectomy from a project earlly in my career. 

What is interesting about this is the importance of some way of reducing the pain, discomfort, fatigue, and other symptoms associated with having fibroids and abnormal uterine bleeding.  There are medical and surgical approaches.  A traditional surgical approach is a total abdominal hysterectomy.  That, however, has some pretty negative short term consequecnes for quality of life and function.  Having a procedure that can be done in a minimally invasive way that leaves the patient with more limited symptoms and side effects seems like an ideal solution.

However, it is possible that the FDA will take the device off the market.  An extreme move done only once before according to the article.  Why?  In 1 in 350 cases (according to the article) women have a cancer that is unrecognized in advance of the procedure but that is then spread in the process of slicing the tissue for removal.  The spread of cancer can lead to a suddenly advanced case

A full understanding of this risk may change the calculus of deciding how and when to use the device.  It calls to question several things.

First, from a policy perpsecitve, what is the risk of spreading cancer this way that society is willing to accept.  As the article points out, each time the 1 in 350 becomes manifest that is someone's daugher, sistern, niece, aunt, spouse, mother, etc.  What risk is too high?  When is the risk low enough to be tolerable?

Second, regardless of what society decides, at what point would we let the patient in careful consultation with her gynecologist make a choice about what risk might be acceptable to her?  Do we allow women to make such a choice?  Can we confidently counsel them on how to make such a choice?  

Third, there are a number of solutions proposed.  Targeting women who are less likely to have cancerous fibroids.  (This would decrease the use of the device and imply that in a decision about whether to acquire and use the device there will be less marginal revenue to collect and count as a positive in the calculation in which the fixed cost is the same no matter who is treated.)  How well can we target?  For how many non-targeted women does it make it difficult or impossible to obtain a less invasive procedure.   Alternatively, the use of containment bags to limit the spread of tissue.  This would require some up front investment in teaching physicians how to use teh tehncology better and then the cost of bags.

Alternatively, the article suggests that physicians without the morcellator may turn to the much more invasive surgery.  This suggests a need to more training about other proceudres.  This is a sunk cost in the process of deciding on how to maximize the profits that could be made with or without the decision to invest.

Any solution to the issue of the power morcellator (better training, better patient choice, or containment bags) will change the economics of relevant patient care.  Women will almost certainly have at least slightly less access to the procedure until a stable equliibrium is found.  Trying to solve one problem may create another as often happens in health care.  I'm not advocating continued use.  I'm simply saying that all points and all unintended consequences must be considered.  

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