Monday, March 15, 2010

A Brain Surgeon Looks at Medical Technology

Editorial By Dr. Thomas Origitano, Chair of Neurological Surgery

The following is an editorial written by Dr. Thomas Origitano, chairman of the Department of Neurological Surgery at Loyola University Chicago Stritch School of Medicine.

We are enamored with technology, especially when it comes to health care. But newer does not necessarily mean better. Technology continues to drive up the cost of health care, often without sufficient proof it is superior to existing medical devices and equipment.

Consider what happened with laser surgery in the late ‘80s and early ‘90s. Neurosurgeons enthusiastically embraced systems that vaporized brain tumors. Lasers were promoted as more precise than the old ways of cutting, suctioning or cauterizing tumors.

But how well did lasers actually work? It was only after lasers were widely disseminated that the evidence caught up with the technology. It turns out that lasers were expensive and time-consuming. Long-term patient outcomes were no better, and in some cases, even worse.

Today, neurosurgeons once again are embracing a seemingly promising new technology, known as intraoperative surgical navigation. An imaging scan such as an MRI or CT is fed into a computer, which produces a 3-D image of the brain. The system, which works like a global positioning system (GPS), enables the surgeon to precisely navigate the brain. This will help the surgeon avoid critical areas such as the optic nerve, and minimize damage to surrounding tissue. The added safety margin will enable surgeons to safely remove larger portions of a tumor.

Intuitively, the technology seems to make sense. But intuition is not proof. While some studies have been published, definitive evidence would require the type of studies that are lacking -- well-designed, multi-center trials in which patients would be randomly assigned to receive either surgical navigation or standard care.

Perhaps we should consider adopting the international model. In other developed countries, new medical technology typically is carefully studied in a handful of academic medical centers of excellence. Only after the technology is validated does it spread far and wide.

In the United States, by contrast, industry aggressively promotes the rapid adoption of new technology. Manufacturers spend heavily to pay for studies, fund medical meetings, advertise in medical journals and sign up influential physicians as well-paid consultants. This raises the possibility that money, rather than data, is driving the use of new technology. When a surgeon uses a particular brand of clip to seal off a brain aneurysm, is it because the product is truly the best clip on the market or because the surgeon is being paid by the manufacturer? (Loyola, like most other academic medical centers, has policies that are designed to protect against such conflicts.)

Industry has been, and will continue to be, a partner in developing innovative technologies to prevent, diagnose and treat disease. But we need to protect against the possible corrupting influence of industry. And with health-care costs exploding, we also must make sure new technology is actually worth the cost. Intraoperative navigation may very well prove to be an effective way for surgeons to safely remove larger portions of tumors. But if this extends patients lives only by two or three months, can we afford the cost?

Among the most expensive new technologies are computer-assisted systems that deliver precisely targeted doses of cancer radiation therapy. Studies have found that each of these systems is effective in treating specific types of tumors and other disorders. But in many cases, these systems are being used additionally to treat different types of tumors or disorders that haven't been studied definitively.

Medical technology also has risks. CT scans and other medical imaging procedures are the greatest contributors to total radiation exposure in the U.S. population. But some of the CT scans we're doing may not be necessary.

This was demonstrated in a recent study at Loyola University Chicago Stritch School of Medicine. Our study, published in the Journal of Neurosurgery, examined the routine use of CT scans in patients following brain surgery. We found that low-tech bedside exams by a skilled physician did a far better job than CT scans in predicting which brain surgery patients would need to return to the operating room to treat complications. Based on our findings, we eliminated about one-third of the post-operative CT scans, because they weren't telling us anything useful.

CT scans, like many other medical technologies, can be really helpful. But technology needs to be tempered by evidence that it works -- and also by the judgment of a skilled physician.

Dr. Origitano is chairman of the Department of Neurological Surgery at Loyola University Chicago Stritch School of Medicine.

About Loyola University Health System

Loyola University Health System (LUHS) is part of Trinity Health. Based in the western suburbs of Chicago, LUHS is a quaternary care system with a 61-acre main medical center campus, the 36-acre Gottlieb Memorial Hospital campus and more than 30 primary and specialty care facilities in Cook, Will and DuPage counties. Loyola University Medical Center’s campus is conveniently located in Maywood, 13 miles west of Chicago’s Loop and 8 miles east of Oak Brook, Ill. At the heart of the medical center campus is a 559-licensed-bed hospital that houses a Level 1 Trauma Center, a Burn Center and the Ronald McDonald® Children's Hospital of Loyola University Medical Center. Also on campus are the Cardinal Bernardin Cancer Center, Loyola Outpatient Center, Center for Heart & Vascular Medicine and Loyola Oral Health Center as well as Loyola University Chicago Stritch School of Medicine, Loyola University Chicago Marcella Niehoff School of Nursing and the Loyola Center for Fitness. Loyola's Gottlieb campus in Melrose Park includes the 255-licensed-bed community hospital, the Professional Office Building housing 150 private practice clinics, the Adult Day Care, the Gottlieb Center for Fitness, Loyola Center for Metabolic Surgery and Bariatric Care and the Loyola Cancer Care & Research at the Marjorie G. Weinberg Cancer Center at Melrose Park.

Trinity Health is a national Catholic health system with an enduring legacy and a steadfast mission to be a transforming and healing presence within the communities we serve. Trinity is committed to being a people-centered health care system that enables better health, better care and lower costs. Trinity Health has 88 hospitals and hundreds of continuing care facilities, home care agencies and outpatient centers in 21 states and 119,000 employees.