Stephen Reintjes, MD
Neurosurgical Resident, University of South Florida
While wandering around the Congress of Neurological Surgeons’ (CNS) 2016 Annual Meeting and 84th AANS Annual Scientific Meeting of the American Association of Neurological Surgeons, I was fascinated by the displays on the exhibition floor. Towering booths demonstrated everything from spine implants to imaging software and the newest radiation therapy, among others. Clearly, the interplay between technology, innovation and responsible cost containment is a tenuous balance. Nearly all the advances in medical care in the last few decades, particularly in specialties such as neurosurgery, are the result of technological advances stemming from innovation. This has benefitted an untold number of patients, their families, and society but clearly, there has been a significant price tag attached. Corporate sponsorship is a vital component of resident and surgeon education. Again, the balance between companies helping and unduly influencing is delicate but most often achieved. The relentless pursuit of technology makes its way into neurosurgical offices, intensive care units and operating rooms across the country.
How does a neurosurgeon make the best decisions given these challenges? Certainly, awareness of the associated costs is important. A recent study published by the Commonwealth Fund demonstrates that the U.S. continues to have the most expensive health care system per capita even compared to other high-income countries. Although the data from the study predates the Affordable Care Act (ACA), it highlights higher costs are most directly associated with greater use of medical technology. A driving component is being a leading consumer of advanced imaging technology with the highest per capita rates of MRI, CT and PET exams. For example, the U.S. (35.5) and Japan (46.9) have the highest number of MRI machines per million people. The next closest nation is Australia with 13.4 MRI machines per million population. While Japan has more MRI machines, the U.S. orders 106.9 MRI exams per 1,000 people to Japan’s 90.9.
Another important consideration is ensuring that the technology we use and tests we order do in fact help our patients and improve outcomes. Studies have shown that neurosurgeons, due to the complexity of their specialty, tend to order higher cost tests because of medical liability concerns. There may also be times when individual surgeons allow vendors undue influence without sufficient supporting evidence — but such cases are extremely rare. Most often, the crux of the problem is the difficulty in optimally studying many medical, especially neurosurgical, questions because of complexity and confounding factors. Additionally, our patients are not like test tube experiments where experiments can be repeated with varying parameters to find the optimal solution.
Touring the wondrous but daunting exhibition hall vendors, I couldn’t help but muse about this conundrum and my part in it. Costs in medicine have never been scrutinized more heavily. In neurosurgery, we celebrate technology breakthroughs on behalf of our suffering patients but need to continually ask ourselves if using technology is really making our patients healthier and if it’s making surgery safer. As a profession, we must continue to strive to be accountable for both its use and misuse.