Just in case some hospital chiefs have millions in the coffers to spend but can't figure out what to buy, a report by the ECRI Institute lists ten high-priced gadgets and systems that bear at least a look.
"Hospitals have very high pressure on their budgets right now," says Diane Robertson, director of ECRI's health technology assessment information service which helped prepare "Top 10 C-Suite Watch List: Hospital Technology Issues for 2012."
"We see them paying more attention to clinical evidence, and more attention to incorporating processes to rationalize their decision-making on where they are going to allocate resources...understanding all the issues, so they're not unaware of something they need to be aware of," she says.
In some cases, such as proton beam or carbon ion radiation treatment centers, for example, "these are $200 million decisions," Robertson says. And in the case of proton beam therapy, "there's still no evidence that shows it's any better than standard photon therapy," even as carbon ion technology, requiring a separate major investment, is now underway in Europe and may be more effective at treating cancer.
The report looks at the promise and cost of surgical tools and techniques, emerging drugs and devices, genotype personalized medicine, and examines in each case whether they are ready for prime time, what pros and cons to weigh.
"Careful consideration of all the factors affecting whether and how to adopt these new interventions will be crucial for short- and long-term strategic planning, effective implementation, and optimal safety and effectiveness for patients," the report says. It adds to and updates the organization's 2009 similarly titled report.
Here is the ECRI's list of the top 10, derived at by the institute's expert consensus:
1. Electronic Health Records
ECRI's experts say that medical device integration is necessary to merge patient care device data into the EHR, either directly or indirectly through an intermediary system, often called medical device integration. This requires clinical engineering and IT staff to work together, and typically, the report says, no single person understands both.
"Most hospitals lack access to the necessary information for medical device integration, such as having a complete inventory of medical devices that use the network, their associated IP addresses, and the firmware and software versions in use, to start," the report says.
Integration is necessary to achieve Stage 2 certification criteria for Meaningful Use, necessary for hospitals to receive American Recovery and Reinvestment Act incentive payments.
2. Minimally Invasive Bariatric Surgery
A slew of emerging technologies make surgery for the obese much easier, much less invasive, with shorter lengths of stay and fewer infections, with increasing evidence that long-term weight loss and reduction in diabetes symptoms can result.
However, hospitals that launch such programs must have interdisciplinary services such as specialized nursing and dietary instruction, counseling and exercise training. They need to invest in special equipment such as patient lifts, laparoscopic instrumentation, fluoroscopic imaging tools. Moreover, hospitals must appreciate the need for clinician training for new and emerging procedures.
One new approach that has gained traction is the laparoscopic sleeve gastrectomy, which alters the stomach but not the intestines, the paper says. "While this procedure does not shift existing bariatric services, it may not help your bottom line because many payers do not reimburse for it because the quality of available evidence on efficacy thus far is low." Another emerging approach is "gastric plication," now being tested by the Cleveland Clinic.
"Some U.S. bariatric surgeons have expressed concern that accounts of substantial weight loss in a short time span using this procedure, compared to other weight loss surgeries, may drive patient demand before sufficient evidence is available to support safety and efficacy," the report says.
Other approaches include devices implanted with an endoscope through the mouth such as the EndoBarrier Gastrointestinal Linder, the intragastric balloon and an implanted intra-abdominal vagus nerve blocking system that signals satiety.
3. Digital Breast Tomosynthesis
3-D digital breast tomosynthesis, which minimizes the shadowing effect of tissue by taking pictures in thin sections, improves diagnostic accuracy, but is hard on budgets and operational costs and the clinical benefit is unclear, the report says. Also, it does not replace full-field digital mammography but must be used in addition.
Additionally, full-field digital mammography images require a lot more expense for data storage.
4. New CT Radiation Reduction Technologies
A few years ago, the dominant topic for CT radiologists was how many slices on could attain: 32, 64, 128. Now, the focus is on reducing radiation.
Now, precision engineering and computer controls eliminate radiation doses that don't add meaningful information to the image, the report says. These "iterative reconstruction" systems currently " are available on only the most advanced platforms and cannot be retrofitted to existing systems.
However, "ECRI Institute believes that tools to assess the amount of radiation dose delivered during a CT scan are just as important as CT scanner technology and will be vital for optimizing CT dose."
5. Transcatheter Heart Valve Implants
Minimally invasive transcatheter aortic valve surgery techniques are promising enough that hospital executives should be planning for the infrastructure and staffing models required.
The Centers for Medicare & Medicaid Services is considering requests for a national coverage decision for these valve techniques from the Society of Thoracic Surgeons and the American College of Cardiology. A decision is expected between June and September.
6. Robot-Assisted Surgery
An "aggressive" competitor to the da Vinci surgical robot is coming in the form of "The Amadeus Composer" and is "smaller and sleeker," with four "snakelike" external arms for improved dexterity, the institute's report says. This may tackle a chief complaint about the da Vinci, which is that it doesn't provide tactile feedback when cutting or suturing tissue.
But ECRI's experts are cautious about robotic surgery, which costs $3.5 million over a five-year period for the da Vinci. "Despite a lack of definitive evidence for the superiority of robot-assisted surgery compared to traditional laparoscopic surgery for many applications, steady growth in both types (general and oncologic) and numbers of robotic procedures continues," the report says.
Still, questions remain about clinician learning curves, the ideal training program, the number of procedures required to maintain operator proficiency, and what criteria to use to credential surgeons who use these systems.
"The high cost and lack of additional reimbursement associated with the use of surgical robots continue to make this technology financially challenging."
The report concludes that while robotic surgery may improve visualization and precision, "the real unanswered questions are how much value they add and, more importantly, how and when will they definitively improve patient care and long-term outcomes?"
7. New Cardiac Stent Developments
New stents and balloons to treat coronary artery disease include those with antibody coatings, bioabsorbable stents that stay in place and then disappear, stents designed to treat bifurcated lesions, and drug-eluting balloons.
"Stent manufacturers are also pursuing low-profile, very thin, and flexible stents intended to minimize stent thickness using newer alloys that enable these stents to maintain sufficient radial support of the artery."
8. Ultrahigh Field Strength MRI Systems
The most-common strength of diagnostic MRI today is 1.5 Tesla, but in recent years, new systems have offered 3 Tesla, with the promise of better images but cost $1 million more.
ECRI issues a few cautions about buying these systems. Reimbursement is the same, regardless of field strength. Use of 3T MRI can either increase image quality or decrease study time, not do both. And these systems "are more susceptible to certain artifacts, which require training and experience to control," and there are patient safety concerns, such as incompatibility with some implants and patient overheating.
To date, the report says, the value, whether more clinically significant lesions can be seen with 3T. has not been determined, although neurologic applications, such as functional, diffusion weighted, and spectroscopy MRI may show more clinically useful information.
"For other applications, little evidence suggests that 3T is necessary or that it improves patient outcomes over 1.5T," the report says. A 3T system for routine MRI applications "is still difficult to justify – at least until additional research demonstrations added clinical utility."
9. Personalized Medicine for Cancer Care
Personalized therapies for oncology patients carry price tags of $100,000 and up, and none replaces existing interventions, the report says. Five such targeted treatments have been released in the last year or so for advanced melanoma, Hodgkin's lymphoma, lung and prostate cancer, "including the first personalized therapeutic cancer vaccine."
However, ECRI experts say, "the average observed survival improvements associated with these therapies, while encouraging, are relatively modest, measured in two to six months," and come with life-threatening side effects.
10. Proton Beam Radiation Therapy
The ability to tightly zero in on a tumor and eradicate it with radiation, with little collateral damage, is the promise, but there is little evidence showing improved patient outcomes. They are expensive, with a $100 million to $200 million price tag, and take up a lot of space.
And they may soon be out of date, the ECRI report suggests, pointing to increasing interest in carbon ion therapy, another type of radiation therapy with advantages over photon or proton beam radiation.
"Compared to protons, the path of heavier carbon ions is less influenced by passage through overlying tissue and, therefore, the peak of ionizing radiation is tighter, potentially allowing more precise targeting and delivery," the report says.
Since proton therapy comparative effectiveness research is lacking, and with carbon ion technology on the way, ECRI suggests that hospital leaders who might be considering a major proton center wait a bit. Also, reimbursement is spotty and at the discretion of local coverage carriers.
ECRI's full report may be viewed here.