Everything you know is wrong.
That phrase comes to mind after a cluster of surprises from news and research papers this week threw conventional practice wisdom onto the bird cage floor like yesterday's news.
First, there was the report showing that a common surgery for benign gynecologic disease such as fibroids produced no better patient quality outcomes when surgeons performed it using the expensive, and heavily marketed, da Vinci robot than when they operated with traditional laparoscopic techniques.
Only the price tag differed, with da Vinci procedures costing on average of $2,189 more. Yet the da Vinci performed 138,000, or 37%, of the total number of 376,000 procedures done by the robot in U.S. hospitals last year, according to the robot's manufacturer, Intuitive Surgical Inc.
The study, published in the Journal of the American Medical Association by Jason Wright, MD, of Columbia University,prompted a comment from Frank Loffer, MD, medical director of the American Association of Gynecologic Laparoscopists, which has recently raised questions about the robot's popularity despite a lack of evidence that it's a better choice for women undergoing a hysterectomy.
"Mainly this is marketing on the part of hospitals and physicians, persuading patients to come in fixed on the idea, saying 'I want the latest; I want a robotic procedure, and if you don't do it I'm going to go to the guy next door.' Robotics is the latest and robotics is sexy," says Loffer, a gynecologic surgeon at the University of Arizona.
Next came a report from JAMA Surgery that was a big upset, and bound to be a controversial one. Johns Hopkins University researchers paired two groups of obese patients insured by any of seven BlueCross BlueShield plans. One group underwent bariatric surgery while the other did not.
Despite the widespread belief that such surgery can dramatically reduce healthcare costs, Jonathan Weiner and health economist colleagues discovered that that after six years of follow-up, total claims for healthcare expenses were no different in the two groups. Bariatric surgery did not lower healthcare costs for the treated group.
Weiner and his team found that while patients who underwent surgery had lower pharmacy costs and lower costs for physician office visits in the six years after their surgeries, they were back in the hospital far more often than the non-surgical group, cancelling out the savings on drugs and doctor visits.
Why this should be so remains unclear, and a source of bitter dispute, with some bariatric surgeons accusing the authors of being biased, using data from 11 years ago when bariatric techniques were riskier, and not recognizing how much the procedure improved patients' lives.
The finding of the bariatric surgery study might give pause to any organization that thinks integrated delivery systems (IDS) or accountable care organizations will reduce costs in the big ticket arena of expensive hospital care as it has been shown to do in less intense ambulatory care settings.
Also in this week's issue of JAMA Surgery, research physicians and colleagues from the Center for Healthcare Outcomes and Policy at the University of Michigan found that among four procedures studied, there was little difference in key quality measures such as operative mortality, post operative complications, readmissions and total surgical episode costs between hospitals with IDS and those without.
"For each of the four procedures, (coronary bypass grafts, hip replacement, back surgery, and colectomy) adjusted rates for operative mortality, complications and readmissions were similar for patients treated in IDS-affiliated compared with non-IDS affiliated hospitals, with the exception that those treated in IDS affiliated hospital shad fewer readmissions after colectomy," the researchers wrote.
With the exception of hip replacement surgery, for which total episode of care cost 4% less at IDS hospitals because of reductions in post-discharge costs, "episode payments differed by 1% or less for the remaining procedures."
This may mean that accountable care organizations may have some rethinking to do if they are to get the quality and shared savings they expect.
The next surprise of the week was not a conclusion from research, but a criminal horror story from venerable Johns Hopkins, where an obstetrician gynecologist, who had practiced there since 1988, was accused in early February of secretly taking pictures of his patients with a camera inside a pen. He was found dead days later.
Now, an estimated 100 women who were treated by physician Nikita A. Levy are coming forward, seeking lawyers and lawsuits, after Baltimore police told reporters for The Baltimore Sun that they uncovered an "extraordinary" amount of evidence at Levy's Towson home.
Of course, healthcare writers who've been around as long as I have develop a cynicism that keeps surprise at bay. We've seen it all before, and often, even at some of our most prestigious medical institutions.
But I was indeed surprised by the Levy story. And I guess I'm glad that I still can be.