Monday, November 9, 2009

Heroic Interventions: Misallocation of Healthcare Resources?

On November 3, Syncardia Systems, Inc. announced a milestone surgery performed in May at the Cleveland Clinic: the first use of a total artificial heart to support a patient to a dual heart and liver transplant. The story is heroic and the technical achievement is striking. The patient, Dr. Michael Zabell, had been admitted to the hospital to wait for a heart transplant on August 18, 2008. By January 8, 2009 (143 days later) his heart was too weak to sustain him, and his liver was failing; doctors needed to implant Syncardia’s temporary total artificial heart to keep him alive until a matching heart and liver could be found. One hundred and thirteen days later, on May 1, 2009, Dr. Zabell received a donor heart and liver in a 14 hour surgery involving two different transplant teams. According to Syncardia, “Today, Zabell is enjoying life at home with his wife and two daughters.”

Is there a problem in this story? One of the leading tertiary care centers in the country used a bed for 256 days (plus unspecified post-transplant time), at a cost certainly well over $1 million, to bridge a patient to a dual-organ transplant. We might reasonably ask “Why?”, and the answer might be troubling. They did it because they could, and because there was something in it for the device company, the medical team, and the clinic. This achievement was about reputation and public perception: being first. It was not in the context of a clinical trial that could lead to further improvements in artificial heart technology or breakthroughs in surgical technique. It did not likely involve “saving” a donor heart that might otherwise have been wasted – there are far more candidates for transplant than there are organs.

Dr. Zabell, of course, appears to have benefitted as well – although we know nothing about his quality of life, medical traumas, course of care, or state of mind during those 8 months of pre-transplant hospitalization and his post-transplant course. Nor do we know anything meaningful about his post-discharge quality of life: there is a wide range of conditions encompassed by “enjoying life at home with ... wife and family.” It may seem small-minded to raise objections. This is, of course, because the patient has been named – he is a real person, quoted in Syncardia's press release with warm words about his doctors ("Dr. Smedira is not only an outstanding surgeon but he’s really a wonderful guy. Cleveland Clinic has an outstanding group of surgeons, physicians and hospital staff, including my cardiologist Dr. Starling. I can’t say enough about the care.". The technical and logistical achievement has been humanized.

But the information that might allow us to make an objective evaluation of the wisdom of the procedure has been withheld. We know very little right now about the details of the case. In addition to the issues I’ve already mentioned, it would be interesting to know why the patient was never a candidate for discharge home with an implantable LVAD, why he was selected as a candidate for the Syncardia heart, why and when his liver function deteriorated so significantly, and how the costs of the case were covered. That information is, of course, personal and sensitive; we can’t demand it now that we know Dr. Zabell’s name, and that is at it should be. But there was a choice: name the patient and withhold the substance; or maintain patient confidentiality and detail the clinical circumstances and decision processes. The decision made reveals a great deal about the motivations of the decision makers.

Some will argue that this case exemplifies what is great in American medicine – the constant striving to do what could not previously be done. Others will see it as the worst – a clear example of our intoxication with the heroic, leading to misallocation of scarce resources. But it should not be seen in isolation. The amounts we spend on end of life care dwarf those of any other country. Some increasingly common practices – chronic hemodialysis, requiring thrice weekly ambulance transport to an outpatient clinic for irreversibly bed-bound and cognitively compromised elders age 85 and over, for example – are indefensible in social policy and/or pharmacoeconomic terms.

A modest proposal for addressing this general problem was broached this summer – Medicare coverage of end of life counseling. The resulting political firestorm – cynical as it may have been – likely took the idea off the action agenda for some years. We just may not be grown up enough to deal in a reasonably rational and humane way with a vexing problem that accounts for a meaningful portion of our excess medical spending.

4 comments:

  1. Great analysis, Ed. Right on. And, it also relates to your next (mammo screening) topic. It's easy to analyze and policize (is that a word?) when it's impersonal. But when I'm the patient, I want the old, heroic America!

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  2. Thank you, Joe. You'll find my initial thoughts about the mammography screening controversy posting tomorrow (11/20/09) on my Reimbursement Row blog at www.massdevice.com.

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