In The Tipping Point, Malcolm Gladwell highlighted the nature and power of trends and that "magic moment when an idea, trend or social behavior crosses a threshold, tips, and spreads like wildfire." Though not specifically about clinical technology or even health care, this book comes to mind when considering one of the most powerful new clinical technologies: the surgical robot known as the da Vinci by Intuitive Surgical.
Gladwell's book comes to mind because of the fascinating rise of this technology over the past decade. Indeed, many organizations have purchased the surgical robot in the past few years but, like many of the social trends described in The Tipping Point, it did not spread wildly when it was first introduced in the late 1990s. Today, the subject creates both buzz and controversy. In many advanced medical centers, the question on leaders' minds may be how many robots to buy, while in community hospitals, leaders are asking if they need to buy a robot to keep pace with the early adopters.
The da Vinci surgical robot allows a surgeon sitting at a console to operate remote-controlled arms facilitating certain laparoscopic procedures, most commonly for prostate cancer and hysterectomies. Surgeons who tout this technology note that it provides 10x magnification in a three-dimensional visual field, thereby improving visualization and depth perception. Other benefits may include faster patient recovery times and shorter hospital stays.
As seems usual with medical technology innovation, this level of progress comes at a fairly steep price: The cost to acquire the robot is approximately $1.7 to $2.2 million, plus additional consumable costs. Though there are other robotic surgery systems on the market and in the pipeline, Intuitive Surgical's da Vinci essentially has no competition. For example, other surgical robots are available and have received FDA approval for specific procedures such as knee replacement, hip arthroplasty or cardiac ablation, but none are as versatile as the da Vinci Si system, which is currently approved for a wide variety of abdominal, thoracic and transoral surgical indications. Hence, the price seems unlikely to fall in the short run, which puts a burden on hospital capital budgets.
The $1.7 Million Question
Given the costs — and lack of additional reimbursement for robotic surgery — hospitals must wrestle with the question of whether the gains from shorter hospital stays, faster patient recoveries and the halo effect from the perception of being a technology leader outweigh the costs and potential added procedural complexity. Further, the clinical evidence does not give a clear advantage to the surgical robot technique when compared with clinical outcomes for traditional approaches. Many emerging technologies present just this sort of quandary. And there is not a one-size-fits-all approach to deciding if or how many robots to acquire.
Nonetheless, a good decision at the board level regarding this type of technology acquisition can be made if some overarching issues are considered. First, the board should ask itself, "Do we have the right mindset — meaning, are we open to hearing both the pros and the cons objectively and are we able to incorporate both what the evidence says and what our judgment tells us when the evidence — financial, clinical or operational — is less than clear?" A good rule of thumb is to get excited but don't get snowed. In other words, the best mindset is neither one that demands absolute proof nor one that embraces every new technology without a careful analysis of the evidence.
Developing this mindset does not come easily simply because organizations are filled with people, and people often prefer to use generalizations to drive decisions rather than the more arduous task of analyzing each individual situation and the facts surrounding it. For example, how many times has being a center of excellence been a justification for an investment because otherwise the organization will lose that status? This is the wrong mindset.
An institution may or may not be a center of excellence, but in the long run, being a center of excellence depends on the quality of care provided to patients. If the new technology improves patient care, then that may be a good reason to acquire the technology. It also means leaders must evaluate whether the technology actually improves outcomes, lessens length of stay, reduces pain or provides some other tangible benefit. So, in the case of the surgical robot, the decision goes back to the core of whether the technology moves overall quality of care forward; in short, back to reviewing the evidence. The fact that an institution is a center of excellence is not, in the end, a meaningful rationale. The appropriate mindset seeks the underlying evidence, not the oft-hyped headlines.
Tipping Point Ahead
But what about perception? How can trustees counter the argument that if the organization does not buy the technology — regardless of its ability to improve outcomes — the community will not perceive it as a leader, which could result in lost patients and reputation?
This brings us to the second overarchÂing issue. What is the current and future technology diffusion rate? In this context, diffusion means how many institutions are acquiring the technology and for what purpose. Though blindly following the crowd is not a good strategy, ignoring it isn't smart either. Thus, the decision to buy any technology should look at the national and local diffusion trends.
This is the value of Gladwell's tipping point. In decision-making processes, we should always ask whether this technology has diffused significantly already or whether the tipping point might be around the corner. In this case, the wisdom of the crowd seems to indicate an approaching tipping point. Intuitive Surgical told The New England Journal of Medicine that the number of installed da Vinci robots went from 800 to 1,400 from 2007 to 2009, a 75 percent increase. If the wisdom of the crowd has not already spoken, it seems to be hinting rather strongly. Of course, those are national statistics, and a board must also look at its local marketplace and analyze local trends.
In this case, the trend seems clear. Though there is no guarantee this diffusion rate will continue, there is also no way to ignore that many organizations are adopting this technology even though the cost-benefit calculation remains somewhat unclear. Are we approaching the tipping point at which surgical robotics will become the virtual standard of care even if the evidence of benefit remains equivocal? Does the evidence trump the trend or does the trend trump the evidence? Answering those questions is your job now.
Anthony J. Montagnolo, M.S. (amontag nolo@ecri.org), is executive vice president and chief operating officer at ECRI Institute, Plymouth Meeting, Pa.
