Hospitals across Oklahoma City have invested in a da Vinci surgical robot, a highly marketed robot that can be used to perform a variety of surgeries. I’ve interviewed several doctors who use the robot to perform surgeries, and many of them rave about it.

They say patients recover faster, have fewer complications and leave the hospital faster than patients who don’t have the same kinds of surgeries using the robot.

But there’s a catch to some of their claims — comprehensive data to back it up.

As this article points out, recently published medical research has found that robotic surgery might not always prove to be more beneficial.

In the dozen years since the Da Vinci robot has been approved for surgeries in the United States, it’s been embraced by health care providers and patients alike. Surgeons routinely use the multi-armed metal assistant to remove cancerous prostate glands and uteruses, repair heart valves and perform gastric bypass operations, among many other procedures.

Lately a key study and reports of problems have raised questions about robotic surgery’s safety and cost-effectiveness, leading to a review of the Da Vinci system by the Food and Drug Administration and causing some experts to wonder whether the benefits of undergoing robot-assisted surgery may have been overstated.

To make any claim in medicine that one approach works better than the other, you need a study published in a medical journal that says “Yes, this is very, very true.” Actually, you probably need several studies by different academic institutes that agree and say, “Yes, that study is very, very true, and here’s what we found that says it’s still very, very true.”

Surgeons I’ve talked to with say the da Vinci robot allows them to operate inside a patient and affect the least amount of tissue while inside. And so far, the debate continues, with the U.S. Food and Drug Administration currently reviewing the system.

Complications can occur with any type of surgery, and so far it’s unclear if they are more common in robotic operations. That’s part of what the FDA is trying to find out.

Intuitive Surgical disputes there’s been a true increase in problems and says the rise reflects a change it made last year in the way it reports incidents.

The da Vinci system “has an excellent safety record with over 1.5 million surgeries performed globally, and total adverse event rates have remained low and in line with historical trends,” said company spokeswoman Angela Wonson.

But an upcoming research paper suggests that problems linked with robotic surgery are underreported. They include cases with “catastrophic complications,” said Dr. Martin Makary, a Johns Hopkins surgeon who co-authored the paper.

And because of that, I can get bored quickly when you start spouting out tons of numbers.

So, here’s a visual aid of what Medicaid expansion would look like in Oklahoma.The Oklahoma Health Care Authority estimates that expanding Medicaid to 138 percent of the federal poverty line would make 180,000 Oklahomans eligible for SoonerCare, the state’s Medicaid program.

What does that look like?

Gaylord Family – Oklahoma Memorial Stadium, filled up about 2.2 times.

Boone Pickens Stadium, about three times full.

Photo by Zach Gray, for The Oklahoman

Chesapeake Energy Arena during an OKC Thunder game, about 10 times full.

Photo by Bryan Terry, The Oklahoman

The BOK Center in Tulsa, about 9 times full.

Because if it weren’t for Mississippi — and generally, West Virginia and Louisiana — Oklahoma would come in last in a variety of health rankings.

But, really — Are we doing that much better? Let’s take a look.

Each year, the United Health Foundation comes out with its annual report, known as America’s Health Rankings. Although the rankings aren’t the end-all be-all of health rankings, our state leaders pay a fair amount of attention to them. That’s because the rankings provide an overall idea of how Oklahoma is doing in a range of categories.

The good news is, Oklahoma improved its ranking this past year. The bad news? We’re still in the bottom 10.

Oklahoma ranked No. 43 in overall health in the national report, the highest ranking the state has received in eight years.

Meanwhile, the top five worst states were  South Carolina (No. 46), West Virginia (No. 47), Arkansas (No. 48), Louisiana (tied No. 49) and Mississippi (No. 49). Meanwhile, Vermont ranked best for overall health.

As you can see from the comparisons below, in some instances, we’re not that far off from sinking back toward the bottom.

Gov. Mary Fallin has said, rather than expanding Oklahoma’s Medicaid program, Oklahoma will instead create its own health plan that will focus on the future health of residents.

I’m curious about what that plan will be. Oklahoma has some of the highest rates in the nation in obesity, diabetes, heart disease, cancer and stroke, and we have a major shortage of primary care doctors. We also eat the fewest fruits and vegetables of any state. And, to top all of that off, poverty in Oklahoma is at a 10-year high.

The solutions for our state won’t be simple, and it will be interesting to see how receptive our lawmakers will be to Fallin’s plan. In her State of the State address, Gov. Fallin came out in support of a bill before the Oklahoma Legislature that would have allowed cities to make their own smoking laws, an idea that multiple lawmakers have shot down in committee.

Medicaid expansion is one of the key elements of the Affordable Care Act, or “Obamacare.” (Want to know more about the health care debate? Here’s a graphic novel we created that explains the basics)

Most leaders have been quoted as saying expanding Medicaid would be too expensive for their states and that they didn’t trust the federal government to hold its end of the bargain.

So what’s the alternative plan?

Gov. Fallin hasn’t yet announced what Oklahoma’s alternative plan might be, but a few state leaders have made a proposals on how to help the uninsured in their states.

Wisconsin

In Wisconsin, Republican Gov. Scott Walker announced in mid-February that he is rejecting Medicaid expansion and instead pushing forward with his own plan.

Walker said he would instead work to increase health coverage for Wisconsinites with an alternate plan that involves lifting an enrollment cap on Medicaid programs for childless adults, tightening income eligibility for state residents able to use Medicaid programs, and bumping thousands of people from such programs to federal government-run health care exchanges where they can buy private insurance.

Avik Roy, a contributor at Forbes, wrote a detailed piece on Walker’s approach, noting:

Prominent Republican governors, like John Kasich in Ohio, have said yes to Medicaid, reasoning that if Ohio doesn’t grab the federal money, other states will. But, as Wisconsin governor Scott Walker now shows, there is a far better path forward, one that reduces the footprint of Medicaid while providing coverage to the uninsured.

Alabama

In Alabama, lawmakers are looking at Oregon’s model and discussing whether they could duplicate something similar:

Over the decades, Oregon has built a relatively generous Medicaid program and has been a bellwether for health policy experimentation. Alabama, like most other southern states, has run a barebones program with few optional benefits.

Launched last year, Oregon’s current Medicaid plan relies on local health care organizations to coordinate all forms of health care, from acute medical services to mental health and dental care, all in an effort to lower costs and improve health. Basically, the local entities, which may be headed by a hospital, physician group, community service provider or a managed care organization, are given a budget and challenged to beat it. If costs exceed the budget, the organization takes the loss.

Alabama lawmakers will soon consider a proposal from Bentley for a Medicaid overhaul based in part on Oregon’s groundbreaking “community care organizations.” Although Bentley has said he would not support an expansion of Medicaid “under its current structure,” the expected reforms are seen as paving the way for a possible expansion as early as 2015.

South Carolina

Lawmakers in South Carolina have proposed their alternative to expanding Medicaid, which includes paying hospitals to send uninsured patients to community health centers.

Instead, House Republicans this week put forward an alternative plan that would pay hospitals up to $35 million to steer uninsured patients to community health centers, free health clinics and rural health clinics. Lawmakers also pledged to give those health centers and clinics an extra $10 million in state money to care for those uninsured patients.

Those clinics, which the state gave $1.8 million this year, hailed the plan Thursday.

“The new plan is a positive alternative if the state does not decide to participate in the Medicaid expansion,” said Lathran Woodard, chief executive of the S.C. Primary Health Care Association.

In case you watched the first presidential debate tonight and found yourself saying, “I have a question!” — you have a chance to ask that question.

WebMD has teamed up with the nonpartisan Commission on Presidential Debates (CPD) to help gather questions for the upcoming debates. If you have a question for the candidates about health care, please submit it below. WebMD will compile the questions to share with the debate moderators.

To ask your question, visit this WebMD page before the next debate.

If I were to submit a question, it would likely be about health care costs (which I might have already submitted…). This Washington Post graphic shows the difference in what residents in the U.S. pay for medical procedures versus in other countries.

What would you ask about? What did you want to hear more about tonight?

Let me know either here on the blog or via Twitter at @jaclyncosgrove.

In the things-to-consider-for-the-sake-of-considering-them category, take a gander at this story from the May 27 edition of The Boston Globe: 

After healthcare reform was made law in Massachusetts in 2006, the number of newly insured patients in the state started to grow, and so did the demand for care. The demand, coupled with a longstanding shortage of primary-care physicians, is creating a real crunch for community clinics, say advocates of healthcare reform as well as area medical professionals.

About 80 percent of the new patients at a community health clinic who are covered under the state’s new health insurance program were formerly uninsured, a clinic supervisor told the newspaper. The result is a lengthy waiting list.

Clinics the newspaper contacted have had difficulty recruiting doctors.

‘What Chapter 58 has done is highlighted the crisis and the problem that we have with the primary-care workforce,’ said Dr. Bruce Auerbach, president of the Massachusetts Medical Society. According to a study conducted in 2006 by the society, 53 percent of patients who had an appointment with a primary-care physician were able to see a doctor within a week of initiating contact. Last year, only 42 percent were able to see a doctor within a week. …

Critics have said healthcare reform should not have been attempted without first addressing the workforce shortages, said John E. McDonough, executive director of Health Care for All, an advocacy group that helped craft the healthcare law. …

Healthcare advocates and providers say that the real problem is that the state underestimated the number of residents without health insurance. …

According to Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, which administers the new health law, 340,000 people who had been mostly uninsured were covered through the state’s program as of Jan. 1. Of that number, about 110,000 have bought private insurance through Commonwealth Choice. But, he said, the remaining 230,000 people have MassHealth or Commonwealth Care, the state’s subsidized health insurance programs.

One thing that’s unclear is why the formerly uninsured choose the types of clinics mentioned in the story when it looks although they could go to any doctor. Maybe they can’t, or maybe the story didn’t address it.

Either way, the unintended consequences of insuring hundreds of thousands of people are worth considering.

Thoughts? Leave a comment on this blog.

Jeff Raymond, Medical Writer

Do you think it’s fair and/or accurate to see Oklahoma ranked at or near the bottom of, well, just about every study of health that comes our way? We can’t be worst in everything health-related, can we?

I say this after reading about Wednesday’s report from The Commonwealth Fund. The nonprofit ranked children’s health in states on 13 indicators that included access to and quality of care, outcomes, equity and cost.

Oklahoma pulled up the rear. Fifty-first. Behind the District of Columbia and Mississippi. Leading the rankings were Iowa, Vermont, Maine, Massachusetts and New Hampshire.

Now, I know the devil’s in the details, and I admit I haven’t looked at the methodology of this report. I usually do, however, which is why I ask about the fairness of all this. I imagine this report would pass muster if you agree what it measures accurately sums up the state of children’s health.

Ah, here’s where it gets tricky: Are the measures used fair? Are small differences in rates or percentages blown out of proportion? Is the information current, or as current as possible?

See the state’s “scorecard” for yourself here.

The interesting thing about these reports is they are all largely slicing and dicing the same data. Sometimes it gets hard to tell them apart.

Anyone who honestly assesses the state’s health will find huge problems. But last or near-last every time? Perhaps I’m becoming desensitized, but my reaction is getting to be “C’mon!?!”

What’s yours? Tell me what you think by posting a comment on this blog.

Jeff Raymond, Medical Writer

USA Today had an interesting story yesterday about how the popularity of angioplasty, a commonly performed procedure in which doctors use a balloon to open blocked coronary arteries, may be eroding.

“The rise of angioplasty procedures has leveled off and appears to be on the decline,” Duke University’s Eric Peterson, who reviewed results of the analysis by the National Cardiovascular Data Registry, told the newspaper.

Three studies in the last two years that indicate that angioplasty may be no more beneficial than medication, and may be riskier. According to the newspaper, the research suggests angioplasty is used too often and its benefits don’t justify the procedure’s $10,000 to $12,000 cost.

The newspaper’s analyses found:

• The number of annual procedures performed each year has declined by 10% to 15% over the last two years.

• Angioplasty and stent use began dropping in June 2006, after two “landmark” studies cast doubt on them. Doctors often implant stents — both bare metal and drug-coated — after angioplasty to keep the artery open.

Angioplasty is used to treat the terrible chest pain, called angina, that comes from a heart without enough oxygen.  The slight decline is important because Centers for Medicare and Medicaid Services guidelines seek to have angioplasty available within 90 minutes of a patient’s arrival at the hospital. This is often called door-to-balloon time.

Many medical authorities tout the benefits of angioplasty.

Because hearts suffer from an inadequate blood supply, Bonnie Weiner, president of the Society for Coronary Angiography, told the newspaper, “(Angioplasty) is very effective at achieving more blood flow to the heart.” 

“I personally wasn’t surprised by the results,” says Michael Rich, a cardiologist at Washington University School of Medicine in St. Louis who will debate the study at the heart meeting.

Michael Rich, a cardiologist at Washington University School of Medicine in St. Louis, said angioplasty won’t prolong a person’s life or decrease the risk of a heart attack but will decrease the symptoms of one.

“The analyses conducted for the newspaper also reflect what may be the beginning of a broader change in medicine: a move toward ‘evidence-based’ care drawing on reams of data from medical research and patient treatment,” USA Today reported.

Jeff Raymond, Medical Writer

 Is retirement going to be a luxury for thirty- and forty- something workers? I increasingly think it will be, and a new estimate from investment giant Fidelity does nothing to dispel that.

A 65-year-old-couple retiring this year will need approximately $225K to cover medical costs in retirement, Fidelity estimates. Let’s not lose sight of the fact that this is in addition to the coverage available under Medicare, which may itself not be available when I and others retire.

The hypothetical retirees will still have to have enough money to live, either independently or in long-term care.

Perhaps what’s even more sobering than the estimate is its growth since 2002 — 41 percent.

The roughly 6 percent annual growth in the Fidelity projection about matches the growth of my 401K fund during a slow year. I know that doesn’t take into account contribution matching and interest compounding, but I think it raises a worthwhile point nonetheless.

And health care costs show no signs of flattening or decreasing.

Does paying for retirement terrify you as much as it terrifies me? Leave me a comment at http://blog.newsok.com/health.

Fidelity recommends:

- Creating an individual retirement plan

- Starting early and maximizing opportunities to save

- Assessing health status and becoming a smarter consumer of health care

- Determining details of any employer-sponsored coverage

- Understanding the financial impact of health care costs on Social Security income

Jeff Raymond, Medical Writer

 The need for donor livers outstrips their supply. Each year, about one-third of those with end-stage liver disease who need an organ will receive one. Some die while on the waiting list.

The February issue of Mayo Clinic Proceedings examines how the current system for allocating organs in the United States affects recipients’ outcomes.

The United Network for Organ Sharing (UNOS) oversees organ allocation. With the goal of giving organs to the most critically ill transplant candidates, UNOS adopted the MELD — Model for End-Stage Liver Disease — scoring system in 2002. The score is calculated from the results of three lab tests.

“Unlike past evaluation systems, the MELD score de-emphasizes the length of time a patient has been waiting for a donor organ. … Research has shown that although the donor liver shortage persists, implementing this allocation system has decreased the number of patients who die while waiting for donor organs,” according to a Mayo Clinic press release.

The study looked at the evaluation practices and acceptance criteria for liver transplant used by the Mayo Clinic Jacksonville Transplant Center after implementation of MELD scoring. Researchers examined medical records from 555 patients referred for liver transplants at the Jacksonville center from Jan. 1 through Dec. 31, 2005. Of these patients, 53 percent were denied for a transplant. Half of those denied were considered too early to have the procedure, while the rest were excluded because of medical conditions and psychosocial issues — poor support systems or continuing substance abuse problems, for example.

Many were subsequently accepted.

“Patients seeking referral often undergo repeated assessments by selection committees, as their eligibility can change over time or following treatment and/or changes in conditions that led to their initial exclusion,” according to the release.

Data suggest a “broad range” of patients could benefit from early referral to a transplant center, according to the release.

Basically, management of their disease and other medical and psychosocial conditions could make them transplant candidates sooner.

To read the report, click here.  

People seldom realize transplant waiting lists are anything but static: They constantly change, depending on organ availability and patients’ medical states. They’re definitely moving targets. People move up, they move down; they drop off, they’re added back.

“Our study suggests that early referral for LT (liver transplant) evaluation is beneficial for reasons unrelated to the time patients spend on the LT waiting list. If patients too early for LT were evaluated but not listed, LT centers could initiate management of ESLD (end-stage liver disease) and address psychosocial issues in a sub-group of patients who could also ultimately benefit from LT,” the authors wrote.

Although not exactly the same thing, last month I wrote about this man, Dr. Ludvik Artinyan, left, who registered on organ waiting lists in California and Oklahoma. He was able to receive a liver transplant quicker by traveling to Integris Baptist Medical Center to have the procedure performed rather than having it done in Los Angeles. Because patients’ MELD scores typically are higher in California for various reasons, double-listing likely allowed the Armenia-born physician to shave months off his wait time and perhaps saved his life.

UNOS allows potential transplant recipients to be listed in multiple regions – they must meet each site’s criteria and be ready to respond to the phone call or page when an organ becomes available.

Is the current organ allocation system fair? E-mail me at jraymond@oklahoman.com or post your thoughts at http://blog.newsok.com/health.  

Jeff Raymond, Medical Writer