Those Expensive New Toys

When the X-ray machine was introduced in 1896, it was as if Hamlet's desire that "this too too solid flesh would melt" had become eerie reality. Public and physicians alike went wild. Gentlemen bought X-ray photographs of objects concealed in boxes, and fashionable ladies had X-ray portraits taken of themselves as gifts for friends and lovers. But it was physicians who were most intoxicated with the new device's possibilities. Without manual probing, they could now evaluate the extent of bone fractures and precisely locate where foreign bodies were lodged in tissues.

Seventy-six years later, the computerized axial tomography, or CAT, scanner, hailed as the greatest advance in radiology since the discovery of X rays, appeared on the medical scene. Combining X-ray equipment with a computer and a television cathode-ray tube, this revolutionary diagnostic device can visualize cross sections of the human body to detect, among other disorders, tumors, blood vessel damage and bile duct obstructions. But whereas an X-ray machine cost $50 in 1896, today's CAT scanner may run to $700,000 or more.

The CAT has become something of a whipping boy in the current cost-containment controversy, a symbol of the insanely soaring expenses of the U.S. medical care system. Government officials and consumers are questioning whether the benefits derived from the flood of innovative techniques of the past 20 years justify the high cost. Even physicians who traditionally have taken to the new technology with the enthusiasm of small boys trying out new toys, are voicing doubts.

In the case of the CAT scanner, for instance, most doctors would agree with the Boston physician who observes: "It has all but relieved us of doing angiograms or putting air into people's brains. Both of those had an element of risk and were not nearly so accurate as the CAT." But when it comes to the usefulness of whole body scanning there is considerably more disagreement, even though evidence is mounting in the machine's favor. Another important question is how many of the devices the country needs, and can afford.

The questions raised by the CAT apply to practically every other procedure and piece of equipment in use today. Items:

> Electronic fetal monitoring is used in many hospital maternity units during labor and delivery. A sonar-like ultrasound system keeps track of the baby's heart rate, and an electrically wired belt across the mother's abdomen notes uterine contractions. Electrodes are attached to the baby's head to get an electrocardiogram. Blood samples for analysis may be drawn from the baby's scalp. The object: to detect fetal problems early enough for physicians to intervene. The U.S. spends some $80 million a year on this effort, and the fetal death rate in the U.S. has in fact declined since electronic monitoring was introduced in the mid-1960s, but there is little evidence linking the two. Moreover, critics say that the benefits are uncertain and that there is risk to the baby of laceration and infection of the scalp and respiratory problems, and to the mother of uterine perforation, pelvic infections and an unnecessary Caesarean section should the monitoring mistakenly indicate the baby is in distress.

> Coronary bypass surgery was introduced in 1967 to combat coronary-artery disease, the nation's No. 1 killer. The disease is characterized by narrowing of the arteries that supply blood to the heart muscle, leading to severe chest pains known as angina pectoris, or to heart attack and sudden death. In the operation doctors graft portions of a leg vein around the clogged part of the artery, thus creating a detour or bypass for the blood. Last year more than 80,000 such operations were performed. The average cost: $10,000 to $15,000. Despite its growing use, the procedure is highly controversial. Though it relieves patients from severe pain, there is. heated debate over whether it is better than less expensive and less risky medicinal treatments in prolonging life.

> Hemodialysis is a lifesaving remedy, though not a cure. Thrice weekly, patients with kidney failure get hooked up to a machine that filters toxic body wastes from the blood. The technique works, no question; the problem is money: about $25,000 a year in special centers, about half that if the treatment can be performed at home. Since 1973, the government has picked up the tab for dialysis (as well as for kidney transplant operations). The program now covers some 44,000 patients at an annual cost of more than $1 billion. By the 1980s the projection is 60,000 patients at an estimated cost exceeding $2 billion a year. Some observers wonder whether the program has been efficient. Even more important is the question of whether society can afford the program at all.

> Intensive care units, whether for newborn infants, postsurgical patients or those with heart problems, provide, as the name implies, constant surveillance and therapy. Because they have the most sophisticated gadgetry outside the operating room and require a staff-to-patient ratio twice that needed elsewhere in the hospital, they are very expensive services to run. The intensive care unit accounts for about 15% of all hospital costs. Coronary care units may charge $400 to $500 a day. Yet, say some doctors, no one is sure whether survival rates are higher than would occur with care in regular hospital beds. Some physicians are also concerned that the bright lights, alarms and lack of privacy can frighten patients, impeding recovery or even precipitating fatal heart attacks. In neonatal centers, the infants are usually preemies and may require months, even years, of care before they are well enough to be released. Last year at Houston's Hermann Hospital, eight newborns spent a total of 95 months in intensive care units at a cost of $1,773,000. Even with this effort, not all babies survive; one died after eleven months.

Is the money spent on these babies justified? Or the $1 billion to keep 44,000 patients in kidney failure alive?

Doctors agree that many of the new high-technology practices do not necessarily cure disease or even prolong life, but that should not be the only gauge of a technique's value. If the quality of life can be improved, they argue, that is sufficient justification for using it. Besides, says Dr. Cheves Smythe, professor of medicine at the University of Texas in Houston: "Our country doesn't believe in putting people on a hillside."

One problem is that new technology and procedures tend to become entrenched before their value or cost is determined. Even established operations such as tonsillectomy, appendectomy and hysterectomy, and routine medical practices like X-raying the skulls of all trauma victims, have only recently come under review. Some doctors argue that new techniques and equipment, no less than new drugs, must be rigorously evaluated for safety and efficacy by an agency like the Food and Drug Administration before they are approved for general use. Leaving technology to be weeded out by a Darwinian selection process is too slow--and too expensive.

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