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PERSONAL VIEW
PERSONAL VIEW Abhishek Trehan, Tristan J Dunn
The robotic surgery monopoly is a poor deal
The lack of competition in the surgical robots market may mean that this technology represents a poorer deal than it
need do for patients, insurance companies, and taxpayers, write Abhishek Trehan and Tristan J Dunn
he adoption of robotic surgery has been
zealous to say the least, especially in
the United States. An ever increasing
number of cases of surgery from several
Tspecialties are being performed with a
robotic approach (in urology and gynaecology in
1-3
particular but by no means exclusively).
Despite increasing demand for such procedures,
only one device is currently approved for soft tissue
surgery by the US Food and Drug Administration—
Intuitive Surgical’s da Vinci robot. The latest model
of the da Vinci costs about £1.7m (€2m; $2.8m).4
The lack of competition in the market for
these devices has likely stemmed from patented SPL
technologies, high barriers to entry, and Intuitive As opposed to tools that can be used unlimited times and replaced at surgeons’
Surgical’s acquisition of a key competitor. discretion, the instruments of Intuitive Surgical’s system can be used only a
Although it is not apparent whether robotic limited number of times before the da Vinci robot will no longer allow their use
surgery is associated with a superior clinical
5 6
outcome, several cost analyses have found Further, as opposed to tools that can be used However, in countries with healthcare systems
robotic surgery to be more expensive than other unlimited times and replaced at surgeons’ similar to that in the United Kingdom, in which
1-7
surgical approaches. discretion, the instruments of Intuitive Surgical’s the NHS is the primary provider, attempts could
You might reasonably assume that the high cost system can be used only a limited number of be made to negotiate the cost of robotic surgical
of robotic surgery lies with high manufacturing, times before the da Vinci robot will no longer devices nationally. The National Institute for
research, and development costs. However, allow their use. As a result, the company profits Health and Care Excellence (NICE) has secured
although these costs are undoubtedly high, you not only from initial sales of the da Vinci robot several favourable deals on behalf of the UK
would be incorrect in thinking that these are the but also from subsequent recurring sales of taxpayer to improve the cost effectiveness of drugs,8
only reasons for the cost of robotic surgery today. instruments, not to mention annual maintenance and a similar approach should be considered to
Indeed, a comparison of Intuitive Surgical with fees of about £140 000 a robot. drive down the cost of robotic surgery.
other companies in the medical devices sector Intuitive Surgical can command high premiums If these negotiations were unfruitful, the
shows that they charge substantially more for seemingly because of its monopoly position as solution is simple: formulate a nationwide policy
their products and services relative to their costs, the sole supplier of soft tissue robotic surgical to eliminate or minimise purchase of robotic
as indicated by Intuitive Surgical’s remarkably equipment: the da Vinci robot is the only system surgical systems until cost effectiveness compared
high operating profit margin compared with those of its kind on the market. There is quite simply with existing surgical approaches is achieved;
of other companies in the medical devices sector a lack of competition, and had the merger of healthcare spending should be driven by cost
(see box). Computer Motion (which developed the ZEUS effectiveness, not by surgical fashion.
robotic system) and Intuitive Surgical in 2003 With the ever increasing adoption of robotic
Operating profit margin for some medical not occurred, the costs associated with robotic surgery, diligent thought is needed sooner rather
devices companies (%) surgery today might be substantially lower given than later before we develop an irreversible and
ArthroCare—17.4 the increased competitive pressure that the two expensive dependence on the da Vinci system.
BD (Becton, Dickinson and Company)—20.2 companies would have placed on each another. We invited Intuitive Surgical to comment on this
Covidien—20.4 It is therefore important for international article but it offered no response.
Edwards Lifesciences—21.5 competition commissions to closely scrutinise Abhishek Trehan is vice president, Hugh Cairns Surgical
Hologic—5.7 any further acquisitions that could hinder the Society, Nuffield Department of Surgery, John Radcliffe
Medtronic—26.5 development of a competitive market. Although Hospital, Headington, Oxford OX3 9DU, UK
NuVasive—6.0 competition in the robotic surgery market abhishek.trehan@lincoln.ox.ac.uk
St Jude Medical—20.0 should be the ultimate goal, it may take years to Tristan J Dunn is graduate researcher, Faculty of Economics,
University of Cambridge, Cambridge CB3 9DD, UK
Stryker—20.1 achieve. In the shorter term, an option to drive Competing interests: None declared.
Thoratec—15.4 down the costs of robotics would be to balance Provenance and peer review: Not commissioned; not
Varian Medical Systems—21.2 the monopoly with a monopsony—that is, the externally peer reviewed.
Volcano Corporation—5.1 formation of a single buying power. References are in the version on bmj.com.
Intuitive Surgical—40.3 In countries such as the United States, in which Cite this as: BMJ 2013;347:f7470
Calculated from company annual reports for the most recent healthcare provision is highly fragmented and bmj.com
complete financial year as of September 2013 ̻ Editorial: Robotic surgery: revisiting “no innovation
competitive, such an approach would be difficult. without evaluation” (BMJ 2013;346:f1573)
26 BMJ | 4 JANUARY 2014 | VOLUME 348
LAST WORDS
FROM THE FRONTLINE Des Spence
Bad medicine: restless legs syndrome
All roads lead to neurology, today’s biologically. In 20 years I have never had describes a twofold difference among
2
repository for the medically unex- a patient present with these as primary countries and between sexes.
plained. Consider the rise of partial epi- symptoms in a consultation. So what I The biological basis of RLS is implau-
lepsy, tremor, sleep disorders, atypical am being told does not reflect what I see. sible, it is not one condition, and the
migraine, complex regional pain syn- The story of RLS is also a big pharma benefit of treatment is marginal. But that
dromes, and paraesthesia, for example. classic, with its fingerprints all over the hasn’t stopped the drug dealing, involv-
These conditions have limited patho- research and even involvement in defin- ing the usual suspects such as gaba-
logical basis, few objective tests, and are ing diagnostic criteria: “pharmaceuti- pentin derivatives (recently approved by
based on symptoms that patients report cal companies attended the workshop the US Food and Drug Administration),10
themselves. The truth is that what we and many of them made very helpful strong opioids, and benzodiazepines.1
4
really know about the higher functioning The big money is contributions.” This cosy group of elite These psychoactive drugs are difficult to
of the brain can be written on the back of with RLS labelled international experts is steeped in direct compare with placebo and are associated
a large postage stamp. payments from pharmaceutical compa- with dependence and rebound insom-
as a chronic disease 5
Restless legs syndrome (RLS) is nies and hence conflicts of interest. nia. Of course the big money is with RLS
deemed a common and serious neuro- so that long term RLS research uses a classic trick: take labelled as a chronic disease so that long
logical syndrome that affects 10% of the treatments can be soft, subjective symptoms that patients term treatments can be peddled,11 despite
1
population, with 2-3% considerably peddled, despite a report themselves and then pseudo- a derelict research base and short dura-
2 12
affected, for which doctors are berated derelict research scientifically convert them to an ille- tion of studies. RLS is medically unex-
3 6
for underdiagnosis and undertreatment. base gitimate numerical rating. This can give plained yet the diagnosis is uncritically
The syndrome disturbs sleep and is char- statistically significant outcomes but with accepted. We risk overdiagnosis, over-
acterised by restless movement and odd almost no discernible benefit for symp- treatment, and iatrogenic harm—classic
7 8
sensations in the legs. It is considered toms, sleep, and quality of life. There bad medicine.
both a movement disorder and a sleep is also a massive unexplainable 40% Des Spence is a general practitioner, Glasgow
9 destwo@yahoo.co.uk
disorder, and various models of causa- Twitter placebo response in RLS. Indeed, ration-
tion have been posited. But these symp- ̻ Follow Des Spence on ally, placebos should be the treatment of References are in the version on bmj.com.
toms are nebulous and unexplained Twitter @des_spence1 choice. In addition the epidemiology Cite this as: BMJ 2013;347:f7615
BMJ.COM BLOG OF THE WEEK Karen van der Veken
Working as a midwife in humanitarian emergencies around the world
The BMJ has chosen Doctors And it’s often the same Then we can start adequately Besides feeling safe, the
of the World for this year’s diseases that occur after major dealing with health issues. It’s women of course should
Christmas charity appeal. Karen disasters. In Haiti, for example, also important to make sure dead be delivering in a clean
van der Veken has worked for there had been no cholera in the bodies are removed as they pose environment. In these
Doctors of the World as a midwife country for more than 100 years, a risk. contexts of
and project coordinator since but we still ordered emergency It is estimated that there are tens displacement
2006, working in many post cholera kits as you must be of thousands of breast feeding there will be
disaster situations including in prepared. And sure enough the and pregnant women affected mobile clinics
Pakistan, Haiti, and Darfur. cholera came. by the Philippines typhoon right that distribute
We also don’t forget about now. What are the challenges hygiene kits
What health problems do people care for older people and that these women face? for pregnant
often suffer from after a major people with chronic diseases They of course need to have women and new
disaster? in disaster situations. There access to pre and post natal care, mothers as well as
If it’s a natural disaster such as are so many people suffering but they also need to have a bed nets, food, and lots of health
an earthquake or a flood, you’ll from cardiovascular diseases, safe, comfortable, environment education, for example, on the
need a lot of orthopaedic and diabetes, and so on, who can die for delivery. What’s sometimes importance of washing hands
surgical materials and services. from these diseases when they forgotten is that in areas where regularly.
If the disaster has created many do not have access to their drugs. women don’t usually deliver in a
refugees and there’s no adequate This can’t just be ignored. hospital, it’s important you make Please support the BMJ
shelter, then there’s more risk the surroundings as home-like as Christmas Appeal. Visit www.
of severe acute respiratory tract What are the first things possible. You have to allow the doctorsoftheworld.org.uk/BMJ
infections. If there is no access that need to be addressed in family, the mother-in-law, and the or see the coupon in the full page
to safe water, then we’ll have a emergency situations? sister, for example, to be there advert in this print issue.
lot of waterborne diseases with Shelter and access to drinking and to make it as cosy as the ̻ Read this blog in full and other blogs
symptoms such as diarrhoea. water are the first priorities. situation allows. at bmj.com/blogs
BMJ | 4 JANUARY 2014 | VOLUME 348 39
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