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January 1997
PEP Pioneers
Second Wind
Torrance, California
Dear Friends:
Many patients with advanced stages of chronic obstructive pulmonary
disease, particularly those with severe emphysema, were excited
when the word got out that reducing the volume of both lungs by
surgical removal of the relatively more damaged upper regions
could be beneficial. This surgery aims to allow for the remainder
of the lungs to re-expand and restore some of the elasticity of
the lungs. This helps to relieve the sensation of shortness of
breath and, in some cases, also reduces the need for oxygen. Unfortunately,
a frantic scramble to develop surgical treatment programs throughout
the United States quickly followed. The first procedures were
performed by highly qualified surgeons with extensive experience
in thoracic surgery. Later others who were less qualified started
to do this procedure. This resulted in the indiscriminate use
of this surgical procedure in some centers.
This treatment of advanced emphysema is not new in principle,
but it has now been perfected by surgeons using new suturing techniques
which could reduce complications. However, the Health Care Financing
Administration (HCFA) quickly realized that they were paying out
a huge amount of money for a procedure which had not been adequately
studied and evaluated. HCFA soon stopped reimbursement for Medicare
patients. Now HCFA has funded 18 centers of excellence in the
United States for the purpose of evaluating the selection of patients,
the best surgical techniques and outcomes, before this procedure
will become established and become reimbursable. Some private
insurances have continued to pay for the surgical technique but
the wave of enthusiasm was naturally dampened by curtailment of
reimbursement for Medicare patients.
My own view is that a careful evaluation of any major surgical
procedure is always wise, recognizing the morbidity and mortality
that inevitably is present, particularly in older individuals
with poor respiratory and perhaps cardiac function. It will take
a number of years to assess the effectiveness of lung volume reduction
surgery and during this evaluation period, much more knowledge
will be forthcoming, which will certainly guide in the selection
of patients for this procedure in the future. Doubtless there
are many who will be disappointed at these restrictions. I feel
that jumping to the conclusion that a potentially dangerous surgical
technique may be helpful could, in fact, shorten the length or
quality of life in the vain hope to find a simple solution to
a complex problem. Thus, I applaud the decision to conduct a careful
assessment of which patients benefit or cannot benefit, and whether
or not this surgical procedure is of lasting value and reasonably
effective for the palliation of advanced stages of emphysema.
I will be in touch next month.
Your friend,
Thomas Petty, MD
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