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.
Thomas Petty, MD