Surgical robot use scrutinized at Cincinnati VA Medical Center

Posted at 5:00 AM, Nov 09, 2016
and last updated 2016-11-10 06:18:41-05

CINCINNATI - The Cincinnati VA Medical Center spent more than $7.6 million since 2009 to purchase four surgical robots that were used in an average of 55 surgeries per year.

Whistleblowers say it's a waste of money.

A WCPO investigation found the Cincinnati VA uses these robots far less than most hospitals, which means it costs more per surgery to use the sophisticated machines.

But the VA says it helps to recruit doctors and provides cutting-edge care for veterans.

Because da Vinci surgical systems cost up to $2 million, most hospitals try to use them in about 200 operations per year, said Christopher Schabowsky, a health-care consultant at ECRI Institute, a medical-product testing laboratory near Philadelphia. The Cincinnati VA has owned two da Vinci robots since 2012 and peaked at 86 robot-assisted surgeries in 2013.

da Vinci robot arms

“Those numbers are very low,” Schabowsky said. “If a hospital is performing fewer than 100 robotic surgeries a year, they need to take a hard look at their program and take a look at whether it’s worth the investment.”

The VA’s robotic surgery program is one of several areas in which Cincinnati whistleblowers told WCPO and the Scripps Washington Bureau that the Vine Street hospital is wasting tax dollars.

It’s among dozens of allegations raised by doctors and nurses who were alarmed by cost-cutting practices, quality of care problems and managerial misconduct at the Cincinnati VA. Their concerns triggered more than a dozen internal reviews and the forced retirement of Ohio’s highest-ranking VA official, Jack Hetrick. They also led to the demotion of the hospital’s chief staff, Dr. Barbara Temeck, after VA investigators in February substantiated allegations that Dr. Temeck prescribed pain killers for Hetrick’s wife.

RELATED: Read all of WCPO’s VA Coverage here

Eight months later, the VA has made five leadership changes in Cincinnati and endured more than a dozen internal and external reviews. But it’s yet to release any final conclusions on most of the allegations raised by whistleblowers.

Whistleblower tip on VA robots

Here’s how Mike Brooks, a certified registered nurse anesthetist, described the Cincinnati VA’s use of surgical robots in December:

“We purchased a million, two million dollars worth of equipment but to save money, we didn’t get the maintenance contract to take care of these very complex instruments ... Unfortunately, one of the arms on one of the robots is broken at this time and it’s sitting in the hallway unusable and the cost of the repair for that arm is more than, as I understand it, more than the warranty cost would have been if they would have paid for the service contract. So, it’s sitting there unused, collecting dust.”

As program manager of ECRI’s Applied Solutions Group, Schabowsky has advised dozens of hospitals on how to use da Vinci robots efficiently. Hospitals have embraced the $2 million machines because they want to be viewed by patients and doctors as having cutting-edge technology. While the research isn’t definitive, Schabowsky said there is evidence that robot-assisted surgery patients recover faster with fewer complications. About 85 percent of prostatectomies are now performed with da Vinci systems.

“Most hospitals will start with one specialty,” Schabowsky said. “They get people trained on a beachhead surgery, then bring in different specialties. As surgical teams become more experienced, you start to see volumes increase.”

Typically, he said hospitals need hundreds of surgeries a year to justify the cost of a da Vinci system. Those with two or more robots often use the machines in more than 1,000 operations a year.

University Hospital owns three da Vinci robots – two in Clifton, one in West Chester -- but did not provide details on its robot-surgery volume. University and Christ Hospital declined to be interviewed about their robotic surgery usage.

Intuitive Surgical Inc., which makes the da Vinci system, reported 652,000 procedures in 2015 with 3,597 installed systems. Those numbers, published in the company’s annual report to shareholders, translate to 181 surgeries per machine.

The robotic surgery program at Cincinnati VA peaked at 86 surgeries in 2013, falling to 47 operations by 2015. The urology department accounts for 85 percent of all robot-assisted surgeries at the Cincinnati VA since 2010.


Given those volumes, Schabowsky sees no way to justify two robots.

“You’re going to be hemorrhaging money,” he said.

The VA responds

The Cincinnati VA has been trying to expand its use of da Vinci robots by making the systems available to multiple specialties and patients from Columbus, Dayton and Chillicothe, said Dr. Krishnanath Gaitonde, chief of urology at the hospital.

Dr. Krishnanath Gaitonde

"We were among the early sites starting the robotic program," Dr. Gaitonde said. "I've helped other VA sites set up their robotic program."

Veterans enjoy faster recovery times than the open-surgery recuperation rate of three to five days, he added.

"Seventy to 80 percent of our patients go home in one day; 100 percent go home in two days," Dr. Gaitonde said. "That's a huge benefit."

The Cincinnati VA is a teaching hospital that provides care for 43,000 area veterans under a capitated system – meaning its funding doesn’t change with higher or lower surgery volumes. So, the hospital has justified the cost of the da Vinci system as an investment in a higher standard of care for veterans and a tool to attract the best surgeons.

Dr. Elizabeth Brill

"Our mission in working with the University of Cincinnati to train their residents; it's critical that we are giving them up to date training," said Dr. Elizabeth Brill, who started May 1 as the hospital's chief of staff. But Dr. Brill added that the hospital has limited resources and should make sure its clinical decisions are financially sound.

"We need to be critical every time we make a decision about a large piece of equipment that we're spending our money wisely," Dr. Brill said.

The new medical director at the Cincinnati VA is a veteran health care administrator who declined to comment on past business decisions involving robotic surgery.

Vivian Hutson

“I can only trust that they had the best intention at heart wanting to provide high-quality technology in our hospital,” said Vivian Hutson, who on Oct. 3 became the Cincinnati hospital’s third director since 2015. “What I want to focus on is our way forward with the robots that we have, how we can best use it, how we can train our residents and expand our program as appropriate.”

The hospital made some progress toward that end in 2016, increasing its total number of robotic surgeries to 79, with the recruitment of a third robotically trained surgeon.

But it still bothers many hospital staffers that so much money was spent on under-used robots at a time when hospital leaders were cutting costs. The hospital has 83 vacant nursing positions, down from 107 a year ago.

“We need nurses, boots on the ground, nurses at the bedside. So, yes that bothers me,” said Sadie Hughes-Young, VA director for National Nurses United, a 471-nurse bargaining unit. “They need to bring the salaries up to a market rate so we can get competent nurses in the building, not just new graduates, but experienced nurses who can do the job.”

The Cincinnati VA paid $2.2 million for its first da Vinci robot in July 2009. It traded in that system in October, 2012, paying $3.9 million for two new robots, one of them equipped with a dual-console viewing screen so it could be used for training.

When it added the second robot, the VA opted not to buy a maintenance contract.

“The expense of the annual service agreement was determined to not be economical as the da Vinci robot repair history showed low failure rates and infrequent need for repair services,” said Cincinnati VA spokesman Todd Sledge. “Thus, a cost-savings decision was made to rely on routine maintenance and repair services on an as-needed basis.”

The decision backfired in June 2015, when a computer card went bad in its single-console robot. The machine sat idle for 13 months, awaiting a $108,000 repair.

Schabowsky said a maintenance contract adds about 10 percent to the total cost of a da Vinci system but it’s rare for a hospital to go without it. He advises his clients to buy it.

The VA ultimately solved the problem by trading the idled da Vinci for a new $2.3 million system in July. As part of the deal, it received a $500,000 trade-in allowance and purchased a $165,000 maintenance contract to cover the new machine for 12 months and paid $158,000 in parts and service fees to fix the old machine.

In addition, the Cincinnati VA has decided to be a one-robot hospital in the future. It’s talking to the Dayton VA Medical Center about transferring one of the machines to that facility, but hasn’t set a date for the transfer.