QUALITY: Domo Arigato Dr. Roboto?

We love robots as much as the next guy, as long the next guy is our colleague Tom Emswiler. No offense to Shia Laboeuf, but Tom knows how to talk about transformative technological change and its place in health reform. His post on minimally invasive, or laparoscopic, surgery perfectly explained the link between innovation and value in medicine--a complex relation on full display in Wednesday's USA Today article on the da Vinci robot—a four-armed surgical system that is the $1.5 million Bentley of laparoscopic surgery.

As Tom writes: "Technology is valuable, even if it costs more, if it improves outcomes." But, "If a hospital spends a million dollars on a new piece of equipment that doesn't do a better job, there is no value added." This dynamic is essential to understanding that: "Comparative effectiveness is not a way to keep new innovations from patients; rather, it is a way to determine what works best, for whom, when. In this case, new technology results in better outcomes."

For the da Vinci robot, Tom's insights made us think about the good, the bad, and the crucial questions of value and cost for patient and provider. Starting with:

• The Good: The doctors quoted in the USA Today article believe the da Vinci robot has the potential to greatly improve the outcomes and costs of coronary bypasses by performing the procedure without having to split open the patient's chest and stop the patient's heart. Two 100-patient studies have produced positive results, with the latest coming from the University of Maryland this week, where researchers found the da Vinci improved mortality rates, reduced complications, decreased in-patient stays and produced savings that made up for its added $8,000 in costs. Encouraging results but with such small sample sizes, they're far from definitive. An editorial last year in the Journal of Thoracic and Cardiac Surgery (subscription) was less convinced by what it called the "emperor's new clothes." Which brings us to:

• The Bad: Prostatectomies accounted for 55,000 of the 85,000 da Vinci procedures last year, despite the lack of clear evidence that laparoscopic surgery produces better results for a patient than open surgery, or that prostatectomies are a better treatment for prostate cancer than other remedies. Forcing us to ask:

• The Crucial Questions of Value and Cost for Patient and Provider: We all know that robots can be great dancers, maids, and even police officers. For health care, robots and medical innovation in general, must be justified in terms of value and improved outcomes. Four robotic arms may be a better option for some procedures (provided the clinical evidence is there), but they should not be just another tool to win market share in a medical arms race. Neither hospitals, nor patients can afford it.