Waiting to Exhale

Dr. Joel Cooper pioneered lung-volume-reduction surgery to save the lives of thousands of emphysema patients. Now he wants the government to get out of the way.

Jim was given painkillers immediately after surgery, and he was up and walking the next day. Five days later, he was on his way home. Before the operation, the volume of air Jim could exhale was only 19 percent of what is considered normal for a man of his age. Six months after the operation, he could exhale 63 percent of normal.

That improvement was the direct result of a surgical procedure Medicare did not and still will not approve. Fortunately for Jim, he had savings.

When Medicare denied approval for lung-volume-reduction surgery for Jim, the couple was forced to use their savings. "It was either hang it up or cash in the IRA," says Jim. "If I hadn't done it, I wouldn't be alive today."

Dr. Keith Naunheim defends the Medicare emphysema trial and insists critics are flat-out wrong about the study: "I don't think it's unethical."
Jennifer Silverberg
Dr. Keith Naunheim defends the Medicare emphysema trial and insists critics are flat-out wrong about the study: "I don't think it's unethical."

The idea that cutting out a part of the lung could actually help emphysema victims breathe easier has been around since at least the 1950s. But no one had demonstrated a consistently successful technique until Joel Cooper and his Barnes-Jewish team did it in the mid-1990s.

When it comes to lungs, the 61-year-old chief of cardiothoracic surgery has been on the cutting edge for decades. At Toronto General Hospital in the 1980s, Cooper pioneered lung-transplant surgery. And in St. Louis, Cooper developed the successful stapler technique for lung-volume-reduction surgery.

If you need an idea of Cooper's credentials, just ask his peers. In 1996, the American College of Surgeons gave him the prestigious Jacobson Innovation Award, recognizing a career of achievement that included his work with emphysema patients. Lung-volume reduction would never have been generally accepted, the surgeons declared, "if Dr. Cooper had not developed and perfected the procedure and conducted the necessary clinical research." Just this April, the International Heart and Lung Society named Cooper one of the three greatest pioneers of heart and lung transplants in the world.

Cooper describes the procedure he developed for lung-volume reduction -- the same procedure he used on Jim Farris -- as a treatment of last resort for emphysema patients who no longer are helped by just physical therapy and medication. He first presented the results of his work on 20 patients at a meeting of the American Association for Thoracic Surgery in April 1994. The following January, the Journal of Thoracic and Cardiovascular Surgery published his results showing an average 82 percent improvement in lung function after lung-volume-reduction surgery in the 20 carefully selected emphysema patients.

"The results were so significant, they got everybody's attention," says Dr. Richard Fischel, director of the Chapman Lung Center in Orange, Calif.

Surgeons saw new evidence the procedure worked, emphysema patients saw new hope that their breathing could be improved and health-care providers saw something new they could sell. So when Medicare indicated in the mid- '90s that it was prepared to begin paying for the procedure, hospitals envisioned a huge and hugely profitable new market and rushed to offer the operation at their own facilities. Surgical-supply companies, anxious to encourage hospitals to launch lung-volume-reduction centers, ran "how-to" seminars and distributed booklets on how to successfully bill Medicare or private insurance companies for the procedure. Desperate emphysema patients, even those who would not benefit, clamored for the surgery.

It was a recipe for abuse.

Even though it took years to perfect the procedure, the technique for lung-volume reduction was almost absurdly simple -- so simple, according to some surgeons, that anybody with a surgical stapler could do it. But deciding which patients would benefit from the procedure and successfully caring for those patients after surgery required, as Cooper says, "a great deal of experience and expertise."

That's where many hospitals fell short. "There was a great deal of misleading promotion and advertising," Cooper says. Hospital administrators thought lung reduction "would be the angioplasty of the '90s," he says, referring to a profitable hospital procedure for unblocking clogged arteries that became common in the 1980s. Anxious for the revenue, they pushed doctors to do the operation even though the hospitals were not ready to care for the patients.

"Places that do normal surgeries tried to offer it. But these (emphysema) patients are respiratory cripples, and those places didn't know how to care for them," agrees Fischel. And it wasn't just because of hospital administrators. Cooper "is just being nice to his fellow surgeons," says Fischel. "There absolutely were greedy surgeons trying to make a buck. There were places doing it with 50- 100 percent mortality."

Indeed, it was an unexpectedly high number of deaths among the 722 claims Medicare paid -- a rate that exceeded what had been reported in medical journals -- that made the agency abruptly reverse course and stop funding the surgical procedure.

A Medicare spokesman referred The Riverfront Times to Dr. Steven Piantadosi, a clinical trialist at Johns Hopkins University in Baltimore and clinical coordinator for NETT. "Medicare said, 'Stop. We're spending a lot of money and we want to know if it really works,'" Piantadosi explains. "When you think about it, that is exactly what you want to happen," Piantadosi continues. "You don't want some cowboy surgeon saying, 'I did a few dozen of these, and the people seem to be OK, so let's make a national policy that any cowboy surgeon can do them.'"

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