Less Invasive/Hybrid CABG: Rationale for Marketing

Robert Poston, MD

“Let no physician teach the people about medicines or even tell them the names of the medicines, particularly the more potent ones. . . . For the people may be harmed by their improper use.”

Royal College of Physicians, circa 1550.

Patients Prefer Less Invasive

1,400,000

1,200,000

1,000,000

800,000

600,000

400,000

200,000

Repeating Story… Arthroscopic surgery Laparoscopic surgery Robotic prostatectomy Robotic hysterectomy Breast lumpectomy/XRT

Pain resolvesquicker

↓ Blood loss ↓ Intubation time ↓ LOS ↓ Complications

CABG Mitral valve Descending aorta

Less Invasive Cardiac Surgery

Pain resolves quicker

↓ Blood loss ↓ Intubation time ↓ LOS ↓ Complications

CABG Mitral valve Descending aorta

Less Invasive Cardiac Surgery

HOW STAKEHOLDERS DEFINE VALUE PATIENT = ↓invasiveness, ↑information HOSPITAL = profitability PAYOR = return to work TRAINING = learn the “cutting-edge” NIH = comparative effectiveness research NQF = shared decision making

Pain resolvesquicker

↓ Blood loss ↓ Intubation time ↓ LOS ↓ Complications

CABG Mitral valve Descending aorta

Less Invasive Cardiac Surgery

LIMA

LAD

RIMA

OM1

COMPLETE REVASCULARIZATION VIA A SMALL THORACOTOMY

Distals via small thoracotomyRobotic assisted BIMA harvest

Hybrid Procedure:

PCI 1st, then CABG

Surgery 1st, then PCI

Simultaneous hybrid OR

Hybrid Cath Lab - OR

Advantages of Robotic CABG

Improved cosmesis Quicker recovery Less chronic pain Avoid sternal

infection1

1. Press Release, 10/1/08 “CMS Improves Patient Safety for Medicare and Medicaid by Addressing Never Events” (http://www.cms.hhs.gov/apps/media/fact_sheets.asp).

Case #1

Case #2

Representative Case #1 52 year old man, chronic angina

secondary to proximal LAD (calcified CTO) and mid-RCA disease (class A lesion).

Self-employed (no paid leave) and very interested in quick recovery time

Consulted with local cardiologist and cardiac surgeon who recommended sternotomy CABG

Sought out alternative options using the internet

RCA – after stenting

RCA – before stenting

LIMA

LAD

focalblockage

Webcast 2/28/07: http://www.or-live.com/umm/17131. Reicher, Poston, et al. Am Heart J. 2008;155(4):661-7

MULTIVESSEL REVASCULARIZATION VIA SIMULTANEOUS HYBRID APPROACH1

Intraoperative angiography

Patient Decision Making in Life Threatening Situations1

1. Pierce. Human Factors 1996; 38(2):278-88

Patient Decision Making in Life Threatening Situations1

1. Pierce. Human Factors 1996; 38(2):278-88

Seek more information

Nallamothu, B. K. et al. JAMA 2007;297:962-968.

Geographic Variations in Referral for CABG

Decision Aides

European Heart Journal 2010; (31):2051-2555 http://www.informedmedicaldecisions.org/

Marketing Environment for Robotic CABG at UC

Strengths Easy to articulate value proposition Substantial barriers to entry Platform for derivative procedures

Weaknesses Learning curve Fierce competition Susceptible to retaliation

Opportunities Large market size Motivated buyers Unmet needs

Threats Declining demand/saturated supply Advances in PCI technology Declining reimbursement/higher costs of robotics Conservative field

Marketing Tactics Public relations Website development Outreach Scientific publications/presentations Advertising

Media Relations

Single vessel robotic CABGStarting 6/03

Hybrid revascStarting 12/04

Multivessel robotic CABG Starting 9/06

1st simultaneous hybrid procedure in US (12/29/04)1

1st robotic-assisted CABG in Maryland (9/26/06)2

400 CASES ~7 years

1st robotic-assisted CABG in Boston (3/4/08)3

1. Am Heart J. 2008;155:661-7. 2. Ann Surg 2008;248:638-46. 3. Am J Card 2010, in press

CAD patientreferred for CABG

(n=403)

Candidate for minimally invasive (n=201)

Hybrid CABG (n=75) Robotic assisted CABG (n=120)

Staged hybrid:CABG 1st (n=39)

Staged hybrid:PCI 1st (n=36)

Sternotomy CABG (n=202)

Suitable anatomyAble to tolerate single lung ventilationStable hemodynamics

Conversions(n=6)

No

Yes

Culprit lesion stentable?No Yes

CABG at Boston Medical Center: 3/08 to present

Data Source: STS National Database 2008-9University HealthSystem Consortium

1. NEJM 2010; 363:701-04

**

Patient Satisfaction

Data from www.hospitalcompare.hhs.gov, accessed on 11/25/09

89%BOSTON MEDICAL CENTER:ROBOTIC CABG PATIENTS

Patient Satisfaction

Mass Media Ads: 7/08 to 7/09

Effect of Advertising

Mass Media Ad Consumer response• 102 inquiries (68 candidates)• 56 new cases – 12 months

Effect of Advertising

Mass Media Ad Consumer response• 102 inquiries (68 candidates)• 56 new cases – 12 months

Meet (emotional) needs of the

consumer

• Empowered with new alternatives• Promise of patient-centered care• Avoid the long recovery/sternotomy

Map of Patient LocationsThis map depicts all patients that had a robotic assisted cardiac procedure at BMC FY08-09.

EasternUnited States

FY09 – 39% outside Mass.

FY07 – 3% outside Mass.

Map of Patient LocationsThis map depicts all patients from outside Massachusetts that had a robotic assisted cardiac procedure at BMC FY08-09.

DRAFT August 31, 2007

Heart Marketing Plan

Tactics/Activities Jul Aug Sept Oct Nov DecJan Yr08

Feb Yr08

Mar Yr08

Apr Yr08

May Yr08

Jun Yr08

Jul Yr08

Aug Yr08

Sept Yr08

Srivastava Intro News Release

Major Breakthrough News Stories Begin (3)*

Shop Newsworthy Items/Human Interest Stories (Qty TBD)

Physician Robost Bios on UCMC Site

Enhanced Program Content on UCMC Site

Edited Srivastava Web Videos Posted to UCMC Site

Google Key Words Purchased/ Executed for Enhanced Search

MIS Heart Web Display Ads (2-3 Rounds)

Patient Stories Begin Appearing on UCMC Site

MIS Heart Radio in Market (4 flights per year)**

MIS Heart Print Ads in Market (4 drops per year)**

NOTE: MIS Heart Ad Rotations are Part of Main Heart Campaign

Use Internal Vehicles to Increase Awareness of Expanded UCMC Heart Expertise

Srivastava Story in The Forefront Internal Newsletter

Srivastava Intranet Announcement

* Minimum number of events recommended

** Targeted timing, timing subject to change

Increase UCMC Internal Awareness

Use Print & Radio Advertising to Increase Awareness of UCMC Advanced Heart Expertise

Increase Consumer Awareness of UCMC Heart Expertise

Utilize Web & UCMC Site to Enhance Awareness

Public Relations

Map of Patient Locations by

Procedure This map depicts all patients that had a robotic assisted cardiac procedure at UCMC FY07-08.

Across the U.S. Chicagoland Area

Robotic, nonCABG

Robotic CABG 7% robotic cases in UCMC primary service area.34% all other cases in PSA

Define the Customer Who they are:

Need CABG, actively seeking alternatives (patient #1)

Need CABG, suitable for robotics but unaware

Interventionalists interested in hybrid

Who they aren’t: Referring

cardiologists (long term relationships with other surgeons)

Not a candidate for robotics

Unstable Need 4-5 grafts

Consequences of AdsCharacteristics AD (n=56) Non-Ad(n=46) P-value

Elective case 74.1 41.5 0.0003Age* (years) 61.7 68.5 0.001Sex (Male) 88.9 68.8 0.011BMI>30 42.5 33.7 0.36

DM 43.1 46.7 0.728

Active Smoking 10.3 16.8 0.325

HTN 86.2 93.5 0.238

MI 42.5 54.5 0.225

CHF 22.2 32.4 0.239

PAD 9.2 11.6 0.777

Renal Failure 3.4 5.1 0.6995

Chronic Lung Disease (%) 5.6 19.4 0.0367

Length of hospital stay (days) 4.4 6.6 0.0018Activity score at 3 weeks (% of baseline)* 74.5 72.2 0.89Satisfaction at 2 weeks (% that would recommend)** 89.5 84.7 0.54Unmet expectations at 6 mo. (total #) “length of incision” “time required for recovery” “expertise of Dr. Poston”

10640

2110

0.04

Consequences of AdsPostoperative Outcome AD

(n=56)Non-Ad (n=46) P-value

*Duke Activity Status Index**Press-Ganey survey

Adverse Effects of Advertising

Mass Media Ad Consumer response

PatientUnrealistic expectations

Robotic surgeonConflict of interest

Referring physicianPatient relationship1,2

ColleaguesEmphasis on individual

1. J Clin Oncol 2009; 27: 4182-41872. Clin Orthop Relat Res 2007;458:202-19.

Robotic CABG: Issues That Go Either Way

Safety Costs Team morale Ethics

Autonomy Vulnerability Doctor-patient relationship

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Robotic CABG: Issues That Go Either Way

Safety Costs Team morale Ethics

Autonomy Vulnerability Doctor-patient relationship

Diff

eren

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co

st ro

botic

vs.

ster

noto

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($/c

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learning curve

June 2008 August 2010

Retaliation

Question Items 1st survey 2nd survey p

Teamwork Climate 2.9 ± 0.6 3.3 ± 1.0 0.05

Disagreements in this ICU are resolved appropriately (i.e., not who is right, but what is best for the patient) (Q32)

2.0 ± 1.0 3.4 ± 1.1 0.0010

Safety Climate 2.9 ± 0.6 3.2 ± 0.8 0.04

Medical errors are handled appropriately in this ICU. (Q5) 2.9 ± 0.9 3.6 ± 1.3 0.0394

In this ICU, it is easy to discuss errors. (Q12) 2.3 ± 1.0 4.3 ± 0.8 <0.001

Robotic CABG and the Culture of Safety

http://www.ahrq.gov/qual/patientsafetyculture/

Likert Scale 1-5: 1 = strongly disagree, 5 = strongly agree

Integrated Marketing Communications

Planned messages External – ads, PR campaign Internal – newsletter, intranet stories,

grand rounds, presentations to stakeholders

Inferred messages - Public impression How our product is perceived Customer service Teamwork, learning curve Response to retaliation

Map of Potential Patients Who Did Not Have a MICS Procedure

Across the U.S. Chicagoland

Insurance problems

Inquired, did not proceed

Not a candidate

Boston – 12 ad responders were candidates and did not have robotic CABG

1. Establish marketing plan

2. Refine the plan

3. Implement themessage

4. Measureoutcomes

5. Reassess localenvironmentFocus group testing

3rd party review for clarity

Improved Clinical Outcomes

Shared Decision Making “the greatest potential to eradicate

disparities, reduce harm, and remove waste from the American healthcare system.’’1

Create greater symmetry of information Only the individual

1. knows their values and preferences2. faces the consequences of the decision.

1. http://www.qualityforum.org/Setting_Priorities/Addressing_National_Priorities.aspx

Robotic CABG is a “preference sensitive” choice – dependent on the context of the patient’s social circumstances and willingness to accept a new option – not solely the preferences of the surgeon and referring provider.

“Shared decision making” is valuable because merely having a choice improves patient satisfaction and outcome.

Having experience with both robotic and open techniques lends credibility to our center as a place that can engage in shared decision making in a meaningful way.

The Message

“Shared Decision Making” Answers the Problems

Cardiology referrals – distinctive service marketed direct to patients

Doctor-patient relationship – ads emphasize the relationship is evolving

Team morale – easier to accept patient’s right to decide

Potential for retaliation – risk is less unless all regional surgeons are discussing robotic CABG