Angioplasty: a surgical perspective Bruce E. Keogh NHS Medical Director Professor of Cardiac Surgery University College Lo...
Evolution & innovation in the Interventional Treatment of Ischaemic Heart Disease 1950 1960 1970 1980 1990 CPB VA Study Eu...
The facts <ul><li>Surgery offers better symptomatic and prognostic benefit for: </li></ul><ul><ul><li>LMS </li></ul></ul><...
Growth of percutaneous & surgical interventions for ischaemic heart disease Ratio 2.5 – 6 PCIs  for  1 CABG
Number of CABG procedures declining in United States <ul><li>National Center for </li></ul><ul><li>Health Statistics </li>...
<ul><ul><li>1 . Cardiologist is the ‘gatekeeper’ </li></ul></ul><ul><ul><li>2 . Extrapolation of RCT findings </li></ul></...
How do new technologies gain a grip? Why do well-managed companies that have their competitiveness, listen astutely to the...
Performance Time Performance trajectory Range of  performance that customers  can utilise The rate at which the performanc...
Performance Time Sustaining innovations Incumbents nearly always win  Sustaining technologies Range Tend to maintain a rat...
Disruptive technologies  <ul><li>New </li></ul><ul><li>Very different package of attributes from the one mainstream custom...
Performance Oversupply <ul><li>Once the performance level demanded of a particular attribute has been achieved, customers ...
Performance Time Sustaining innovations Incumbents nearly always win  Entrants nearly always win Disruptive technologies <...
Disruptive strategies – non medical <ul><li>Amazon – low end disrupt to bookstores </li></ul><ul><li>Bloomberg – financial...
Disruptive strategies in healthcare <ul><li>Drugs for TB and peptic ulcer </li></ul><ul><li>Endoscopic surgery </li></ul><...
Disruption enables less-skilled people to do more sophisticated things <ul><li>Disruptive innovations enable a larger popu...
Percutaneous coronary interventions <ul><li>Prior to 1980’s – Bypass surgery </li></ul><ul><li>1980s – Angioplasty introdu...
Performance Time Sustaining innovations Coronary Artery Bypass Angioplasty as a disruptive technology Stent  Initially a l...
Conclusion <ul><li>Innovation is inevitable </li></ul><ul><li>PCI Innovation is driven by industry & patients </li></ul><u...
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A surgical perspective

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  • -example – motor cars increasing power but constrained by laws re speeding etc
  • A surgical perspective

    1. 1. Angioplasty: a surgical perspective Bruce E. Keogh NHS Medical Director Professor of Cardiac Surgery University College London
    2. 2. Evolution & innovation in the Interventional Treatment of Ischaemic Heart Disease 1950 1960 1970 1980 1990 CPB VA Study European Study CASS LIMA Bypass Grafts Venous Bypass grafts Vineberg 2000 PTCA Endarterectomy RITA-1 BARI EAST ARTS STENTS CABRI Surgical / Medical RCT’s Surgical / PCI RCT’s 2005 DES
    3. 3. The facts <ul><li>Surgery offers better symptomatic and prognostic benefit for: </li></ul><ul><ul><li>LMS </li></ul></ul><ul><ul><li>3VD </li></ul></ul><ul><li>Surgery is invasive </li></ul><ul><li>Surgery costs more initially </li></ul><ul><li>Variation in philosophy, technology & results </li></ul>
    4. 4. Growth of percutaneous & surgical interventions for ischaemic heart disease Ratio 2.5 – 6 PCIs for 1 CABG
    5. 5. Number of CABG procedures declining in United States <ul><li>National Center for </li></ul><ul><li>Health Statistics </li></ul><ul><li>& </li></ul><ul><li>Northern New England Registry </li></ul><ul><li>Peak 1999 </li></ul><ul><li>Decline from 2000 </li></ul>Society of Thoracic Surgeons decline in number of CABG despite increasing number of contributing centers
    6. 6. <ul><ul><li>1 . Cardiologist is the ‘gatekeeper’ </li></ul></ul><ul><ul><li>2 . Extrapolation of RCT findings </li></ul></ul><ul><ul><ul><li>Conducted in 5 % of atypical, highly select patients (1 or 2 VD and normal LV function) </li></ul></ul></ul><ul><ul><ul><li>Results inappropriately generalized to the whole population (true multivessel disease and poor LV) </li></ul></ul></ul><ul><ul><li>3 EBM challenged by a multi billion dollar industry </li></ul></ul>So why is PCI replacing CABG?
    7. 7. How do new technologies gain a grip? Why do well-managed companies that have their competitiveness, listen astutely to their customers, invest aggressively in new technologies, and yet still lose market dominance?
    8. 8. Performance Time Performance trajectory Range of performance that customers can utilise The rate at which the performance of a product has improved or is expected to improve, over time e.g. improvements in car engines, constrained by speed limits Performance that customers can utilize or absorb
    9. 9. Performance Time Sustaining innovations Incumbents nearly always win Sustaining technologies Range Tend to maintain a rate of improvement; that is, they give customers something more or better in the attributes they already value e.g. improvements in Intel chips now overshot capacity for mainstream use Performance that customers can utilize or absorb Pace of Technological Progress
    10. 10. Disruptive technologies <ul><li>New </li></ul><ul><li>Very different package of attributes from the one mainstream customers historically value </li></ul><ul><li>Often perform far worse along one or two dimensions that are particularly important to some customers </li></ul><ul><li>Products based on disruptive technologies are typically cheaper , simpler , smaller , and more convenient to use. </li></ul>
    11. 11. Performance Oversupply <ul><li>Once the performance level demanded of a particular attribute has been achieved, customers are less willing to pay a premium price for continued improvement in that attribute </li></ul><ul><li>This triggers a shift in the basis of competition, and the criteria used to choose one product over another changes to attributes for which market demands are not yet satisfied. </li></ul>
    12. 12. Performance Time Sustaining innovations Incumbents nearly always win Entrants nearly always win Disruptive technologies <ul><li>Disruptive products </li></ul><ul><ul><li>worse performance </li></ul></ul><ul><ul><li>simpler and cheaper; </li></ul></ul><ul><ul><li>lower margins, not greater profits </li></ul></ul><ul><ul><li>typically are first commercialized in emerging or insignificant markets </li></ul></ul>Performance that customers can utilize or absorb Pace of Technological Progress Disruptive technologies
    13. 13. Disruptive strategies – non medical <ul><li>Amazon – low end disrupt to bookstores </li></ul><ul><li>Bloomberg – financial info, E stock clearing </li></ul><ul><li>Dell – direct to customer computers </li></ul><ul><li>E-mail – postal services </li></ul><ul><li>Intel microprocessors & then Celeron – mainframes </li></ul><ul><li>Kodak cameras (Brownie and Funsaver) </li></ul><ul><li>Photographic film – digital media </li></ul><ul><li>Low cost airlines – Easyjet, Ryanair –established airlines </li></ul><ul><li>Palm pilot, Blackberry - notebooks </li></ul><ul><li>Steel minimills – integrated mills collapsed </li></ul><ul><li>Toyota / Lexus – initially cheap low end now high end </li></ul><ul><li>Xerox copiers – relative to offset printing </li></ul>
    14. 14. Disruptive strategies in healthcare <ul><li>Drugs for TB and peptic ulcer </li></ul><ul><li>Endoscopic surgery </li></ul><ul><li>Portable blood glucose meters </li></ul><ul><li>Portable INR monitors </li></ul><ul><li>Novopen </li></ul><ul><li>Ultrasound relative to X-ray </li></ul><ul><li>Sonosite portable ultrasound machines </li></ul><ul><li>Physicians Assistants ? </li></ul><ul><li>Critical care technologists? </li></ul><ul><li>Stent Angioplasty </li></ul>
    15. 15. Disruption enables less-skilled people to do more sophisticated things <ul><li>Disruptive innovations enable a larger population of less-skilled, less-wealthy people to do things in a more convenient, lower-cost setting, which historically could only be done by specialists in less convenient settings. Disruption has been one of the fundamental causal mechanisms through which our lives have improved . </li></ul><ul><li>Computers </li></ul><ul><li>Photocopying </li></ul><ul><li>Angioplasty </li></ul>Almost always, disruptive innovations such as these have been ignored or opposed by the leading institutions in their industries for perfectly rational reasons.
    16. 16. Percutaneous coronary interventions <ul><li>Prior to 1980’s – Bypass surgery </li></ul><ul><li>1980s – Angioplasty introduced </li></ul><ul><ul><li>Often ineffective, restenosis rate high (50% per year), couldn’t solve difficult blockages so surgeons not worried </li></ul></ul><ul><ul><li>But, it was inexpensive and simple to use by cardiologists who didn’t have to refer to a surgeon and kept the fees </li></ul></ul><ul><ul><li>Led to massive growth in the market because it enabled less seriously ill patients get treatment that was better than the alternative (nothing) </li></ul></ul><ul><ul><li>Cardiac Bypass continued to grow for difficult and restensoed arteries </li></ul></ul><ul><li>1995 Stents </li></ul><ul><ul><li>Rapid increase in number of Angioplasty procedures </li></ul></ul><ul><ul><li>Bypass operations started to drop </li></ul></ul><ul><li>Cardiac surgeons slow to react </li></ul><ul><li>Stent Angioplasty done in non surgical centres </li></ul><ul><ul><li>Which are another disruption in relation to full scale hospitals </li></ul></ul>
    17. 17. Performance Time Sustaining innovations Coronary Artery Bypass Angioplasty as a disruptive technology Stent Initially a lot of Non-consumption POBA Disruptive technologies
    18. 18. Conclusion <ul><li>Innovation is inevitable </li></ul><ul><li>PCI Innovation is driven by industry & patients </li></ul><ul><ul><li>Answerable to shareholders </li></ul></ul><ul><ul><li>Little innovation in coronary surgery </li></ul></ul><ul><li>Margins of utility are often blurred in innovation </li></ul><ul><li>Surgery and PCI are moving in to different territories </li></ul><ul><li>The balance will shift to a debate between medical therapy and angioplasty </li></ul>

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