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Grand Rounds: Univ of Chicago Cardiology

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Grand Rounds: Univ of Chicago Cardiology

  1. 1. Less Invasive/Hybrid CABG: Rationale for Marketing Robert Poston, MD
  2. 2. “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.
  3. 3. Patients Prefer Less Invasive 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000
  4. 4. Repeating Story…  Arthroscopic surgery  Laparoscopic surgery  Robotic prostatectomy  Robotic hysterectomy  Breast lumpectomy/XRT
  5. 5.  Pain resolves quicker  ↓ Blood loss  ↓ Intubation time  ↓ LOS  ↓ Complications CABG Mitral valve Descending aorta Less Invasive Cardiac Surgery
  6. 6.  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
  7. 7.  Pain resolves quicker  ↓ Blood loss  ↓ Intubation time  ↓ LOS  ↓ Complications CABG Mitral valve Descending aorta Less Invasive Cardiac Surgery
  8. 8. LIMA LAD RIMA OM1 COMPLETE REVASCULARIZATION VIA A SMALL THORACOTOMY Distals via small thoracotomyRobotic assisted BIMA harvest
  9. 9. Hybrid Procedure:  PCI 1st, then CABG  Surgery 1st, then PCI  Simultaneous  hybrid OR Hybrid Cath Lab - OR
  10. 10. 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
  11. 11. 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
  12. 12. RCA – after stenting RCA – before stenting LIMA LAD focal blockage Webcast 2/28/07: http://www.or-live.com/umm/1713 1. Reicher, Poston, et al. Am Heart J. 2008;155(4):661-7 MULTIVESSEL REVASCULARIZATION VIA SIMULTANEOUS HYBRID APPROACH1 Intraoperative angiography
  13. 13. Patient Decision Making in Life Threatening Situations1 1. Pierce. Human Factors 1996; 38(2):278-88
  14. 14. Patient Decision Making in Life Threatening Situations1 1. Pierce. Human Factors 1996; 38(2):278-88 Seek more information
  15. 15. Nallamothu, B. K. et al. JAMA 2007;297:962-968. Geographic Variations in Referral for CABG
  16. 16. Decision Aides European Heart Journal 2010; (31):2051-2555 http://www.informedmedicaldecisions.org/
  17. 17. 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
  18. 18. Marketing Tactics  Public relations  Website development  Outreach  Scientific publications/presentations  Advertising
  19. 19. Media Relations Single vessel robotic CABG Starting 6/03 Hybrid revasc Starting 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
  20. 20. CAD patient referred 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 anatomy Able to tolerate single lung ventilation Stable 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 2008-9 University HealthSystem Consortium
  21. 21. 1. NEJM 2010; 363:701-04 * *
  22. 22. Patient Satisfaction Data from www.hospitalcompare.hhs.gov, accessed on 11/25/09
  23. 23. 89% BOSTON MEDICAL CENTER: ROBOTIC CABG PATIENTS Patient Satisfaction
  24. 24. Mass Media Ads: 7/08 to 7/09
  25. 25. Effect of Advertising Mass Media Ad Consumer response •102 inquiries (68 candidates) •56 new cases – 12 months
  26. 26. 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
  27. 27. Map of Patient Locations This map depicts all patients that had a robotic assisted cardiac procedure at BMC FY08-09.
  28. 28. Eastern United States FY09 – 39% outside Mass. FY07 – 3% outside Mass. Map of Patient Locations This map depicts all patients from outside Massachusetts that had a robotic assisted cardiac procedure at BMC FY08-09.
  29. 29. DRAFT August 31, 2007 Heart Marketing Plan Tactics/Activities Jul Aug Sept Oct Nov Dec Jan 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
  30. 30. 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
  31. 31. 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
  32. 32. Consequences of Ads Characteristics AD (n=56) Non-Ad(n=46) P-value Elective case 74.1 41.5 0.0003 Age* (years) 61.7 68.5 0.001 Sex (Male) 88.9 68.8 0.011 BMI>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
  33. 33. Length of hospital stay (days) 4.4 6.6 0.0018 Activity score at 3 weeks (% of baseline)* 74.5 72.2 0.89 Satisfaction at 2 weeks (% that would recommend)** 89.5 84.7 0.54 Unmet expectations at 6 mo. (total #) “length of incision” “time required for recovery” “expertise of Dr. Poston” 10 6 4 0 2 1 1 0 0.04 Consequences of Ads Postoperative Outcome AD (n=56) Non-Ad (n=46) P-value *Duke Activity Status Index **Press-Ganey survey
  34. 34. Adverse Effects of Advertising Mass Media Ad Consumer response Patient Unrealistic expectations Robotic surgeon Conflict of interest Referring physician Patient relationship1,2 Colleagues Emphasis on individual 1. J Clin Oncol 2009; 27: 4182-4187 2. Clin Orthop Relat Res 2007;458:202-19.
  35. 35. Robotic CABG: Issues That Go Either Way  Safety  Costs  Team morale  Ethics  Autonomy  Vulnerability  Doctor-patient relationship Differencein costroboticvs. sternotomy($/case)
  36. 36. Robotic CABG: Issues That Go Either Way  Safety  Costs  Team morale  Ethics  Autonomy  Vulnerability  Doctor-patient relationship Differencein costroboticvs. sternotomy($/case) learning curve
  37. 37. June 2008 August 2010 Retaliation
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 1. Establish marketing plan 2. Refine the plan 3. Implement the message 4. Measure outcomes 5. Reassess local environmentFocus group testing 3rd party review for clarity
  42. 42. 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 preferences 2. faces the consequences of the decision. 1. http://www.qualityforum.org/Setting_Priorities/Addressing_National_Priorities.aspx
  43. 43. 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
  44. 44. “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

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