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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 resolves
quicker
 ↓ 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 resolves
quicker
 ↓ 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
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
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 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
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
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 Locations
This map depicts all patients that had a robotic assisted cardiac procedure at BMC FY08-09.
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.
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
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 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
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
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.
Robotic CABG: Issues That Go Either Way
 Safety
 Costs
 Team morale
 Ethics
 Autonomy
 Vulnerability
 Doctor-patient relationship
Differencein
costroboticvs.
sternotomy($/case)
Robotic CABG: Issues That Go Either Way
 Safety
 Costs
 Team morale
 Ethics
 Autonomy
 Vulnerability
 Doctor-patient relationship
Differencein
costroboticvs.
sternotomy($/case)
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 the
message
4. Measure
outcomes
5. Reassess local
environmentFocus 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 preferences
2. 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

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Less Invasive Cardiac Surgery Marketing Strategy

  • 1. Less Invasive/Hybrid CABG: Rationale for Marketing Robert Poston, MD
  • 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.
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  • 10. Patients Prefer Less Invasive 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000
  • 11. Repeating Story…  Arthroscopic surgery  Laparoscopic surgery  Robotic prostatectomy  Robotic hysterectomy  Breast lumpectomy/XRT
  • 12.  Pain resolves quicker  ↓ Blood loss  ↓ Intubation time  ↓ LOS  ↓ Complications CABG Mitral valve Descending aorta Less Invasive Cardiac Surgery
  • 13.  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
  • 14.  Pain resolves quicker  ↓ Blood loss  ↓ Intubation time  ↓ LOS  ↓ Complications CABG Mitral valve Descending aorta Less Invasive Cardiac Surgery
  • 15. LIMA LAD RIMA OM1 COMPLETE REVASCULARIZATION VIA A SMALL THORACOTOMY Distals via small thoracotomyRobotic assisted BIMA harvest
  • 16. Hybrid Procedure:  PCI 1st, then CABG  Surgery 1st, then PCI  Simultaneous  hybrid OR Hybrid Cath Lab - OR
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. Patient Decision Making in Life Threatening Situations1 1. Pierce. Human Factors 1996; 38(2):278-88
  • 21. Patient Decision Making in Life Threatening Situations1 1. Pierce. Human Factors 1996; 38(2):278-88 Seek more information
  • 22. Nallamothu, B. K. et al. JAMA 2007;297:962-968. Geographic Variations in Referral for CABG
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  • 28. Decision Aides European Heart Journal 2010; (31):2051-2555 http://www.informedmedicaldecisions.org/
  • 29. 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
  • 30. Marketing Tactics  Public relations  Website development  Outreach  Scientific publications/presentations  Advertising
  • 31. 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
  • 32. 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
  • 33.
  • 34. 1. NEJM 2010; 363:701-04 * *
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  • 36. Patient Satisfaction Data from www.hospitalcompare.hhs.gov, accessed on 11/25/09
  • 37. 89% BOSTON MEDICAL CENTER: ROBOTIC CABG PATIENTS Patient Satisfaction
  • 38. Mass Media Ads: 7/08 to 7/09
  • 39. Effect of Advertising Mass Media Ad Consumer response •102 inquiries (68 candidates) •56 new cases – 12 months
  • 40. 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
  • 41. Map of Patient Locations This map depicts all patients that had a robotic assisted cardiac procedure at BMC FY08-09.
  • 42. 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.
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. 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
  • 47. 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
  • 48. 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.
  • 49. Robotic CABG: Issues That Go Either Way  Safety  Costs  Team morale  Ethics  Autonomy  Vulnerability  Doctor-patient relationship Differencein costroboticvs. sternotomy($/case)
  • 50. Robotic CABG: Issues That Go Either Way  Safety  Costs  Team morale  Ethics  Autonomy  Vulnerability  Doctor-patient relationship Differencein costroboticvs. sternotomy($/case) learning curve
  • 51. June 2008 August 2010 Retaliation
  • 52. 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
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. 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
  • 57. 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
  • 58. “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