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.

3.
Patients Prefer Less Invasive
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000

4.
Repeating Story…
 Arthroscopic surgery
 Laparoscopic surgery
 Robotic prostatectomy
 Robotic hysterectomy
 Breast lumpectomy/XRT

5.
 Pain resolves
quicker
 ↓ Blood loss
 ↓ Intubation time
 ↓ LOS
 ↓ Complications
CABG Mitral valve Descending aorta
Less Invasive Cardiac Surgery

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.
 Pain resolves
quicker
 ↓ Blood loss
 ↓ Intubation time
 ↓ LOS
 ↓ Complications
CABG Mitral valve Descending aorta
Less Invasive Cardiac Surgery

8.
LIMA
LAD
RIMA
OM1
COMPLETE REVASCULARIZATION
VIA A SMALL THORACOTOMY
Distals via small thoracotomyRobotic assisted BIMA harvest

9.
Hybrid Procedure:
 PCI 1st, then CABG
 Surgery 1st, then PCI
 Simultaneous
 hybrid OR
Hybrid Cath Lab - OR

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.
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.
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.
Patient Decision Making in Life
Threatening Situations1
1. Pierce. Human Factors 1996; 38(2):278-88

14.
Patient Decision Making in Life
Threatening Situations1
1. Pierce. Human Factors 1996; 38(2):278-88
Seek more
information

15.
Nallamothu, B. K. et al. JAMA 2007;297:962-968.
Geographic Variations in Referral for CABG

16.
Decision Aides
European Heart Journal 2010; (31):2051-2555
http://www.informedmedicaldecisions.org/

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

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.
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.
1. NEJM 2010; 363:701-04
*
*

22.
Patient Satisfaction
Data from www.hospitalcompare.hhs.gov, accessed on 11/25/09

23.
89%
BOSTON MEDICAL CENTER:
ROBOTIC CABG PATIENTS
Patient Satisfaction

24.
Mass Media Ads: 7/08 to 7/09

25.
Effect of Advertising
Mass Media Ad Consumer response
•102 inquiries (68 candidates)
•56 new cases – 12 months

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

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.
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.
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.
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.
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.
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.
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.
Robotic CABG: Issues That Go Either Way
 Safety
 Costs
 Team morale
 Ethics
 Autonomy
 Vulnerability
 Doctor-patient relationship
Differencein
costroboticvs.
sternotomy($/case)

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.
June 2008 August 2010
Retaliation

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.
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.
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.
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.
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.
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.
“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