angioplasty: a surgical perspective bruce e. keogh€¦ · advanced angioplasty 2008 disruptive...

Advanced Angioplasty 2008

Angioplasty: a surgical perspective

Bruce E. Keogh NHS Medical Director

Professor of Cardiac Surgery University College London


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


The facts

•  Surgery offers better symptomatic and prognostic benefit for: – LMS – 3VD

•  Surgery is invasive •  Surgery costs more initially •  Variation in philosophy, technology & results


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

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 20060

100

200

300

400

500

600

700

800

900

1000

No of CABGNo of centers

National Center for Health Statistics & Northern New England Registry • Peak 1999 • Decline from 2000

Society of Thoracic Surgeons decline in number of CABG despite increasing number of contributing centers


1. Cardiologist is the ‘gatekeeper’ 2. Extrapolation of RCT findings

•  Conducted in 5 % of atypical, highly select patients (1 or 2 VD and normal LV function)

•  Results inappropriately generalized to the whole population (true multivessel disease and poor LV)

3 EBM challenged by a multi billion dollar industry

So why is PCI replacing CABG?


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?


Perf

orm

ance

Time

Performance that customers

can utilize or absorb

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


Perf

orm

ance

Time



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


Disruptive technologies

•  New •  Very different package of attributes from the

one mainstream customers historically value •  Often perform far worse along one or two

dimensions that are particularly important to some customers

•  Products based on disruptive technologies are typically cheaper, simpler, smaller, and more convenient to use.


Performance Oversupply

•  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

•  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.


Perf

orm

ance

Time




Incumbents nearly always win

Entrants nearly always win


Disruptive products • worse performance • simpler and cheaper; • lower margins, not greater profits • typically are first commercialized in emerging or insignificant markets


Disruptive strategies – non medical

•  Amazon – low end disrupt to bookstores •  Bloomberg – financial info, E stock clearing •  Dell – direct to customer computers •  E-mail – postal services •  Intel microprocessors & then Celeron – mainframes •  Kodak cameras (Brownie and Funsaver) •  Photographic film – digital media •  Low cost airlines – Easyjet, Ryanair –established

airlines •  Palm pilot, Blackberry - notebooks •  Steel minimills – integrated mills collapsed •  Toyota / Lexus – initially cheap low end now high end •  Xerox copiers – relative to offset printing


Disruptive strategies in healthcare

•  Drugs for TB and peptic ulcer •  Endoscopic surgery •  Portable blood glucose meters •  Portable INR monitors •  Novopen •  Ultrasound relative to X-ray •  Sonosite portable ultrasound machines •  Physicians Assistants ? •  Critical care technologists? •  Stent Angioplasty


Disruption enables less-skilled people to do more sophisticated things 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.

• Computers

• Photocopying

• Angioplasty

Almost always, disruptive innovations such as these have been ignored or opposed by the leading institutions in their industries for perfectly rational reasons.


Percutaneous coronary interventions •  Prior to 1980’s – Bypass surgery •  1980s – Angioplasty introduced

–  Often ineffective, restenosis rate high (50% per year), couldn’t solve difficult blockages so surgeons not worried

–  But, it was inexpensive and simple to use by cardiologists who didn’t have to refer to a surgeon and kept the fees

–  Led to massive growth in the market because it enabled less seriously ill patients get treatment that was better than the alternative (nothing)

–  Cardiac Bypass continued to grow for difficult and restensoed arteries •  1995 Stents

–  Rapid increase in number of Angioplasty procedures –  Bypass operations started to drop

•  Cardiac surgeons slow to react •  Stent Angioplasty done in non surgical centres

–  Which are another disruption in relation to full scale hospitals


Perf

orm

ance

Time


Coronary Artery Bypass

Angioplasty as a disruptive technology

Stent

Initially a lot of Non-consumption

POBA


Conclusion

•  Innovation is inevitable •  PCI Innovation is driven by industry & patients

–  Answerable to shareholders –  Little innovation in coronary surgery

•  Margins of utility are often blurred in innovation •  Surgery and PCI are moving in to different territories •  The balance will shift to a debate between medical

therapy and angioplasty

angioplasty: a surgical perspective bruce e. keogh€¦ · advanced angioplasty 2008 disruptive...

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