Coronary Stenting as a Model of Disruptive Technology in CV Care…With More Disruption to Come

Marsha Knapik is a Director at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon holds a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach the author, email mknapik@corazoninc.com.

Technological advances seemingly arrive almost daily in healthcare, and the cardiovascular specialty is not exempt! While early adopters of these advances are often touted as being on “the cutting edge,” not every new device, technique, or technology becomes an industry mainstay. In fact, many new trends are transient, just one small step on the way to a much bigger, better, greater trend…one that may or may not be permanent either. Hospital leaders and physicians are challenged to understand and evaluate the pros and cons and the benefits and drawbacks of any new advance, along with the likelihood that the change will “stick” as a means to improve process, outcomes, or some aspect of care delivery. Corazon believes that being able to in some ways predict the widespread success of a new advance can lead to market leadership in cardiovascular care, though being fully aware that any new procedure, device, technique, or technology (regardless of clinical, operational, or financial benefits) can disrupt the status quo and greatly impact the service line for better or worse.  A challenge, indeed!

For cath lab or cardiovascular clinicians, disruptive technology can be a new catheter or stent that causes the program to abandon previous items, change inventory and the resulting required education and training, readjust the chargemaster (usually a price increase), and other impacts to day-to-day workings of the program. Certainly, this is disruptive on a department level; however, considering a technology as truly disruptive alludes to an impact on a much broader and larger scale for the healthcare industry as a whole.

The McKinsey Global Institute defines disruptive technologies as those that “have the potential to disrupt the status quo, alter the way people live and work, rearrange value pools, and lead to entirely new products and services.”¹ In healthcare, the impact of new technology, including its cost and adoption, along with implications on the workforce, patient care, and the economy, is so significant that Carnegie Mellon University in Pittsburgh, Pennsylvania has developed a Disruptive Technology Institute devoting time, energy, and resources to review how new advances impact the overall healthcare marketplace.² Furthermore, the impact of new technologies, and how they can disrupt or change multiple aspects of cardiovascular care delivery, was deemed significant enough to be the topic of the opening presentation of the Society for Cardiovascular Angiography and Interventions (SCAI) 2015 Scientific Sessions.^3,4

Look no further in cardiovascular care than intracoronary stenting as a stellar example of disruptive healthcare technology. In the late 1970s, the complexity of procedures performed in the cardiac catheterization laboratory was significantly lower than the complexity of stenting procedures done today. At that time, the diagnostic catheterization could lead to percutaneous transluminal coronary angioplasty, more simply known as balloon angioplasty. This was considered state-of-the-art and heralded as a great alternative to coronary bypass surgery for some patients…and indeed it was. Decades were spent on refining the catheter, the balloon materials, etc. But, then came the downfall of angioplasty — restenosis. Researchers began to quickly investigate how stenting technology, already being used in biliary and urological procedures, could be applied towards the treatment of coronary artery disease. 

The advent of Johnson & Johnson’s Palmaz-Schatz Balloon-Expandable Stent, approved by the U.S. FDA in 1994, quickly followed by other vendors, was a truly disruptive technology. The stenting procedure had early adopters in tertiary centers and with the documentation of good outcomes, the adoptions quickly spread to larger community hospitals. The stent, while continuing to be refined, caused economic turmoil in cath labs worldwide, as the cost was significant compared to balloon angioplasty. The initial impact on hospital length-of-stay was that of a long inpatient stay, since in those early days patients remained in the hospital from several days to a week with ongoing anticoagulation and IV dextran administration. Only hospitals with open heart surgery (OHS) as a back-up could provide these stenting services in the cath lab.  

Meanwhile, this shift in interventional procedures hurt diagnostic-only cath labs as patients demanded procedures to be done where the intervention could also take place. As stent refinement, safety, and outcomes were documented over the next 20 years, stenting has now become permitted in the vast majority of states in some fashion, even in the smallest hospitals with interventional cardiology programs (no on-site OHS required).

Consider the impact that first coronary stent (from purely a device perspective) has had on interventional cardiology and on the non-surgical management of heart disease. Table 1 lists the rapid-paced adaptations to the original stent devices as a natural progression of the stent technology.

Beyond the improvements to the stent device itself, it is slightly less apparent how stenting “disrupted” cardiac and vascular care overall and continues to do so at present. The McKinsey article states that technologies that matter possess four criteria: 

1. Rapidly advance or experience breakthroughs;

2. Have the potential for broad impact;

3. Have significant economic value that can be affected;

4. The economic impact can dramatically change the status quo.  

Consider how these four points apply to the coronary stent, and the stenting applications and advancements that have followed (Table 2). We can see how the disruptive nature of this technology, in essence, improved patient care in a revolutionary way, eliminating the need for complex and potentially risky cardiac surgery.  

Corazon believes the invasive laboratory will continue to struggle with budgets, trading out inventory, updating the chargemaster, and training to incorporate yet the next generation of stents for the foreseeable future. There is, however, no lack of other new technologies to focus on as well. Advances in remote monitoring technology (for use in rhythm management, wellness monitoring, device transmissions, simulation laboratories, and activity and fitness monitoring), stereotactic magnetic navigation applications to cardiology, ongoing advances with percutaneous valve repair and replacement, percutaneous left atrial appendage (LAA) closure, 3D printing in healthcare, and genotyping are but a few of the items either making great strides or rapidly emerging in the cardiovascular healthcare technology field.  

The real challenge is how to adapt these new technologies into day-to-day work while watching the horizon to see which new technology will emerge as the next great “disrupter” in cardiovascular care.  And what the impact will be — for better or worse — will be difficult to predict; however, staying abreast of industry literature, new medical discoveries, trending hot topics, and clinical trials and studies will assist with remaining on the forefront of what’s to come. n

References

1. Manyika J, Chui M, Bughin J, Dobbs R, Bisson P, Marrs A. Disruptive technologies: advances that will transform life, business, and the global economy. Report, McKinsey Global Institute. 2013 May. Available online at https://www.mckinsey.com/insights/business_technology/disruptive_technologies. Accessed July 22, 2015.

2. What is disruptive health technology? Carnegie Mellon University Disruptive Health Technology Institute. Available online at https://www.dhti.cmu.edu/dhti/definition.asp. Accessed July 22, 2015.

3. SCAI 2015 opening session to highlight disruptive technologies in cardiovascular care. Diagnostic and Interventional Cardiology (DAIC). 2015 April 6. Available online at https://www.dicardiology.com/article/scai-2015-opening-session-highlight-disruptive-technologies-cardiovascular-care. Accessed July 22, 2015.

4. Schussler JM. The new frontier: interventional cardiology and technology. Healio. MedBlog. 2015 May 7. Available online at https://www.healio.com/cardiology/intervention/news/blogs/%7Bf73c5c92-79d2-4798-a652-6e1b64e32c59%7D/eye-on-intervention/the-new-frontier-interventional-cardiology-and-technology. Accessed July 22, 2015.