All right, so these are my disclosures. So again, just to put this into context, and I think we've seen this already, intracoron imaging in the U.S. is quite low. These kind of three recent studies, ranging anywhere from kind of 9% to 17% of PCIs, so 80-plus percent of PCIs being done in the United States right now are not being done with imaging. As a country, we could be doing significantly better, and I think our patients would do better. You know, we now have the data to support this, and this was Greg Stone's meta-analysis just published a month or two ago. As Evan said, now more than 20 randomized controlled trials comparing imaging to angioguided PCI and substantial benefits, including a significant reduction in both cardiac death and all-cause death. What leads to this, I think, is still a matter of debate, but this is what's been shown in the meta-analysis. So I'm going to talk a little bit about my experience at my home institution. We used to be called Spectrum Health. We were 13 hospitals in the west side of Michigan. The flagship hospital in Grand Rapids, we were the only ones with a cath lab, so we got all the business from the other facilities, so a big, busy cath lab. But we're now called Corwell Health. We recently merged with the Beaumont system, so now we have 22 hospitals across the state of Michigan. But going back to 2018, our imaging rates as a cath lab, doing about 1,500 PCIs per year, we were imaging 29% of those. As cath lab director, I thought there was room for improvement, had an interest in trying to increase this, because 2018 we had the ultimate trial came out showing in an all-comers population roughly a 50% reduction in target vessel failure. And so my opinion, 2018 with this trial, IVUS-XPL had come out. The data were really very convincing to me that this is something we should be doing more. And so I started to think about how are we going to change this, and just reflecting on kind of our whole experience, I put together a couple of practical tips that you could take home to your own cath lab, and I put in parentheses here, or your state, and I'll talk a little bit more about that in a bit. But I think the first thing is you need to ensure that physicians and staff understand the data and the benefits of intracorne imaging. It is going to make your procedures better. Your patients are less likely to have problems with that stent if you use imaging to put it in, and everybody on the team needs to understand that. And if the staff don't understand that but the physicians do, your likelihood of successfully implementing that in your lab are less. So, again, I think you need to educate both. And then you need to know where you're starting out from. Know what your percentage of PCIs are, both your rate individually, but I think also for your cath lab so you have a starting point, and then you can measure that as you go forward. And so 2018 at my institution we knew what our baseline rate was at one of the meetings. I presented the research behind why patients who get intracorne imaging do better. Everybody, all the physicians at the meeting, you know, enjoyed seeing the data, agreed this makes sense. Next slide goes up, which is shown there on the right. It's the physicians and what your current use of intracorne imaging was. And so the difference, the slide that I showed there, everybody's physician, the name was up there. They were unblinded. So we all knew where we were. Our partners knew where we were and vice versa. And then just the rest of the meeting was just an open discussion. The data are very clear that patients do better. We all agreed on that. Here's our rates, and I just went around the room and asked each physician, why are you at, you know, 18% imaging if you believe, you know, the data are that patients do best. And so as a group in a very open and honest discussion, you know, we agreed that we should be doing more. And so we actually set this as a quality metric for our institution. And so we made this a quality metric. It's really important to potentially increase intracorne imaging in your lab. We set a goal, and we began to track usage. And so this is, again, where we were in calendar year 2019 at baseline. The metric, this was completely arbitrary. After talking about this as a group, we thought if each physician could just see an absolute increase of roughly 20%, that that might be meaningful or, you know, hit a value of greater than 50% of all of your cases. There was no data behind why we selected these. It was just a metric that we seemed like at least was a stretch for a lot of the physicians and so something that they would really have to work hard to achieve. And so this was what happened in 2020 when this metric was in place. Each of these physicians, you can see, went up. I think we had one physician who went down slightly. Everybody in the group with the exception of one was over 50%. And you can see a lot of the individuals here, you know, hitting 70%, 80%, 90%, or even 100% in one case. And so just this metric in place that was backed by everybody in the group believing that this was something that was meaningful, believing the data, and then putting a goal in place actually moved the needle. And then, as I said, I think one of the biggest barriers to adoption is just that, you know, physicians don't necessarily know how to use it. And so I think we need to simplify the teaching and make it practical. Putting the catheter in and out, as Rob said, isn't going to do the trick. You need to know what you're looking at. And so in 2021, we put a new quality metric in place. Your cath lab report has to have an MSA that you measured. This was guaranteeing that our physicians were at least thinking about is this stent optimally expanded. And so that was the metric in 2021. And so just having put this in place, this is what happened over the next few years. And so the metric in 2020 was, you know, 50% or a 20% increase. We hit 63% that year. With just not increasing the metric at all above that 50% number, suddenly as a cath lab we were at 80% in the first quarter of 2021. We are now consistently annually at 90% as an institution. And I have this hypothesis that if you get to that 50%, suddenly you're going to jump to 90% because you realize that it's changing what you do in the cath lab in the majority of your procedures. So this was kind of the practical tips that I talked about. I had an interest of knowing whether we could then do this on the state level. And so we did the same thing through our BMC squared meetings. We have quarterly meetings with all 48 cath labs across the state of Michigan. We looked at our baseline data. We educated the physicians. But these were our baseline data. Each bar here represents a different cath lab in the state of Michigan. These are 48,000 PCIs represented in this figure. And this is the rate of each hospital's use of intracorne imaging. Everywhere from 0% of procedures to, you know, over 70% of procedures. And as Denise said, the biggest predictor besides left main PCI was either the physician or the hospital that was performing it. This was opportunity for quality improvement for us. And so we have been focusing on this in the state of Michigan through education and other things. We are now, as of June of last year, and these data have not yet been published, across the state of Michigan, all 48 cath labs in the state, we are imaging more than 40% of our PCIs. When it comes to left main, instant restenosis or stent thrombosis, that's the dark bars there, more than 60% of cases are being imaged. And in 2023, we actually put a quality metric in place. But I think what we can see is just through the education through the end of 2022, we still saw a significant rise just because I think people believed in it. We provided education on how to do it. And I think we're going to see these numbers continue to go up because I think when you get to a critical mass and you realize that this is changing your procedures, you know, I think people really buy into it and they see the value and they start using it consistently. So I think that's it. Thank you.

intracoronary imaging

patient outcomes

PCI

imaging rates

education and quality metrics