It's a pleasure to be here as part of the SCI MedAxium collaboration to improve the use of intravascular imaging. My job is to tell you a little bit about, yes, why it's not being used, but my proposition here is that it has to do with we don't do a good job of implementation with a lot of things. My disclosures are none, except I took care of my first cardiac patient a long time ago in 1979, when angioplasty was two years old, so needless to say I've seen a lot of change. With that, I'm sharing Ryan's paper here that highlighted some of the findings from the Blue Cross Blue Shield Cardiovascular Consortium, and a key finding in the conclusion was in fact that other than left main PCI, the hospital and the physician were the main reasons or the strongest association with the use of intracoronary imaging. So it's those two factors that were the primary determinants. Now what's going on there? I'd say it has to do with operational performance, and we know that good operations, performance, the ability to perform something, and quality are closely intertwined. You can hold on to the tool, but if you don't use the tool, if you've got a gap in the ability to use the tool, if things don't go smoothly, it's just not going to happen. So it always starts with an individual. Whenever you go to change things, it always comes down to each person that's going to be affected by the change. These are likened to me as the four stages of grief, and that is like, oh, my gosh, why do we have to do this? This is not something I wanted to do. I don't like it. I wish we could go back. And then finally, like, well, maybe it's not so bad after all. So the first thing you always need to keep in mind is that even though you might be making organizational change, it starts with every individual that you deal with. So speaking to the individual and understanding where they're at is the first place. The other thing I'd say is it really starts with good leadership. If you don't have good leadership, it's also going to be difficult to have change in your system. So I would say those of you out there who might already be leaders or aspire to be leaders or wish to lead a change in your organization, to think of these in two ways. First, to help create that common purpose that helps people be motivated and able to change. Second, to create an engaging structure in which you say, this is why we need to do it. It's to maybe meet the quadruple aim. It improves quality, it improves patient experience, it makes it safer, and we have better outcomes. And also it's important for leaders to give people the tools they need to do their job. Making it easy, again, with the skills and the support and the right equipment is what allows you to get stuff done. Now, in terms of that influential leadership with change, there are really six factors, and I stole these from the book The Influencer, a really good book if you have time to pick it up and read. But the first thing is to make the undesirable desirable. So some level of personal motivation, again, this is your burning platform, and then correlate that with some intrinsic satisfaction. It's that internal sense of this is a reason why I need to do something. That's followed with a little bit of peer pressure. I've never met a cardiologist who isn't just a wee bit competitive. And so that's always a nice way in which you can kind of harness the energy of the group is to share data, give a little bit of peer accountability and competition. That starts with a leader who's able to get the attention of the group and to encourage them along the way. Always identify a champion, a peer champion is a good way to start. And I would say that peer champion needs to be both amongst the cardiologists as well as amongst the cath lab team. So having somebody who's in charge of leading the way, designing some rewards that meet the demand and that meet what you're requiring them to do, and then asking for accountability to that. So these could be monetary, they could be other things. Give people a team that supports them so it might be tied to a quality bonus. Give them a clear sense as this is what we want to achieve. We want to achieve a 20% improvement or something along those lines. But making sure it's clear what you're aiming for. And then you as an individual, if you're the leader, need also to engage in the change, to be an active demonstrator that it is possible. Get really good at it so you too can provide elbow to elbow support and provide feedback to others that are participating. Get strength in numbers, that is performance management. Create a culture of accountability. If you allow things to just slip by and say like, well, I guess it doesn't really matter, then everything centers toward the mean. And then finally, change the overall environment, making sure you reduce any friction, making sure if we're talking about intravascular imaging, you've got the equipment nearby, and that's not a matter of, oh, now I'm going to pull out an IVUS or an OCT catheter and somebody's got to go look for the console. In terms of how things get done, and I stole this, another one of Ryan's papers that comes from the BMC too, how did something like this happen? This shows reduction in radiation exposure during a several year period, but you'll see a dramatic reduction in the exposure of patients to radiation. It was really done with supported incremental change. Along the side, which is probably a little too small to read, our listing of the different safety initiative steps that we're taking, and this really comes down to what's referred to as ADCAR, and that's Awareness, Desire, Knowledge, Ability, and Reinforcement. It's providing people with the awareness and the desire to make a change. It's giving them the knowledge that they need. We just heard about a lot of examples, what we know is true of intravascular imaging. The ability is like, what are those skills I need in order to actually measure lesions, you know, understand where the position of the stent is, and then it's giving reinforcement, and that's feedback by way. These are your numbers. This is how you are doing. If we've asked you all to improve and you are not improving, help us to understand why. Is it a skills? Is it a concern with safety? What's the issue? So, feedback is extremely important. And then lastly, it's making sure that people really have those tools. This is commonly known within change as the tools, if there's any one thing missing, then you're not going to have lasting change. So, highlighted along the side is that when you have all of these elements in place, you really will be able to both achieve and sustain change. One of the key things I think that will oftentimes happen is that you say, like, we've got this great program, we're underway, we make a big effort, and then it falls flat because we fail to follow up. That's when you get your false start. So, making sure you provide, again, the information people need, the understanding of the why or the burning platform, give people the right sort of motivation, the resources, and then, again, the action plan or the feedback that they need. So, in summary, I'd just say the keys to success are really threefold, preparing and making sure you've got a plan, that is, have a champion that's going to help to lead the way in your organization, define success for the team, have an approach that says, this is how we will do it, we'll maybe include in the timeout that we're going to be using imaging today or the team says to the cardiologist, will we be using imaging today? So, create little prompts that help make it easier to succeed. You want to make that plan and then actually act on it, track performance and give feedback, because it is an iterative process. And then, finally, sustain those outcomes by being able to review performance, give an overview to leaders above yourselves in the division, hardwire your process, make it standard work, and then make sure you transfer ownership so that the leader is the one who can hand it off to somebody else for a more permanent change. So, thank you, I appreciate your attention. So, this is actually a good time to pause with me and just have a little bit of a panel discussion. So, you know, it's interesting. We set a goal for our health system at NYU to have at least 50% of our PCIs done using intercoronary imaging, and this was something that was very much supported by the administration. But you know, in my current role, where I do wear an administrative hat, the financial issues are real, and it's not about physician reimbursement, because I think, in general, our motivation is to do the right thing for the patients. But there is an issue where there's no hospital reimbursement for intercoronary imaging on the outpatient side. How much of a barrier do you think that really is, and, you know, do any of you have any speculation on whether that's changing over time? I'll make a comment. I don't know that that's the biggest barrier. I still think most physicians who aren't imaging, and they'll never admit this, I think it's because they don't know how. They don't know, you know, how to interpret the images. They don't know, you know, what to look for on the pre and the post. And so I think education is, you know, something that's going to have to be a prerequisite before, you know, we move the needle on this. And it could actually help to become more profitable for the hospital, because when you do intravascular imaging, aside from just getting a more accurate diagnosis, what often happens, the procedural complexity increases, and it raises the DRG. You know, this is something we talked about yesterday, where it can become a bifurcation lesion in calcified stenosis. And sometimes with that junk of tools that you end up treating, it ends up raising the reimbursement that offsets the cost of the imaging catheter. But yeah, I agree with Ryan. I don't think that's the real reason. It's often cited that it takes too long, there's no reimbursement, there's not enough data despite there being 22 randomized controlled trials that show a strong trend consistently favoring it. But I think there are excuses, and a lot of Ryan's data will help to support that, that once you have a real push to use this as a quality metric, there's real growth. Yeah, I think that's sort of the motivation behind this partnership between Sky and Metaximus. I actually leverage data to figure out where the imaging rates are low, identify those sites, and then create a coalition of the willing who are willing to actually participate in a strategy or a campaign to increase the use of intercoronary imaging. The challenge, of course, is that, you know, it's interesting when you look at the distribution of intercoronary imaging uptake, it tends to be very early career people who trained in a lab doing intercoronary imaging, and then oftentimes late career, because it makes sort of PCI interesting again. And we saw the same exact uptake of radial approach, for example, about a decade ago. And it's that sort of mid-career where it becomes a little bit challenging. And so, you know, getting those interventionists to admit that this is something that they need to start doing, and then admitting that they don't know what they're looking at is, I think, an important piece of that. Well, you know, one question is, I guess, how long does it take to actually change your practice? And do you need to go back to fellowship and do a whole year? Is this a, do you have to go to university? Or is this something that you can pick up when you go to a conference and do hands-on imaging training? You know, I think one example, Alex, maybe you could comment on, six months ago, how many times have you done a zero contrast PCI? And you know, Alex is someone who, you know, treats, she does complex PCI in her region, and has a lot of patients with CKD, and wanted to learn a new skill on how to do zero contrast PCI. And that's really just an intravascular imaging and physiology guided procedure. It's not, we don't have any special magical ways to do zero contrast PCI. It's using intravascular imaging. And you know, you could correct me if I'm wrong, but Alex came to a one-day course, and is now implementing this in her practice. Absolutely. And I think that I'm going to echo on what Ryan said. I have a different perspective, because I am from Canada, so reimbursement is not an issue. However, people are either, they don't know what they're looking at, they're scared of what they're going to find. And that being said, they will not image. I am probably the only person in my center, in the center of three people, who imaged more than 60% of her cases. And concerning the ultra low contrast PCI, this is an excellent example, because I spent what, eight hours at St. Francis, and look at me now, I'm not using contrast, and it changed our practice. I'm showing this to my colleagues, and it definitely changes the way we approach patients with severe CKD. And it's a trickle-down effect, too. Once you have one champion of it, people in your region, people in your lab, start to pick it up. And they come in, and they'll ask you questions. Wait, what am I looking at? Can you help me with this? And then, also, the techs and nurses are comfortable setting up the equipment, like what Rob was saying. That's a major barrier. So, no one uses it when there's inertia, but once people start picking this up, it spreads like wildfire. Yeah, I mean, my own personal story, I've told you many times, Evan, is I, in 2000, it was either 18 or 19, I came to the fellows course at OPCI, because I realized that I had actually very poor training in intercoronary imaging, and just sort of spending that day learning about it, and hands-on, really changed my practice, certainly.

intravascular imaging

healthcare settings

implementation strategies

change management

education and feedback