Cover Story | Radial access continues to gain more of a grip; the looming shortage of cardiologists shows no sign of resolving; and if you're going to be overworked, maybe you'll at least be able to get more done with Google Glass...

The sky was the limit at the Society for Cardiac Angiography and Interventions (SCAI) 2014 Scientific Sessions. CardioSource WorldNews: Interventions reports on some of the innovative and practice-changing highlights from the meeting.

Radial Expands
A new study led by Michael Howe, MD, University of Michigan Cardiovascular Center in Ann Arbor, analyzed how often radial or femoral access was used during primary percutaneous coronary intervention (PPCI) across 44 hospitals in Michigan from January 2010 through June 2013. In early 2010, less than 1% of patients treated with PPCI had radial artery access, but by mid-2013 that rate had grown to 14.2%.

The study cohort comprised 108,060 PCI procedures, of which 14,780 (13.7%) patients presented with ST-elevation myocardial infarction (STEMI). Of these STEMI patients, 993 (6.72%) underwent PCI via radial approach, but the rate of use increased substantially over the study period. Those treated via radial access experienced half the rate of bleeding complications compared with patients treated with femoral artery access (2.42% vs. 5.62%) and less than two-thirds the likelihood of needing a blood transfusion (3.42% vs. 5.3%). There was no significant difference in in-hospital mortality (1.51% vs. 2.34%).

Dr. Howe noted that adoption of radial artery access was growing about twice as fast in patients undergoing non-emergency PCI: 2.2% in early 2010 increasing to 27.5% by mid-2013.

Tight and Tighter
The common wisdom at the end of the 20th century: the United States was producing too many specialists, including cardiologists. The rapid growth of for-profit managed care, with its gatekeeper model and other obstacles to specialty services, was transforming the medical landscape. At the same time, the Clinton administration was promoting an ambitious plan to reform health care delivery that emphasized primary rather than specialty care.

Acknowledging that predicting the future is fraught with peril, the 1993 ACC Bethesda Conference report concluded: "The cardiovascular community should adopt the general concept that the numbers of adult cardiology trainees be decreased."¹ Subsequently, resources started to shift to educate more primary care practitioners. Ten years later, however, the situation had changed dramatically and the 2004 Bethesda Conference struggled with the implications of a growing shortage of cardiologists.² These concerns have had legs and now, yet another 10 years down the road, the conversation continues.

In many parts of the United States, there aren't enough interventional cardiologists for all of the patients who need them, a problem that could worsen in the future unless critical steps are taken to change the way doctors are trained. At SCAI 2014, ACC President Patrick O'Gara, MD, addressed the cardiologist shortage, noting "If we are unable to restore the cardiovascular workforce to the numbers needed, patients' access to quality care could be threatened."

He cited several factors contributing to this problem:

• A growing supply/demand gap: An aging population, scientific advances, and the anticipated effects of the Affordable Care Act all create the need for more cardiologists, not fewer.
• The gender gap in cardiology: Although women make up slightly more than half of medical school graduates, fewer than one in five cardiovascular specialists are women, a ratio that shrinks to one in 10 among interventional cardiologists.
• An ethnic/racial gap: Hispanics and African Americans are particularly under-represented in cardiology.
• Marked geographic variations across the United States: Many cardiologists practice in major metropolitan areas, while smaller towns and rural areas have limited access to cardiovascular care.

"These are not easy problems to fix," said Dr. O'Gara. "Unfortunately, it is not as simple as just increasing the number of medical school graduates. We need to take a step back and ask the question, 'Where are we going with the current training and distribution of cardiovascular specialists in the United States?'"

One possible solution, he noted, is to revamp Medicare-based funding of residencies and fellowships that lead to careers in cardiology and interventional cardiology. Another important step could be to improve funding for research into heart disease, as this would strengthen academic medical programs—the training ground for all cardiovascular specialists.

Just Google It
With the dearth of interventional cardiologists, everyone will undoubtedly work harder, but with recent advances in wearable technology it may at least be possible to work smarter. The concept of heads-up monitors has been kicking around for the last 20 years, but the designs were impractical and clunky. Even Google's prototype Glass weighed 8 pounds; now it's lighter than an average pair of sunglasses.

Enter the streamlined Google Glass, and what better target audience than interventional cardiologists and radiologists, who are used to craning their necks to look at displays that help guide their every move?

In a first-of-its-kind special session, SCAI 2014 presented an in-depth look at Google Glass, exploring the concept of wearable technology in medicine, how interventional cardiologists are already using it to transform education, and both the challenges and opportunities for future, more widespread use.

To underscore the timeliness of the SCAI session, just 1 week before attendees convened in Las Vegas, the University of California Irvine Medical School suggested that Google Glass is the new iPad. A few years ago, it was among the first medical schools to issue iPads to its students, now it will have a total of 30 to 40 Glass units on hand: 10 for third- and fourth-year students to use in the operating room and emergency department and the rest for first- and second-year students to use in the classroom.

They are piloting the wearable computer in "operating rooms, intensive care units, and the emergency department in order to assess its impact on physician efficiency and patient safety," according to a release from the university. In the classroom, Glass will allow professors to transmit first-person recordings of medical procedures or examinations to their class. Students will also be able to use Glass for their coursework, potentially having a faculty member provide guidance to a student in real time. Students will use Glass in anatomy labs, the medical simulation center, the ultrasound institute, the clinical skills center, and even the basic science lecture hall. Another potential application: giving Glass to patients to record the visit from their perspective, allowing students to learn more about the patient experience.

"Medical education has always been very visual and very demonstrative, and Glass has enormous potential to positively impact the way we can educate physicians in real time," said Warren Wiechmann, MD, assistant clinical professor of emergency medicine and associate dean of instructional technologies, in a release from the university. "Indeed, all of medicine is based on 'seeing,' not 'reading,' the patient."

Morton J. Kern, MD, SCAI 2014 program director and co-moderator of the session, said "We are at an exciting point in our profession, where we are discussing a technology whose potential uses can transform the work we do, from the care we provide patients to the education we share with one another."

"Just as smartphones have transformed our everyday lives in ways we once thought unimaginable, it is hard to imagine the effect the next technology phase will have," added session co-moderator Barry F. Uretsky, MD.

Wearable, Hearable, "Watch-able," and Useful!
Cecilia Abadie, a software developer, said in her presentation at SCAI that Google scaled back expectations and actually developed a comfortable device that "you can wear all day." Not that you should: she was the first motorist cited for "driving under the influence of Google." However, the San Diego court threw out the case when the officer could not provide proof beyond a reasonable doubt that the device was in operation.

Mark it as the first shot across the bow of wearable computers but it won't be the last as 30,000 Glass Explorers test the new technology in the real world and as Google plans to bring the devices to the public later in the year. Speaking of the legal aspects of Google Glass, in order to make their Glass program HIPAA compliant, UC Irvine is working with Pristine, one of several Google Glass-focused startups.

Watching her presentation at SCAI 2014, clearly Ms. Abadie's run-in with the law has done nothing to dampen her enthusiasm. Of all the device components, she said, "the most magical part of Google Glass has to be the display that is like watching a floating screen up in the air." Now, Google Glass also can be paired with prescription lenses.

"We're trying to get away from looking down," she said, which is a hazard in the real world where looking down can bring texters and their screen-locked eyes into dangerous situations. Google Glass represents a more immersive technology that is highly personal, with future versions taking on more of a personal assistant role.

In an effort to create an ever-more natural interface, Google Glass already responds to voice commands, and may eventually pair with a "hearable" or smart earpiece that can interact with you. In a sense, voice will become the new touch, permitting hands-free commands—for example, an earpiece may connect you to a trainer or an outside expert, who could be just beyond the cath lab doors or on the other side of the planet. Within a month or so, Google will start manufacturing a new generation of iWatches that may further enhance what Ms. Abadie calls context augmentation; the technology is not meant to augment reality, like gaming glasses, but rather augment the moment, helping you seamlessly and then standing by for the next command.

Homero Rivas, MD, MBA, Stanford University's director of innovative surgery, demonstrated how emergency medical technicians using Google Glass can share vitals and an image of the patient to the Google Glass of the physician who will be treating them in just minutes. During interventions, he said, the Glass screen can show patient vitals, real-time or recorded electrocardiograms, and a nearby imaging screen, as well as take a photo for later reference or video tape a procedure.

Dr. Rivas said wearable computers can offer

• just-in-time references
• remote training
• clinical simulation
• collaborative learning
• safety checklists
• a "cheat sheet" to assist in learning new techniques or procedures
• patient education and engagement

In general, he said, "wearable technologies will be transformational across a vast variety of industries." Sure, he noted, there will be privacy concerns, cost implications, and technological limitations versus expectations—especially in the beginning.

Heather Evans, MD, an assistant professor of surgery at the University of Washington, did tap the brakes a bit, noting that various issues must be addressed before adopting Glass in your hospital. "We are innovators and explorers and we have been running up against problems since before we even got the device," she said. One potentially Glass-shattering concern: Does it pose a safety problem for you or your patient? It is inherently a distraction, said Dr. Evans, whether it's the response of people seeing you wear the device or to the technology itself which, at the moment, she said, "is a solution looking for a problem." That's why she and other Explorers are trying to find novel ways to incorporate the technology into day-to-day practice.

Wearing Glass creates a loss of "situational awareness," as Dr. Evans calls it, even if it is just for those few microseconds while you give a command or check the screen, and IT guys may have the same concerns. Indeed, Dr. Evans said, "This is your IT guy's nightmare; this device has not been vetted, we do not know what its interoperability is, we don't know whether we can keep it secure." It has about 16 gigabytes of storage space, which can include a lot of non-HIPPA compliant information. That information lives not only on your specific device, but the automatic back-up feature sends everything to the cloud. You have no control over when that happens, she said, and that's an issue that has to be overcome. Admittedly, some start-ups are working on encryption questions.

At the University of Washington, they are collaborating with a vendor to provide encryption for the device, which is being used in the emergency department to evaluate burn patients and do telemedicine, but Dr. Evans explained, it's a very narrow encrypted data stream, and there will be no other functionality on the devices. "We've been able to work this out with our IT folks because we have really constrained the device."

Christian Assad-Kottner, MD, University of Arkansas for Medical Sciences, recently authored in JACC a case report of a cardiovascular procedure using Google Glass and 'tele-mentoring,' where an expert was consulted to assist in the procedure.³ Said Dr. Assad-Kottner at SCAI, "We have entered an interconnected era where telemedicine, telehealth, and telementoring will play a crucial role in patient care."

If you doubt that, just ask UC Irvine. But the Glass experience today is more akin to your first cell phone. As updates and new versions emerge, it will become more like the smartphone; much more useful than your first cell phone, even maybe eventually replacing what we'll think of as that old-fashioned iPhone we all used to carry around.

References

1. Ritchie JL, Cheitlin MD, Hlatky MA, Ryan TJ, Williams RG; Task Force 5. J Am Coll Cardiol. 1994;24:313-21.
2. Fye W. J Am Coll Cardiol. 2004;44:221-232.
3. Assad-Kottner C, Hakeem A, Fontenot E, Uretsky BF. J Am Coll Cardiol. 2014;63:1022.

Keywords: CardioSource WorldNews Interventions

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