Interventional radiology is at a critical juncture. In many medical centers, demand is high and ability to deliver is limited—as is space for new technology.
CT scanners were paid for and deployed in an era when the questions were two-fold: “Is it cancer?” and “What type of cancer is it?” In today’s clinical trials, there is an increasing demand for more frequent biopsies and tissue analysis, driven by the need to advance immunotherapies and biomarkers. The addition of CT scanners remains cost and space prohibitive for medical centers and radiology departments. Furthermore, labor shortages among technologists, nurses and proceduralists would limit utilization even if additional technology could be deployed.
Endovascular procedures like prostate artery embolization (PAE) are available to patients with access to highly specialized medical centers but remain elusive to those in settings where specialists are not available. At times, critically ill patients who may need experienced proceduralists are too sick to reach the specialized medical center for an embolization (or a global pandemic triggers resource limitations and inability to transfer patients). All this demand is occurring in the setting of burnout among healthcare workers and social events like “quiet quitting.”
In short, how do we provide more IR services to more patients more efficiently and more effectively without adding any resources or increasing risk of burnout or adverse event?
The potential for robotics
The current pace of healthcare mandates the development of a new platform technology that would address these clinical needs. Medical robotics has the potential to reflect that platform.
Figure 1. The likelihood of adoption of new platform technology like medical robotics in IRcan be defined by the equation represented. This formula should drive quality metrics inevaluating new technology and providing standardization for the literature.
Previous devices have entered the market but have failed to gain widespread utilization. This can be attributed, in part, to their exorbitant costs, large device footprint, significant learning curves to successful utilization, cultural inertia to adoption and absence of well-defined needs-driven problem statements for which the technology is being deployed.
To be effective, medical robotic technology must address what is described as the “core four” needs:
- Automation: mitigating frequent labor-intensive or inconsistent tasks
- Augmentation: improving human capabilities of focus, attending, fine-motor movement, degrees of freedom and capabilities
- Democratization: ensuring consistent high-quality delivery of procedural technique/therapy regardless of operator, experience, location, or patient
- Trailblazing: creating new diagnostic or therapeutic options for patients by altering the risk/benefit ratio
We define two subcategories of medical robotics in IR: 1) percutaneous and 2) endovascular. Presently, our institution has deployed a percutaneous robot for CT-guided procedures and has done extensive research on the utilization of endovascular robots.
Robotics in action: What’s the measure of success?
As medical robotics are deployed in IR and image-guided medicine, it is crucial that institutions develop standardized systems for evaluating the impact of this technology on practice. As demonstrated in Figure 1, the likelihood of adoption is directly related to the pain of the current state and the speed of visualization of impact over the friction of adoption and the unexpected outcome rate.
- Pain of the current state: This concept is best defined as the clinical-needs driven problem statement. This could include the four targets of medical robotics as previously defined. Given the current state of IR as described above, the most pressing concern is the ability to perform more with the same or fewer resources effectively and safely. Thus, metrics measured should include number of procedures, procedure and table time, radiation dose, and the amount of time proceduralists wear lead.
- Speed of visualization of impact: This concept emphasizes the importance of a dashboard to provide feedback updates. If a robot was deployed for a specific or primary reason (such as improved efficiency/optimization), proceduralists must receive feedback about the deployment impact on this outcome in a timely manner. The longer it takes for this feedback to be provided, the greater the costs to deployment without understanding effect and the more likely users will become despondent. These metrics should also include measures of technical and clinical success, with comparisons to the “pre-robotic” state.
- Friction of adoption: This concept epitomizes the “learning curve” to the platform technology. One feature that needs to be addressed specifically for any highly skilled proceduralists involves assessing how different this technology is from the current state. Can an endovascular robot be controlled like a normal guidewire until the challenge is reached or must it be controlled in a completely different manner from the start? How complex is the setup, use and breakdown? The technology may be very frustrating to an experienced proceduralist in the first use or first several uses. How many times, on average, does it take to reach “steady-state” optimization? Every proceduralist, as well, has a threshold of tolerance of what it takes to reach that steady state.
- Unexpected outcome rate: This concept involves assessing the adverse event rate with use of medical robotics compared to the rate with conventional approaches. It also involves addressing how often the new platform technology does not function as expected (such as if the robot stops working mid-procedure and what is required to convert the procedure to a conventional approach).
Conclusion
In summary, IR and image-guided medicine are poised to embark on a new era of medical robotics, directed at the challenges we face but inspired by the opportunities it creates to provide new access and opportunities for patients. Integration into practice will take culture change with buy-in from all key stakeholders (physicians, residents, advanced practice providers, administrators, technologists and nurses). Emphasis of clinical needs will ensure timely and effective use of this platform technology.
