The rise and fall of medical technologies

When does one recognize that horse-and-buggy whips are in decline and auto-mobiles are on the rise?

When does one recognize that a new technology is a definite advance over established ones in the treatment of particular disease, in cost or quality?

Technologies go through life cycles.

A medical technology is introduced that is found effective in the management of a disease. Over time, the technology is improved upon marginally, but eventually a new technology, often radically different, emerges that is more effective or better (cheaper, less invasive, easier to use). It enters the market, takes market share from and grows, only to be later eclipsed by a new (apologies) “paradigm”. Each new technology, marginal or otherwise, advances the limit of what is possible in care.

Predicting the marginal and the more radical innovation is necessary to illustrate where medicine is headed, and its impact. Many stakeholders have interest in this — insurance companies (reimbursing technologies or covering the liabilities), venture capitalists, healthcare providers, patients, and the medical technology companies themselves.

S-curves illustrate the rise in performance or demand over time for new technologies and show the timing and relative impact of newer technologies when they emerge. Importantly, the relative timing and impact of emerging technologies can be qualitatively and quantitatively predicted. Historic data is extremely useful predicting the rise and fall of specific medical technologies in specific disease treatment.

Following are two examples of diseases with multiple technologies arcing through patient demand over time.

  • Ischemic Heart Disease Past, Current, and Future Technologies
    • Open bypass
    • Percutaneous transluminal coronary angioplasty
    • Minimally invasive direct coronary artery bypass (MIDCAB)
    • Percutaneous CABG
    • Stem-cell impregnated heart patches

The treatment of ischemic heart disease, given the seriousness of the disease and its prevalence, has a long history in medicine and within the past fifty years has a remarkable timeline of innovations. Ischemia is condition in which inadequate blood flow to an area due to constriction of blood vessels from inflammation or atherosclerosis can cause cell death. In the case of cardiac ischemia, in which the coronary arteries that supply the heart itself with blood are occluded, the overall cell death can result in myocardial infarction and death.

The effort to re-establish adequate blood flow to heart muscle has evolved from highly invasive surgery in which coronary artery bypass graft (CABG) requires cutting through the patient’s sternum and other tissues to access the heart, then graft arteries and/or veins to flow to the poorly supplied tissue, to (2) minimally invasive, endoscope procedures that do not require cutting the sternum to access the heart and perform the graft and significantly improve healing times and reduced complications, to as illustrated, multiple technologies rise and fall over time with their impacts and their timing considered.

Technology S-Curves in the Management of Ischemic Heart Disease

(Note: These curves are generally for illustrative purposes only; some likely dynamics may not be well represented in the above. Also note that, in practice, demand for old technologies doesn’t cease, but declines at a rate connected to the rise of competing technologies, so after peaking, the S-curves start a descent at various rates toward zero. Also, separately note that the “PTCA” labeled curve corresponds to percutaneous transluminal coronary angioplasty, encompassing the percutaneous category of approaches to ischemic heart disease. PTCA itself has evolved from balloon angioplasty alone to the adjunctive use of stents of multiple material types with or without drug elution and even bioabsorbable stents.)
Source: MedMarket Diligence, LLC

Resulting Technology Shifts

Falling: Open surgical instrumentation, bare metal stents.
Rising and leveling: thoracoscopic instrumentation, monitors
Rising later: stem-cells, extracellular matrices, atherosclerosis-reducing drugs
Rising even later: gene therapy

The minimally invasive technologies enabled by thoracoscopy (used in MIDCAB) and catheterization pulled just about all the demand out of open coronary artery bypass grafting, though the bare metal stents used initially alongside angioplasty have also been largely replaced by drug-eluting stents, which also may be replaced by drug-eluting balloon angioplasty. Stem cells and related technologies used to deliver them will later represent new growth in treatment of ischemia, at least to some degree at the expense of catheterization (PTCA and percutaneous CABG). Eventually, gene therapy may prove able to prevent the ischemia to develop in the first place.

  • Wound Management Past, Current, and Future Technologies
    • Gauze bandages/dressings
    • Hydrogel, alginate, and antimicrobial dressings
    • Negative pressure wound therapy (NPWT)
    • Bioengineered skin substitutes
    • Growth factors

Another great example of a disease or condition treated by multiple evolving technologies over time is wound management, which has evolved from simple gauze dressings to advanced dressings, to systems like negative pressure wound therapy, hyperbaric oxygen and others, to biological growth factors to bioengineered skin and skin substitutes.

Technology S-Curves in the Management of Ischemic Heart Disease

Source: MedMarket Diligence, LLC

Resulting Technology Shifts

Falling: Traditional gauze and other simple dressings
Falling: NPWT, hyperbaric oxygen
Rising: Advanced wound dressings, bioengineered skin, growth factors

Wound management has multiple technologies concurrently available, rather than sequential (when one largely replaces the other) over time. Unsurprisingly, traditional dressings are in decline. Equipment-related technologies like NPWT and hyperbaric oxygen are on the wane as well. While wound management is not a high growth area, advanced dressings are rising due to their ability to heal wounds faster, an important factor considering that chronic, slow-healing wounds are a significant contributor to high costs. Bioengineered skin is patient-specific, characterized by faster healing and, therefore, rising.

Medical and Surgical Sealants, Glues, and Hemostats, to 2022

There are several different classes of surgical sealants, glues and hemostatic products used to prevent or stop bleeding, or to close a wound or reinforce a suture line. These include fibrin sealants, surgical sealants, mechanical hemostats, active hemostats, flowable hemostats, and glues. Both sealants and medical glues are increasingly used either as an adjunct to sutures or to replace sutures.

Medical Sealants

Fibrin sealants are made of a combination of thrombin and fibrinogen. These sealants may be sprayed on the bleeding surface, or applied using a patch. Surgical sealants might be made of glutaraldehyde and bovine serum albumin, polyethylene glycol polymers, and cyanoacrylates.

Sealants are most often used to stop bleeding over a large area. If the surgeon wishes to fasten down a flap without using sutures, or in addition to using sutures, then the product used is usually a medical glue.

Source: MedMarket Diligence, LLC; Report #S290.

Hemostatic Products

The surgeon and the perioperative nurse have a variety of hemostats from which to choose, as they are not all alike in their applications and efficacy. Selection of the most appropriate hemostat requires training and experience, and can affect the clinical outcome, as well as decrease treatment costs. Some of the factors that enter into the decision-making process include the size of the wound, the amount of hemorrhaging, potential adverse effects, whether the procedure is MIS or open surgery, and others.

Active hemostats contain thrombin products which may be derived from several sources, such as bovine pooled plasma purification, human pooled plasma purification, or through human recombinant manufacturing processes. Flowable-type hemostats are made of a granular bovine or porcine gelatin that is combined with saline or reconstituted thrombin, forming a flowable putty that may be applied to the bleeding area.
Mechanical hemostats, such as absorbable gelatin sponge, collagen, cellulose, or polysaccharide-based hemostats applied as sponges, fleeces, bandages, or microspheres, are not included in this analysis.

Source: MedMarket Diligence, LLC; Report #S290.

Medical Glues

Sealants and glues are terms which are often used interchangeably, which can be confusing. In this report, a medical glue is defined as a product used to bond two surfaces together securely. Surgeons are increasingly reaching for medical glues to either help secure a suture line, or to replace sutures entirely in the repair of soft tissues. Medical glues are also utilized in repairing bone fractures, especially for highly comminuted fractures that often involve many small fragments. This helps to spread out the force-bearing surface, rather than focusing weight-bearing on spots where a pin has been inserted.

Thus, the surgeon has a fairly wide array of products from which to choose. The choice of which surgical hemostat or sealant to use depends on several factors, including the procedure being conducted, the type of bleeding, severity of the hemorrhage, the surgeon’s experience with the products, the surgeon’s preference, the price of the product and availability at the time of surgery. For example, a product which has a long shelf life and does not require refrigeration or other special storage, and which requires no special preparation, usually holds advantages over a product which must be mixed before use, or held in a refrigerator during storage, then allowed to warm up to room temperature before use.

Source: MedMarket Diligence, LLC; Report #S290.

From “Worldwide Market for Medical and Surgical Sealants, Glues, and Hemostats, 2015-2022.” See details at link. Order online.