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I professionisti e l'HTA al 4° Congresso della SIHTA, Udine, 17-19 novembre 2011

I professionisti e l'HTA al 4° Congresso della SIHTA, Udine, 17-19 novembre 2011

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  • Impact of Health Care Performance Measurements on the Development of Health Technology Assessment at the Micro, Meso, and Macro Levels David J. Ballard, MD, PhD, MSPH, FACPSenior Vice President and Chief Quality Officer Baylor Health Care System Dallas, Texas, USA4th National Conference of the Italian Society of Health Technology Assessment Udine, Italy November 19, 2011
  • Overview  Definition of terms: micro, meso, and macro levels  Meaning of these terms as they relate to health care and health technology assessment (HTA)  Baylor Health Care System context  Definition of STEEEP  Example of isolated coronary artery bypass surgery (CABG)  Health policy implications of information generated at the micro, meso, and macro levels 2 ©2009 Baylor Health Care System
  • Definition of Terms   Micro Describes the daily actions and interactions of individual people in society   Meso Describes organizations and institutions that are on a medium level between the micro and macro levels   Macro Examines how institutions within a large population interrelate and affect people in these populationsSource: AppliedSoc.org. An Introduction to Sociology Today. http://appliedsoc.org/. Accessed 02 June 2011. 3 ©2009 Baylor Health Care System
  • Overview  Definition of terms: micro, meso, and macro levels  Meaning of these terms as they relate to health care and health technology assessment (HTA)  Baylor Health Care System context  Definition of STEEEP  Example of isolated coronary artery bypass surgery (CABG)  Health policy implications of information generated at the micro, meso, and macro levels 4 ©2009 Baylor Health Care System
  • Definition of Terms as They Relate to Health Care  Micro Individual practitioners and patients  Meso Health care organizations and institutions  Macro Population and health policy level 5 ©2009 Baylor Health Care System
  • “Natural History” of Health Technology Assessment (HTA)  Emergence Focus on developing an initial capacity to meet modest demands from a small group of like-minded decision makers  Consolidation HTA transitions from a venture investment by health care systems to an operational feature  Expansion The need for HTA becomes widely recognized and promoted by high-level figures at the government or policy levelSource: Battista RN and Hodge MJ. The “natural history” of health technology assessment. International Journal of 6Technology Assessment in Health Care. 2009; 25 (Supplement 1): 281-284. ©2009 Baylor Health Care System
  • Overview  Definition of terms: micro, meso, and macro levels  Meaning of these terms as they relate to health care and health technology assessment (HTA)  Baylor Health Care System context  Definition of STEEEP  Example of isolated coronary artery bypass surgery (CABG)  Health policy implications of information generated at the micro, meso, and macro levels 7 ©2009 Baylor Health Care System
  • Texas Map Dallas-Fort Worth Metroplex: Location of Baylor Health Care System 8 ©2009 Baylor Health Care System
  • Baylor Health Care System•  Integrated health care system in north Texas –  26 owned, leased, ventured, and affiliated hospitals –  23 joint ventured ambulatory surgical centers –  50 satellite outpatient locations –  4 senior centers –  525 employed physicians in the BHCS affiliated physician network, HealthTexas Provider Network•  22,000 employees•  2.6 million patient encounters per year•  130,000 admissions per year•  $4 billion net operating revenue 9 ©2009 Baylor Health Care System
  • Definition of Terms as They Relate to Baylor Health Care System  Micro 43 cardiac surgeons who performed 2218 coronary artery bypass graft surgeries within BHCS (some of these surgeons performed procedures at non-BHCS hospitals) in calendar year 2010  Meso 6 BHCS hospitals that perform cardiac surgery: Baylor University Medical Center, The Heart Hospital Baylor Plano, Baylor All Saints Medical Center, Baylor Medical Center Garland, Baylor Regional Medical Center Grapevine, Baylor Medical Center Irving; 2218 cardiac surgical procedures performed in calendar year 2010  Macro In Dallas-Fort Worth 4,424 coronary artery bypass surgeries were performed in calendar year 2009 (we have surgeons at BHCS who also work across multiple non-BHCS hospitals) 10 ©2009 Baylor Health Care System
  • Overview  Definition of terms: micro, meso, and macro levels  Meaning of these terms as they relate to health care and health technology assessment (HTA)  Baylor Health Care System context  Definition of STEEEP  Example of isolated coronary artery bypass surgery (CABG)  Health policy implications of information generated at the micro, meso, and macro levels 11 ©2009 Baylor Health Care System
  • Health Care Quality  Safe – avoiding injury to patients from care that is intended to help them  Timely – reducing waits and harmful delays  Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding overuse and underuse)  Equitable - providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographical location, and socioeconomic status  Efficient – avoiding waste  Patient Centered - providing care that is respectful of and responsive to individual patient preferences, needs, and valuesSource: Institute of Medicine. Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001. 12 ©2009 Baylor Health Care System
  • Overview  Definition of terms: micro, meso, and macro levels  Meaning of these terms as they relate to health care and health technology assessment (HTA)  Baylor Health Care System context  Definition of STEEEP  Example of isolated coronary artery bypass surgery (CABG)  Health policy implications of information generated at the micro, meso, and macro levels 13 ©2009 Baylor Health Care System
  • STEEEP Applied to Coronary Artery Bypass Graft (CABG) Surgery: Examples  Safe – Mortality rates  Timely – Post-operative ventilation time  Effective – Use of internal mammary artery  Equitable – Mortality rates by race  Efficient – Hospital length of stay  Patient Centeredness – Patient satisfaction rates 14 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe X TimelyEffectiveEquitableEfficient PatientCentered 15 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Micro (Individual Surgeon) Level: Safety 2010 Isolated CABG - Volume and Observed Mortality 100,0 120 90,0 100 80,0 70,0Mortality Percentage 80 60,0 Volume 50,0 60 40,0 40 30,0 20,0 20 10,0 0,0 0 87 2 67 56 41 50 14 12 85 75 49 54 16 46 44 51 61 8 57 6 77 47 33 45 53 55 79 3 48 83 31 35 5 43 13 7 Volume Observed Mortality 16 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Micro (Individual Surgeon) Level: Safety 2010 Isolated CABG - Volume and Risk Adjusted Mortality 40,0 120 35,0 100Mortality Percentage 30,0 80 Volume 25,0 20,0 60 15,0 40 10,0 20 5,0 Society  of  Thoracic  Surgeons  =  1.9   0,0 0 87 2 67 56 41 50 14 12 85 75 49 54 16 46 44 51 61 8 57 6 77 47 33 45 53 55 79 3 48 83 31 35 5 43 13 7 17 Volume RAM ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe Timely XEffectiveEquitableEfficient PatientCentered 18 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Micro (Individual Surgeon) Level: Timeliness 2010 Isolated CABG - Volume and Average Post Operative Ventilation Hours 500 120 450Post-Operative Ventilation Hours 100 400 350 80 Volume 300 250 60 200 40 150 100 20 50 0 0 87 2 67 56 41 50 14 12 85 75 49 54 16 46 44 51 61 8 57 6 77 47 33 45 53 55 79 3 48 83 31 35 5 43 13 7 Volume PostOp Vent Hrs 19 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffective XEquitableEfficient PatientCentered 20 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass (CABG) Surgery at Micro (Individual Surgeon) Level: Effectiveness 2010 Isolated CABG Internal Mammary Artery Use and Volume 100% 120 90% 100Internal Mammary Artery Use 80% 70% 80 60% Volume 50% 60 40% 40 30% 20% 20 10% 0% 0 87 2 67 56 50 41 14 12 85 75 54 49 46 16 51 44 61 8 57 6 77 47 33 45 53 55 79 3 48 83 31 35 5 43 13 7 Volume IMA Usage 21 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitable XEfficient PatientCentered 22 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass (CABG) Surgery at Micro (Individual Surgeon) Level: Equity  Mortality rates by race at the surgeon level may not be informative due to the small number of patients across different racial groups  While the probability of other patient characteristics (e.g., socioeconomic status) related to CABG surgery may be meaningful, we do not have this data 23 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitableEfficient X PatientCentered 24 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass (CABG) Surgery at Micro (Individual Surgeon) Level: Efficiency 2010 Isolated CABG Average Post Operative Length of Stay (LOS) and Volume 12 120Post-Operative Length of Stay (Days) 10 100 8 80 Volume 6 60 4 40 2 20 0 0 2 87 56 41 50 12 14 85 75 49 54 16 46 44 51 61 8 57 6 77 47 33 45 53 55 79 3 48 83 31 35 5 43 13 7 25 Volume PostOp LOS (days) ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitableEfficient Patient XCentered 26 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass (CABG) Surgery at Micro (Individual Surgeon) Level: Patient Centeredness CABG Patient Satisfaction Likelihood to Recommend Mean Score: A Hypothetical Example 100,0 120 90,0 100 80,0Likelihood to Recommend Score 70,0 80 60,0 Volume 50,0 60 40,0 40 30,0 20,0 20 10,0 0,0 0 87 2 67 56 41 50 14 12 85 75 49 54 16 46 44 51 61 8 57 6 77 47 33 45 53 55 79 3 48 83 31 35 5 43 13 7 27 Volume Likelihood to Recommend Mean Score ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe X TimelyEffectiveEquitableEfficient PatientCentered 28 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Meso Level: Safety 2010 All Isolated CABG - Risk Adjusted Mortality Rates 5 4.1 4 3.3 3Percentage 2.6 2.5 2.2 2 Society of Thoracic Surgeons = 1.9 1 0.0 0 Irving Garland Grapevine BASMC BUMC THHBP Hospital (N=4/149)   29 (N=1/57)   (N=0/64)   (N=3/94)   (N=10/340)   (N=7/408)   ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe Timely XEffectiveEquitableEfficient PatientCentered 30 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Meso Level: Timeliness 2010 Isolated CABG Average Total Post Operative Ventilation Hours 40 35 33,8 30 25 21,2Hours 20 17,5 Society  of  Thoracic  Surgeons  =  20.6   14,8 15 10,8 9,5 10 5 0 Irving Garland Grapevine BASMC BUMC THHBP Hospital (N=149)   31 (N=57)   (N=64)   (N=94)   (N=340)   (N=408)   ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffective XEquitableEfficient PatientCentered 32 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Meso Level: Effectiveness 2010 All Isolated CABG Internal Mammary Artery Use By Hospital (re-operations excluded from denominator) 100% 96,8% 98,2% 96,8% 95,3% 90% 90,9% 89,1% Society  of  Thoracic  Surgeons  =  95.0%   80% 70% 60%Percent 50% 40% 30% 20% 10% 0% Irving Garland Grapevine BASMC BUMC THHBP Hospital (N=142/149)   33 (N=51/55)   (N=61/63)   (N=82/94)   (N=318/323)   (N=365/377)   ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitable XEfficient PatientCentered 34 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Meso Level: Equity 2010 Isolated CABG Mortality Percentage by Race: p-value = 0.273,50%3,25%3,00%2,75%2,50%2,25%2,00%1,75%1,50%1,25%1,00%0,75%0,50%0,25%0,00% N = 20/877 N = 5/232 White Other 35 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitableEfficient X PatientCentered 36 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Meso Level: Efficiency 2010 All Isolated CABG Average PostOp Length Of Stay 7 6,9 Society  of  Thoracic  Surgeons  =  6.8   6,8 6,6 6,5 6,4 6,3 6,2Days 6 5,9 5,8 5,8 5,8 5,6 5,4 5,2 Irving Garland Grapevine BASMC BUMC THHBP 37 Hospital ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitableEfficient Patient XCentered 38 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Meso Level: Patient Centeredness BHCS Cardiovascular Patient Satisfaction “Likelihood to Recommend” FY10100 90 80 70 60 50 40 30 20 10 0 Baylor Medical Center Baylor Medical Center Baylor All Saints Medical Baylor Regional Medical Baylor University Medical The Heart Hospital Irving (N=272) Garland (N=280) Center (N=369) Center Grapevine Center (N = 570) Baylor Plano (N=1067) (N=452) 39 Mean Score Percentile Ranking ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe X TimelyEffectiveEquitableEfficient PatientCentered 40 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery atMacro (Texas) Level: Safety 41 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery atMacro (Texas, Dallas-Fort Worth, and BHCS)Level: Safety 42 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe Timely XEffectiveEquitableEfficient PatientCentered 43 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Macro (BHCS and US) Level: Timeliness 2010 Isolated CABG Average Total Post Operative Ventilation Hours 30 20,6 19,6 20 Hours 10 0 BHCS Overall United States 44Note: Data at DFW hospital level is not available. ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffective XEquitableEfficient PatientCentered 45 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Macro (BHCS and US) Level: Effectiveness 2010 Isolated CABG Internal Mammary Artery Usage (excludes re-operations)100,0%90,0% 96,0% 95,0%80,0%70,0%60,0%50,0%40,0%30,0%20,0%10,0% 0,0% BHCS Overall United StatesNote: Data at DFW hospital level is not available. 46 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitable XEfficient PatientCentered 47 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery atMacro (Texas, Dallas-Fort Worth, and BHCS)Level: Equity 48 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitableEfficient X PatientCentered 49 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery atMacro (Texas, Dallas-Fort Worth, and BHCS)Level: Efficiency 50 ©2009 Baylor Health Care System
  • Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality Micro Meso Macro Safe TimelyEffectiveEquitableEfficient Patient XCentered 51 ©2009 Baylor Health Care System
  • Isolated Coronary Artery Bypass Surgery at Macro (BHCS, Texas, and US) Level: Patient Centeredness Facility % Definitely Would Recommend All Facilities in US 70% All Facilities in Texas 71% Baylor Medical Center Irving 78% Baylor Medical Center Garland 73% Baylor All Saints Medical Center 82% Baylor Regional Medical Center Grapevine 79% Baylor University Medical Center 80% The Heart Hospital Baylor Plano 93% Data from: http://www.hospitalcompare.hhs.gov/ Data is for patients who had overnight hospital stays from January 2010 through December 2010Note: These data do not exist specifically at the level of the procedure. 52 ©2009 Baylor Health Care System
  • Overview  Definition of terms: micro, meso, and macro levels  Meaning of these terms as they relate to health care and health technology assessment (HTA)  Baylor Health Care System context  Definition of STEEEP  Example of isolated coronary artery bypass surgery (CABG)  Health policy implications of information generated at the micro, meso, and macro levels 53 ©2009 Baylor Health Care System
  • Dallas-Fort Worth Distribution of CABG VolumeCardiovascular Surgery Utilization: Open Heart Facilities and CY2011 Case Volume Color Legend 54 Decreasing Volume from ‘09 No Change Increasing Volume from ‘09 ©2009 Baylor Health Care System
  • Health Care Policy Implications•  Micro •  Large variability in volume among surgeons •  What is the minimum annual volume that is safe for a surgeon to perform? •  From a statistical analysis perspective, it is difficult to classify individual surgeons as high-mortality outliers 55 ©2009 Baylor Health Care System
  • Health Care Policy Implications•  Meso •  Should a given health care system restrict performance of CABG to hospitals of a certain volume? •  What percentage of hospitals are high-volume, medium-volume, or low-volume for CABG surgery? •  What should be done about high-volume hospitals with poor CABG surgery outcomes? 56 ©2009 Baylor Health Care System
  • Health Care Policy Implications•  Macro •  How many Dallas-Fort Worth hospitals should be performing CABG? •  Whose responsibility is it to decide whether to close a cardiac surgery program? (Should this be decided by a health care system, by state or national regulation, or by another method?) 57 ©2009 Baylor Health Care System
  • Adjusted Mortality Rate and Italy–Texas Comparison Volume Jan 02 – Sep 04 Summary Statistics –isolated CABG Italy Texas # of hospitals 64 139 Mean monthly volume 25.1 14.5Range mean monthly volume 5.7 – 69.6 1.0 – 73.2 Risk adjusted rate mean 2.6 3.3 Risk adjusted rate range 0.3 – 8.8 1.5 – 6.9 58 ©2009 Baylor Health Care System
  • Adjusted Mortality Rate and Italy–Texas Comparison Volume Jan 02 – Sep 04Adjusted Mortality Rate and Monthly Volume 59 ©2009 Baylor Health Care System
  • Adjusted Mortality Rate and Italy–Texas Comparison Volume Jan 02 – Sep 04Estimated Adjusted Mortality Rate and Monthly Volume 60 ©2009 Baylor Health Care System
  • Adjusted Mortality Rate and Italy–Texas Comparison Volume Jan 02 – Sep 04 Conclusions1. Mean mortality rate was lower in Italy than in TX2. In TX lower adjusted mortality rate was associated withhigher volume3. The three highest mortality hospitals in Italy had monthlyvolumes above the average monthly volume4. Monthly volume was higher in Italy than in TX5. In 2002-04 TX had twice as many cardiac programs thanItaly despite having half of the population than Italy 61 ©2009 Baylor Health Care System
  • Adjusted Mortality Rate and Italy–Texas Comparison Volume Jan 02 – Sep 04 LimitationsDifferent participation rate (100% in Texas vs 72% in Italy)Different cohorts, data, and modeling strategies were usedfor the estimation of the adjusted mortality rates 62 ©2009 Baylor Health Care System
  • Discussion•  While there are opportunities in the US to close low-volume coronary artery bypass graft (CABG) programs, are there opportunities in Italy to consolidate low-volume to medium-volume CABG programs?•  Both Texas and Italy have some high-volume centers with high mortality – do they need new leadership or some other intervention? 63 ©2009 Baylor Health Care System