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Pima society

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Presentation given in March 2014 as an invited speaker at the PIMA Medical Society (http://www.pimamedicalsociety.org/schedule/). These society presentations are widely attended by physicians in the Tucson area. The topic was innovation in CT surgery at UA.

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Pima society

  1. 1. Innovative Cardiac Surgery Robert Poston, MD Professor of Surgery, Director of Cardiac Surgery University of Arizona College of Medicine
  2. 2. Overview • New CT programs at UAMC • Framework for implementation – Manage the team • Change management • Strategies for team development – Business model • Outcomes
  3. 3. R-CABG (n=406) New Programs at UAMC
  4. 4. R-CABG R-MVrepair Redo r-cardiac cases New Programs at UAMC
  5. 5. Right ventricle dissected away from posterior sternum Old Sternal Wire Heart Bipolar forceps Unipolar cautery Abstract presentation, Hansen A, et al., ISMICS 2012
  6. 6. Head Exposure of Coronary Target Abstract presentation, Hansen A, et al., ISMICS 2011
  7. 7. Mitral Valve Repair
  8. 8. Redo MVRepair
  9. 9. R-CABG R-MVrepair R-Lobectomy R-Mesothelioma R-Esophagectomy TAVI Alternate access TAVI R-mini-VADRedo r-cardiac cases New Programs at UAMC
  10. 10. R-VAD Program Khalpey, Poston “LVAD implant using robotic assistance”, JTCVS, in press sternum right ventricle
  11. 11. Cardiothoracic Surgery at UAMC Before Jan 2011 Jan 2011 to present Traditional, open approach Less invasive approach Postonarrival 0.5% less invasive 82% less invasive Source: University Healthservices Consortium (UHC) database
  12. 12. Expectations Time Fenn, J et al. (2008). Understanding Gartner's Hype Cycles. Harvard Business Press Performance Low High Low High Rapid Learning
  13. 13. Change Management1 1. Deliberately select the team 2. Define the metrics of success 3. Measure and communicate progress 4. Multidisciplinary problem solving 1. Pisano, Edmunson et al, Organizational differences in the rates of learning: Lessons from the adoption of minimally invasive cardiac surgery. Management Science, 2001; 47(6): 752-69.
  14. 14. Total number of cases SurgicalORtimes 0 100 Standard learning Minimal learning curve Variable Performance During Growth Phase 1. Pisano, Edmunson et al, Organizational differences in the rates of learning: Lessons from the adoption of minimally invasive cardiac surgery. Management Science, 2001; 47(6): 752-69.
  15. 15. Procedure/ORtimes Total number of cases0 100 Team development and simulation training Standard learning Minimal clinical learning curve Variable Performance During Growth Phase
  16. 16. TEAM SIMULATION TRAINING: OR and ICU Supported by ASTEC and a grant from the UMCC IFL Risk Management Fund Program, 2011
  17. 17. Robotic Simulation: Animal Lab Supported by grants from Heartware and Ethicon
  18. 18. Robotic Simulation: Cadaver Lab Supported by grants from Heartware
  19. 19. TRAINING HIGH PERFORMANCE TEAMS BRIEF – PERFORM - DEBRIEF S Paidy, et al, Abstract presentation, American Society of Anesthesia, 10/2013
  20. 20. Metrics of Success: Robotic Mitral Valve • SAFETY: Composite morbidity/mortality do not exceed 10% • COSTS: No greater than 25% increase over conventional cases • SATISFACTION: – Staff: “Culture of safety”1 survey results do not decline by more than 5% – Patients: Patient satisfaction exceeds the results for conventional cases • EFFECTIVENESS: – 90% repair rate – 90% freedom from reoperation at 1 year 1. http://www.ahrq.gov/qual/patientsafetyculture/
  21. 21. Mitral Valve Repair at UAMC 2011-13 STS National Database Report 2013 Q3
  22. 22. Mitral Valve Repair at UAMC 2011-13 STS National Database Report 2013 Q3
  23. 23. 532 cases in the STS Adult Cardiac database, spanning 6/2011 to 12/2013 (2 years and 6 months) 484 cases have STS risk models (iso-CABG, Iso-AVR, Iso-MV Replace, Iso-MV Repair, CABG+AVR, CABG+MV Repair, TAVRs are NOT included in risk model) 375 are isolated CABGs 109 are isolated valves or valve+CABG cases with risk models Procedure Category n In-Hospital Mortality Rate Operative Mortality O/E ratio (STS risk model) Combined Operative Mortality or Major Morbidity Rate (patients who experienced operative mortality or at least one major morbidity) Combined Operative Mortality or Major Morbidity O/E ratio (STS risk model, includes non-cardiac reops) All cases in database (excluding TAVRs) - Poston 528 11/528 = 2.1% For the 484 cases with risk models: 1.28 69/528 = 13.1% For the 484 cases with risk models: 0.81 Isolated CABG - Poston 375 4/375 = 1.1% 0.88 32/375 = 8.8% 0.66 STS Iso-CABG benchmark (mean value for all participants during Jan-June 2013) 99,259 1.6% 1.00 13.2% 1.00 Isolated Valves and Valve+CAB Poston (only included non-CABG risk model cases, e.g. mitral valve with afib procedures excluded, n=32) 109 4/109 = 3.7% 1.68 26/109 = 23.9% 1.15 Data Sources (for benchmark): UAMC Adult Cardiac STS Database and "Data Analyses of The Society of Thoracic Surgeons National Adult Cardiac Surgery Database" produced October 2013 for period ending 6/30/201 Report Created on 1/27/14 by: Heather Reeves, RN, BSN, BA 106 Hybrid Cases 4 TAVRs 438 cases (82%) used "less invasive" techniques - robotic, mini-sternotomy, TAVR
  24. 24. Business Case for New Program Development
  25. 25. ↑48% incremental volume at UAMC #Cardiac cases/mo. 2010 (all cases) 2011-13 (all cases) In house referral External referral In house referral External referral CT surgery referral source Source: University Healthservices Consortium (UHC) database
  26. 26. 15 miles 87 miles Travel Distance: Traditional vs. Robotic traditional robotic Abstract presentation, ISMICS 2014, Bhatnagar, Poston
  27. 27. Robotic Surgery: Added Transaction Costs • 72 more miles @ $0.35/mi = $25.20 • 83% more lodging @ $100/d = $249.00 • 26% more per diem food @ $25/d = $19.50 • 14% more airfare @ $550/pt = $77.00 TOTAL $370.70/pt Abstract presentation, ISMICS 2014, Bhatnagar, Poston
  28. 28. –Costs of option A vs. option B • Hospital capacity • Medicare P4P – Sternal infections as a “never event”1 – Patient satisfaction score (i.e. Value Based Purchasing)2 • Payer mix – 5% difference = $1 million Robotic Surgery: Opportunity Costs A B 1. Medicare program; payment adjustment for provider-preventable conditions including health care acquired conditions. Final rule. Centers for Medicare and Medicaid Services (CMS), HHS. Fed Regist. 2011 Jun 6; 76(108):32816-38. 2. www.cms.gov/Hospital-Value-Based-Purchasing
  29. 29. n Operative Mortality Rate (includes deaths during admit and up to 30 days post-procedure, even if discharged) Operative Mortality O/E ratio (STS risk model) Combined Operative Mortality or Major Morbidity Rate (patients who experienced operative mortality or at least one major morbidity) Isolated CABG - Robotic 347 6/347 = 1.7% 0.93 31/347 = 8.9% Isolated CABG - Sternotomy 148 7/148 = 4.7% 1.94 19/148 = 12.8% STS Iso-CABG benchmark 143,628 2.0% 1.00 13.8% Outcomes for Robotic CABG Source: H. Reeves, Society of Thoracic Surgeons (STS) database query, 9/13
  30. 30. www.sts.org
  31. 31. http://www.unitedhealthcareonline.com http://www.bcbs.com/why-bcbs/blue-distinction/
  32. 32. Domain Percentile for R-CABG (n=60) Percentile for all UAMC (n=3107) Rate hospital 9-10 90th 44th Recommend the hospital 91st 54th Comm with nurses 78th 23rd Pain management 71st 28th Discharge information 76th 37th Comm with doctor 99th 7th Hospital environment 6th 13th Patient Satisfaction (HCAPHS) Source: J Rocha, HCAPHS database query, 9/13
  33. 33. Redefining Value (in the era of patient centered care) 1. Clinical outcomes 2. Cost-effectiveness 3. Quality of life 4. If less-invasive is not inferior, then it is superior. Michael Mack, MD; http://www.thebeatingedge.org/tag/valve-surgery/

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