Innovative Cardiac Surgery
Robert Poston, MD
Professor of Surgery, Director of Cardiac Surgery
University of Arizona College of Medicine

Overview
• New CT programs at UAMC
• Framework for implementation
– Manage the team
• Change management
• Strategies for team development
– Business model
• Outcomes

R-CABG (n=406)
New Programs at UAMC

R-CABG R-MVrepair
Redo r-cardiac cases
New Programs at UAMC

Right ventricle dissected away from
posterior sternum
Old Sternal
Wire
Heart
Bipolar forceps
Unipolar cautery
Abstract presentation, Hansen A, et al., ISMICS 2012

Head
Exposure of Coronary Target
Abstract presentation, Hansen A, et al., ISMICS 2011

Mitral Valve Repair

Redo MVRepair

R-CABG R-MVrepair R-Lobectomy R-Mesothelioma R-Esophagectomy
TAVI Alternate access TAVI R-mini-VADRedo r-cardiac cases
New Programs at UAMC

R-VAD Program
Khalpey, Poston “LVAD implant using robotic assistance”, JTCVS, in press
sternum
right ventricle

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

Expectations
Time
Fenn, J et al. (2008). Understanding Gartner's Hype Cycles. Harvard Business Press
Performance
Low
High
Low
High
Rapid Learning

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.

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.

Procedure/ORtimes
Total number of cases0 100
Team development
and simulation training
Standard learning
Minimal clinical
learning curve
Variable Performance During Growth Phase

TEAM SIMULATION TRAINING: OR and ICU
Supported by ASTEC and a grant from the UMCC IFL Risk Management Fund Program, 2011

Robotic Simulation: Animal Lab
Supported by grants from Heartware and Ethicon

Robotic Simulation: Cadaver Lab
Supported by grants from Heartware

TRAINING HIGH PERFORMANCE TEAMS
BRIEF – PERFORM - DEBRIEF
S Paidy, et al, Abstract presentation, American Society of Anesthesia, 10/2013

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/

Mitral Valve Repair at UAMC 2011-13
STS National Database Report 2013 Q3

Mitral Valve Repair at UAMC 2011-13
STS National Database Report 2013 Q3

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

Business Case for New Program
Development

↑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

15 miles
87 miles
Travel Distance: Traditional vs. Robotic
traditional
robotic
Abstract presentation, ISMICS 2014, Bhatnagar, Poston

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

–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

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

www.sts.org

http://www.unitedhealthcareonline.com
http://www.bcbs.com/why-bcbs/blue-distinction/

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

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/