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Summary of UA CT Surgery 2011-14

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Presentation given to cardiology group at Northwest Medical Center in 2014 about outcomes at UAMC CT surgery program.

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Summary of UA CT Surgery 2011-14

  1. 1. Era of Innovation for CT Surgery at UAMC Robert Poston Chief, Division of CT Surgery
  2. 2. R-CABG R-MVrepair R-Lobectomy R-Mesothelioma R-Esophagectomy TAVI Alternate access TAVI R-mini-VADRedo r-cardiac cases New Programs at UAMC 2011-14
  3. 3. JTCVS 2014 Apr; 147: 1423-5 JTCVS 2014 May; 147:1708-9
  4. 4. 1 2 Cardiothoracic Surgery at UAMC Before Jan 2011 Jan 2011 to 2014 Traditional, open approach Less invasive approach 0.5% less invasive 82% less invasive Source: University Healthservices Consortium (UHC) database
  5. 5. Robotic Coronary Bypass https://www.youtube.com/user/postonlab
  6. 6. Robotic Mitral Valve Repair https://www.youtube.com/user/postonlab
  7. 7. Value of Robotics: Patient Larry Fish, CEO, Piers Corp. First robotic CT patient at UAMC https://www.youtube.com/user/postonlab
  8. 8. Value of Robotics: Organization Rainer Gruessner, MD, Chair of Surgery at UAMC https://www.youtube.com/user/postonlab
  9. 9. Data query/analysis by Heather Reeves, RN, Database Manager for CT Surgery, on 3/3/14 STS Cases for Dr. Robert Poston 540 cases in the STS Adult Cardiac database, spanning 2/2011 to 1/2014 (3 years) 490 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) 379 are isolated CABGs 111 are isolated valves or valve+CABG cases with risk models Procedure Category n In-Hospital Mortality Rate 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) All cases in database (excluding TAVRs) - Poston 535 11/535 = 2.1% 16/535 = 3.0% For the 490 cases with risk models: 1.22 69/535 = 12.9% All cases in database for all UAMC surgeons, excluding Poston, excluding TAVRs 587 40/587 = 6.8% 47/587 = 8.0% For the 368 cases with risk models: 1.48 167/587 = 28.4% Isolated CABG - Poston 379 4/379 = 1.1% 6/379 = 1.6% 0.86 32/379 = 8.4% Isolated CABG for all UAMC surgeons, excluding Poston 189 6/189 = 3.2% 9/189 = 4.8% 1.62 27/189 = 14.3% STS Iso-CABG benchmark (mean value for all participants during Jan-Sept 2013) 105,846 1.5% 1.9% 1.00 13.1% Isolated Valves and Valve+CABG Poston (all non-CABG risk model cases) 111 4/111 = 3.6% 7/111 = 6.3% 1.91 26/111 = 23.4% Isolated valve and valve+CABG for all UAMC surgeons, excluding Poston 179 9/179 = 5.0% 10/179 = 5.6% 1.37 38/179 = 21.2% 109 Hybrid Cases 5 TAVRs 444 cases used "less invasive" techniques - robotic, mini-sternotomy, TAVR
  10. 10. Domain Percentile for Poston cases (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 Source: J Rocha, HCAPHS database query, 9/13 Value of Robotics: Patients
  11. 11. http://www.unitedhealthcareonline.com http://www.bcbs.com/why-bcbs/blue-distinction/
  12. 12. (2009)
  13. 13. Composites 2/2011 N = 53 8/2011 N = 103 2/2012 N = 70 9/2012 N = 53 2/2013 N = 57 1. Teamwork within units 79 82 81 83 79 2. Supervisor/Manager 66 74 61 68 58 3. Learning 59 74 60 74 67 4. Management support 52 59 36 38 45 5. Overall perceptions 40 50 34 41 39 6. Feedback & Communication 46 60 43 58 53 7. Communication openness 54 58 49 53 44 8. Frequency of reports 50 61 55 51 53 9. Teamwork across units 53 56 42 49 45 10 Staffing 41 40 25 42 26 11. Handoffs and transitions 38 34 31 24 23 12. Nonpunitive response 32 36 37 44 22 % Positive response for nurses (OR, 4NE, 4NW) Source: T Pearson, RN, Culture of Safety Survey, results tabulated 4/13
  14. 14. Composites 2/2011 N = 53 8/2011 N = 103 2/2012 N = 70 9/2012 N = 53 2/2013 N = 57 1. Teamwork within units 79 82 81 83 79 2. Supervisor/Manager 66 74 61 68 58 3. Learning 59 74 60 74 67 4. Management support 52 59 36 38 45 5. Overall perceptions 40 50 34 41 39 6. Feedback & Communication 46 60 43 58 53 7. Communication openness 54 58 49 53 44 8. Frequency of reports 50 61 55 51 53 9. Teamwork across units 53 56 42 49 45 10 Staffing 41 40 25 42 26 11. Handoffs and transitions 38 34 31 24 23 12. Nonpunitive response 32 36 37 44 22 % Positive response for nurses (OR, 4NE, 4NW) Source: T Pearson, RN, Culture of Safety Survey, results tabulated 4/13
  15. 15. Economics of Learning Curve of rCABG CUSUM of rCABG Costs -50000 0 50000 100000 150000 200000 1 11 21 31 41 51 61 71 81 91 101 111 121 131 Case Number CumulativeDifferenceCompared toAverageCost(in$) Institution A Institution B AZ experience: comprehensive team training Boston experience: minimal team development Kianni, Poston et al, Abstract presentation, STS 2012 $6000 $4000 $2000 0 Cost of robotic vs. sternotomy CABG Costs and the Learning Curve
  16. 16. 0 5 10 15 20 25 30 35 40 January February March April May June July August September October November December 2010 2011 ↑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
  17. 17. Year Appropriate Uncertain Inappropriate 2011 98 (86%) 17 (14%) 0 2012 114 (87%) 15 (11.5%) 2 (1.5%) 2013 48 (84%) 7 (13%) 1 (2%) NY State database1 90.25% 8.63 1.11% Cardiology at UAMC2 - - 36% Appropriate Use of r-CABG 1. Analysis performed by Patty Kelley, RN, data analyst for CT surgery 2. Appropriateness of Coronary Revascularization for Patients without ACS, Hanan et al, JACC 2012; 59: 1870-1875. 3. C. Marulic, Quality Review Board, data query 6/13
  18. 18. Arizona Star, May 25, 2014Arizona Star, January 15, 2014
  19. 19. Conclusions • Innovation is a safe and effective way to build a cardiothoracic program • Changing a conservative field like CT surgery is a challenging and highly political process • Ultimately, patient demand will be the driving factor for creating sustainable change

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