1. Era of Innovation for
CT Surgery at UAMC
Robert Poston
Chief, Division of CT Surgery

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. JTCVS 2014 Apr; 147: 1423-5
JTCVS 2014 May; 147:1708-9

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. Robotic Coronary Bypass
https://www.youtube.com/user/postonlab

6. Robotic Mitral Valve Repair
https://www.youtube.com/user/postonlab

7. Value of Robotics: Patient
Larry Fish, CEO, Piers Corp.
First robotic CT patient at UAMC
https://www.youtube.com/user/postonlab

8. Value of Robotics: Organization
Rainer Gruessner, MD, Chair of Surgery at UAMC
https://www.youtube.com/user/postonlab

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

12. (2009)

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. 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. 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. 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. 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. Arizona Star, May 25, 2014Arizona Star, January 15, 2014

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