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David J. Ballard, MD, PhD, MSPH, FACP Senior Vice President and Chief Quality Officer

Baylor Health Care System Dallas, Texas, USA

4th National Conference of the Italian Society of Health Technology Assessment

Udine, Italy November 19, 2011

Impact of Health Care Performance Measurements on the Development of Health Technology Assessment at the Micro, Meso, and Macro Levels

©2009 Baylor Health Care System

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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


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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 populations

Source: AppliedSoc.org. An Introduction to Sociology Today. http://appliedsoc.org/. Accessed 02 June 2011.


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Overview   Definition of terms: micro, meso, and macro levels

  Meaning of these terms as they relate to health care and health technology assessment (HTA)






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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


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“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 level

Source: Battista RN and Hodge MJ. The “natural history” of health technology assessment. International Journal of Technology Assessment in Health Care. 2009; 25 (Supplement 1): 281-284.


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  Baylor Health Care System context   Definition of STEEEP




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Texas Map

Dallas-Fort Worth Metroplex:

Location of Baylor Health Care System


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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


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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)


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  Definition of STEEEP   Example of isolated coronary artery bypass surgery

(CABG)



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Health Care Quality

Source: Institute of Medicine. Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001.

  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 values


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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


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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality

Micro Meso Macro

Safe X

Timely

Effective

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Micro (Individual Surgeon) Level: Safety

0

20

40

60

80

100

120

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

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

2010 Isolated CABG - Volume and Observed Mortality

Volume Observed Mortality

Volu

me

Mor

talit

y Pe

rcen

tage


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Isolated Coronary Artery Bypass Surgery at Micro (Individual Surgeon) Level: Safety

0

20

40

60

80

100

120

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

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

2010 Isolated CABG - Volume and Risk Adjusted Mortality

Volume RAM

Society of Thoracic Surgeons = 1.9

Volu

me

Mor

talit

y Pe

rcen

tage


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Micro Meso Macro

Safe

Timely X

Effective

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Micro (Individual Surgeon) Level: Timeliness

0

20

40

60

80

100

120

0

50

100

150

200

250

300

350

400

450

500

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

2010 Isolated CABG - Volume and Average Post Operative Ventilation Hours

Volume PostOp Vent Hrs

Volu

me

Post

-Ope

rativ

e Ve

ntila

tion

Hou

rs


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Micro Meso Macro

Safe

Timely

Effective X

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass (CABG) Surgery at Micro (Individual Surgeon) Level: Effectiveness

0

20

40

60

80

100

120

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

2010 Isolated CABG Internal Mammary Artery Use and Volume

Volume IMA Usage

Volu

me

Inte

rnal

Mam

mar

y A

rter

y U

se


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Micro Meso Macro

Safe

Timely

Effective

Equitable X

Efficient

Patient Centered


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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


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Micro Meso Macro

Safe

Timely

Effective

Equitable

Efficient X

Patient Centered


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Isolated Coronary Artery Bypass (CABG) Surgery at Micro (Individual Surgeon) Level: Efficiency

0

20

40

60

80

100

120

0

2

4

6

8

10

12

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

2010 Isolated CABG Average Post Operative Length of Stay (LOS) and Volume

Volume PostOp LOS (days)

Volu

me

Post

-Ope

rativ

e Le

ngth

of S

tay

(Day

s)


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Micro Meso Macro

Safe

Timely

Effective

Equitable

Efficient

Patient Centered

X


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Isolated Coronary Artery Bypass (CABG) Surgery at Micro (Individual Surgeon) Level: Patient Centeredness

0

20

40

60

80

100

120

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

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

CABG Patient Satisfaction Likelihood to Recommend Mean Score: A Hypothetical Example

Volume Likelihood to Recommend Mean Score

Volu

me

Like

lihoo

d to

Rec

omm

end

Scor

e


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Micro Meso Macro

Safe X

Timely

Effective

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Meso Level: Safety

2.6

0.0

4.1

3.3

2.5 2.2

0

1

2

3

4

5

Irving Garland Grapevine BASMC BUMC THHBP

Perc

enta

ge

Hospital

2010 All Isolated CABG - Risk Adjusted Mortality Rates


(N=10/340) (N=7/408) (N=4/149) (N=0/64) (N=3/94) (N=1/57)


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Micro Meso Macro

Safe

Timely X

Effective

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Meso Level: Timeliness

21,2

33,8

10,8 9,5

14,8 17,5

0

5

10

15

20

25

30

35

40


Hou

rs

Hospital

2010 Isolated CABG Average Total Post Operative Ventilation Hours


(N=340) (N=408) (N=149) (N=64) (N=94) (N=57)


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Micro Meso Macro

Safe

Timely

Effective X

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Meso Level: Effectiveness

90,9%

96,8%

89,1% 95,3%

98,2% 96,8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Perc

ent

Hospital

2010 All Isolated CABG Internal Mammary Artery Use By Hospital

(re-operations excluded from denominator)

Society of Thoracic Surgeons = 95.0%

(N=82/94) (N=142/149) (N=51/55) (N=365/377) (N=61/63) (N=318/323)


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Micro Meso Macro

Safe

Timely

Effective

Equitable X

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Meso Level: Equity

0,00%

0,25%

0,50%

0,75%

1,00%

1,25%

1,50%

1,75%

2,00%

2,25%

2,50%

2,75%

3,00%

3,25%

3,50%

2010 Isolated CABG Mortality Percentage by Race: p-value = 0.27

White Other

N = 20/877 N = 5/232


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Micro Meso Macro

Safe

Timely

Effective

Equitable

Efficient X

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Meso Level: Efficiency

5,8

6,9

5,9

6,3

6,5

5,8

5,2

5,4

5,6

5,8

6

6,2

6,4

6,6

6,8

7


Day

s

Hospital

2010 All Isolated CABG Average PostOp Length Of Stay



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Micro Meso Macro

Safe

Timely

Effective

Equitable

Efficient

Patient Centered

X


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Isolated Coronary Artery Bypass Surgery at Meso Level: Patient Centeredness

BHCS Cardiovascular Patient Satisfaction “Likelihood to Recommend” FY10

0

10

20

30

40

50

60

70

80

90

100

Baylor Medical Center Irving (N=272)

Baylor Medical Center Garland (N=280)

Baylor All Saints Medical Center (N=369)

Baylor Regional Medical Center Grapevine

(N=452)

Baylor University Medical Center (N = 570)

The Heart Hospital Baylor Plano (N=1067)

Mean Score Percentile Ranking


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Micro Meso Macro

Safe X

Timely

Effective

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Macro (Texas) Level: Safety


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Isolated Coronary Artery Bypass Surgery at Macro (Texas, Dallas-Fort Worth, and BHCS) Level: Safety


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Micro Meso Macro

Safe

Timely X

Effective

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Macro (BHCS and US) Level: Timeliness

Note: Data at DFW hospital level is not available.

19,6 20,6

0

10

20

30

BHCS Overall United States

Hou

rs

2010 Isolated CABG Average Total Post Operative Ventilation Hours


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Micro Meso Macro

Safe

Timely

Effective X

Equitable

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Macro (BHCS and US) Level: Effectiveness

96,0% 95,0%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

90,0%

100,0%

BHCS Overall United States

2010 Isolated CABG Internal Mammary Artery Usage (excludes re-operations)

Note: Data at DFW hospital level is not available.


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Micro Meso Macro

Safe

Timely

Effective

Equitable X

Efficient

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Macro (Texas, Dallas-Fort Worth, and BHCS) Level: Equity


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Micro Meso Macro

Safe

Timely

Effective

Equitable

Efficient X

Patient Centered


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Isolated Coronary Artery Bypass Surgery at Macro (Texas, Dallas-Fort Worth, and BHCS) Level: Efficiency


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Micro Meso Macro

Safe

Timely

Effective

Equitable

Efficient

Patient Centered

X


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Isolated Coronary Artery Bypass Surgery at Macro (BHCS, Texas, and US) Level: Patient Centeredness

Note: These data do not exist specifically at the level of the procedure.

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 2010


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Dallas-Fort Worth Distribution of CABG Volume Cardiovascular Surgery Utilization: Open Heart Facilities and CY2011 Case Volume

Color Legend Decreasing Volume from ‘09

No Change Increasing Volume from ‘09


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•  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

Health Care Policy Implications


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•  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?



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•  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?)



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Adjusted Mortality Rate and Volume

Summary Statistics –isolated CABG

Italy–Texas Comparison Jan 02 – Sep 04

Italy Texas # of hospitals 64 139

Mean monthly volume 25.1 14.5 Range 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


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Adjusted Mortality Rate and Monthly Volume



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Estimated Adjusted Mortality Rate and Monthly Volume



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Conclusions

1. Mean mortality rate was lower in Italy than in TX

2. In TX lower adjusted mortality rate was associated with higher volume 3. The three highest mortality hospitals in Italy had monthly volumes above the average monthly volume

4. Monthly volume was higher in Italy than in TX

5. In 2002-04 TX had twice as many cardiac programs than Italy despite having half of the population than Italy



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Limitations

Different participation rate (100% in Texas vs 72% in Italy)

Different cohorts, data, and modeling strategies were used for the estimation of the adjusted mortality rates



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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?

01 ballard

Health & Medicine

health technology assessment

health policy implications

adjusted mortality rate

macro levels meaning

dfw hospital level

fort worth

health care

macro levels