Post on 30-Nov-2014
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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
©2009 Baylor Health Care System
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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.
©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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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.
©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
©2009 Baylor Health Care System
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Texas Map
Dallas-Fort Worth Metroplex:
Location of Baylor Health Care System
©2009 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
©2009 Baylor Health Care System
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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)
©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
©2009 Baylor Health Care System
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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
©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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely X
Effective
Equitable
Efficient
Patient Centered
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective X
Equitable
Efficient
Patient Centered
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable X
Efficient
Patient Centered
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient X
Patient Centered
©2009 Baylor Health Care System
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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)
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient
Patient Centered
X
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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
Society of Thoracic Surgeons = 1.9
(N=10/340) (N=7/408) (N=4/149) (N=0/64) (N=3/94) (N=1/57)
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely X
Effective
Equitable
Efficient
Patient Centered
©2009 Baylor Health Care System
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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
Irving Garland Grapevine BASMC BUMC THHBP
Hou
rs
Hospital
2010 Isolated CABG Average Total Post Operative Ventilation Hours
Society of Thoracic Surgeons = 20.6
(N=340) (N=408) (N=149) (N=64) (N=94) (N=57)
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective X
Equitable
Efficient
Patient Centered
©2009 Baylor Health Care System
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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%
Irving Garland Grapevine BASMC BUMC THHBP
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)
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable X
Efficient
Patient Centered
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient X
Patient Centered
©2009 Baylor Health Care System
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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
Irving Garland Grapevine BASMC BUMC THHBP
Day
s
Hospital
2010 All Isolated CABG Average PostOp Length Of Stay
Society of Thoracic Surgeons = 6.8
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient
Patient Centered
X
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Isolated Coronary Artery Bypass Surgery at Macro (Texas) Level: Safety
©2009 Baylor Health Care System
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Isolated Coronary Artery Bypass Surgery at Macro (Texas, Dallas-Fort Worth, and BHCS) Level: Safety
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely X
Effective
Equitable
Efficient
Patient Centered
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective X
Equitable
Efficient
Patient Centered
©2009 Baylor Health Care System
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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.
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable X
Efficient
Patient Centered
©2009 Baylor Health Care System
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Isolated Coronary Artery Bypass Surgery at Macro (Texas, Dallas-Fort Worth, and BHCS) Level: Equity
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient X
Patient Centered
©2009 Baylor Health Care System
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Isolated Coronary Artery Bypass Surgery at Macro (Texas, Dallas-Fort Worth, and BHCS) Level: Efficiency
©2009 Baylor Health Care System
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Micro, Meso, and Macro Levels and the STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient
Patient Centered
X
©2009 Baylor Health Care System
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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
©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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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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?
Health Care Policy Implications
©2009 Baylor Health Care System
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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?)
Health Care Policy Implications
©2009 Baylor Health Care System
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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
©2009 Baylor Health Care System
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Adjusted Mortality Rate and Volume
Adjusted Mortality Rate and Monthly Volume
Italy–Texas Comparison Jan 02 – Sep 04
©2009 Baylor Health Care System
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Adjusted Mortality Rate and Volume
Estimated Adjusted Mortality Rate and Monthly Volume
Italy–Texas Comparison Jan 02 – Sep 04
©2009 Baylor Health Care System
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Adjusted Mortality Rate and Volume
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
Italy–Texas Comparison Jan 02 – Sep 04
©2009 Baylor Health Care System
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Adjusted Mortality Rate and Volume
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
Italy–Texas Comparison Jan 02 – Sep 04
©2009 Baylor Health Care System
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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?