Pima society

Innovative Cardiac Surgery

Robert Poston, MDProfessor 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

BeforeJan 2011

Jan 2011to present

Traditional, open approach

Less invasiveapproach

Post

on ar

rival

0.5% less invasive

82% less invasive

Source: University Healthservices Consortium (UHC) database

Expectations

TimeFenn, 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 team2. Define the metrics of success3. Measure and communicate progress4. 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

Surg

ical

OR

times

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.

Proc

edur

e/O

R tim

es

Total number of cases0 100Team 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

STS Cases for Dr. Robert Poston532 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 CABGs109 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+CABPoston(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 6/30/2013 (most recent report)

Report Created on 1/27/14 by:Heather Reeves, RN, BSN, BA

106 Hybrid Cases4 TAVRs438 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 surgeryreferral 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

B1. 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.comhttp://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 outcomes2. Cost-effectiveness3. Quality of life

4. If less-invasive is not inferior, then it is superior.

Michael Mack, MD; http://www.thebeatingedge.org/tag/valve-surgery/