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VA Center for Clinical Management Research VA Ann Arbor Healthcare System*. Profiling Hospital Differences in the Quality of CABG Surgery Using Quality-Adjusted Life Expectancy. Justin W. Timbie, PhD* David M. Shahian, MD Joseph P. Newhouse, PhD - PowerPoint PPT Presentation
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AcademyHealth 2008
VA Center for Clinical Management Research
VA Ann Arbor Healthcare System*
Profiling Hospital Differences in the Quality of CABG Surgery Using Quality-Adjusted
Life Expectancy
Profiling Hospital Differences in the Quality of CABG Surgery Using Quality-Adjusted
Life Expectancy
Justin W. Timbie, PhD*David M. Shahian, MD
Joseph P. Newhouse, PhDMeredith B. Rosenthal, PhD
Sharon-Lise T. Normand, PhD
Funding: Alfred P. Sloan Foundation
AcademyHealth 2008
Outline
• Context: Summary measures of quality
• Framework: Use 10 quality measures to estimate survival and utility outcomes.
• Illustration: Estimate QALY outcomes for 14 hospitals performing CABG surgery.
• Discussion: How to generalize the approach
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Background: Composite Measures
Main issues:
1) Weights have limited (or no) clinical basis.
2) Assigning “importance” weights is a challenge.
3) Weighting of mortality vs. other measures is conceptually weak.
Approach Example
Equal weights CMS Hospital Quality Demos
“Importance” weights The Leapfrog Group
“All-or-nothing” Institute for Healthcare Improvement
Latent variable model
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Rationale for QALY composite measure
• QALY = Quality-Adjusted Life Year• Incorporates mortality and morbidity effects (via utility) of poor
quality.• Time horizon is one year.
QALYs address main issues:1) Weights are based on clinical outcomes.
2) Weights determined by fitting survival model and utility weights from literature.
3) Mortality/morbidity tradeoff determined by utility.
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CABG Quality Measures
Measure % Failure
1 Preoperative beta-blocker 15.2
2 Use of internal mammary artery 4.9
3 Aspirin at discharge 5.2
4 Beta-blocker at discharge 15.2
5 Anti-lipids at discharge 21.6
6 Stroke (lasting >72 hours) 1.2
7 Deep sternal wound infection 1.2
8 Renal failure 2.9
9 Prolonged ventilation (>24 hours) 11.9
10 Re-operation 2.2
Source: Massachusetts Data Analysis Center (Mass-DAC), 2004.
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Utilities for CABG complications
Complication Duration Estimate
Reoperation 30 d 0.78
Prolonged ventilation 30 d 0.76
Renal failure 30 d 0.63
Deep sternal wound infection 60 d 0.58
Stroke 1 y 0.52
Renal failure with hemodialysis 1 y 0.49
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Estimating QALYs
Unit Survival Model
Patient j
in
hospital i
P(Survival|β0i,X,Q)ij
AcademyHealth 2008
Estimating QALYs
Unit Survival Model
Patient j
in
hospital i
P(Survival|β0i,X,Q)ij
Patient j in any hospital
P(Survival|μ,X,Q)ij
AcademyHealth 2008
Estimating QALYs
Unit Survival Model Complication Models
Patient j
in
hospital i
P(Survival|β0i,X,Q)ij 1. P(Complication|β0i,X)ij
2. EU(Stroke)ij
= P(Stroke)*U(Stroke) +
1-P(Stroke)*U(No Stroke)
3. EU (All comps)ij = Π EU
Σ EdU
Patient j in any hospital
P(Survival|μ,X,Q)ij 1. P(Complication|μ,X)ij
2. Same as above
3. Same as above
AcademyHealth 2008
Estimating QALYs
Unit Survival Model Complication Models
Patient j
in
hospital i
P(Survival|β0i,X,Q)ij 1. P(Complication|β0i,X)ij
2. EU(Stroke)ij
= P(Stroke)*U(Stroke) +
1-P(Stroke)*U(No Stroke)
3. EU (All comps)ij = Π EU
Σ EdU
Patient j in any hospital
P(Survival|μ,X,Q)ij 1. P(Complication|μ,X)ij
2. Same as above
3. Same as above
Incremental QALY = P(S)*EU – P(S)*EU
Hospital i Any hospital
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AcademyHealth 2008
AcademyHealth 2008
Key findings
• Incorporating longer-term survival and utilities can change inferences on outliers.
• Low incidence of major complications.• Limitations:
– Process measures had negligible survival effects.– Disagreement on utility estimates and aggregation
method.
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Generalizing the QALY approach
• Consider excluding some process measures from QALY composite.
• Surgical: – Mortality and complications are key measures.
• Medical:– 30-day mortality is current standard.– Readmission, functional status measures on horizon.
• Safety: – NQF “Safe Practices”: Large quality problem, high
morbidity.
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QALY composites for diabetes
• Measures: – BP < 130/80 mmHg– A1c < 7%– LDL < 100 mg/dL
• QALYs summarize implications of current risk factor levels relative to goals. – Survival outcomes simulated via Markov model.– Utilities reflect future complications and cardiac events.
• Medical Care 2007;45:315-321.
5-fold greater odds of mortality (over 10 years)