Summary of UA CT Surgery 2011-14

Era of Innovation for CT Surgery at UAMC

Robert PostonChief, Division of CT Surgery

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

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

12

Cardiothoracic Surgery at UAMC

BeforeJan 2011

Jan 2011to 2014

Traditional, open approach

Less invasiveapproach

Posto

n ar

rival

0.5% less invasive

82% less invasive

Source: University Healthservices Consortium (UHC) database

Robotic Coronary Bypass

https://www.youtube.com/user/postonlab

Robotic Mitral Valve Repair

https://www.youtube.com/user/postonlab

Value of Robotics: Patient

Larry Fish, CEO, Piers Corp.First robotic CT patient at UAMChttps://www.youtube.com/user/postonlab

Value of Robotics: Organization

Rainer Gruessner, MD, Chair of Surgery at UAMChttps://www.youtube.com/user/postonlab

Data query/analysis by Heather Reeves, RN, Database Manager for CT Surgery, on 3/3/14

STS Cases for Dr. Robert Poston540 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 CABGs111 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+CABGPoston(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%

Data Sources:UAMC Adult Cardiac STS Database and "Data Analyses of The Society of Thoracic Surgeons National Adult Cardiac Surgery Database" produced January for period ending 9/30/2013 (most recent report)

Report Created on 3/3/14 by:

109 Hybrid Cases5 TAVRs444 cases used "less invasive" techniques - robotic, mini-sternotomy, TAVR

Heather Reeves, RN, BSN, BAManager, Cardiovascular Quality DataCardiovascular ServicesThe University of Arizona Medical Center - University CampusTucson, [email protected]

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

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

http://www.unitedhealthcareonline.com/

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

(2009)

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

-50000

0

50000

100000

150000

2000001 11 21 31 41 51 61 71 81 91 101

111

121

131

Case Number

Institution AInstitution 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

January February March April May June July August Sep-tember

October No-vember

De-cember

0

5

10

15

20

25

30

35

40

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 surgeryreferral source

Source: University Healthservices Consortium (UHC) database

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 surgery2. 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

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

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

Summary of UA CT Surgery 2011-14

Healthcare

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