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/
(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
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
Top Related