I professionisti e l'HTA al 4° Congresso della SIHTA, Udine, 17-19 novembre 2011

1. Impact of Health Care Performance
Measurements on the Development of
Health Technology Assessment at the
Micro, Meso, and Macro Levels
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

2. 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
2
©2009 Baylor Health Care System

3. 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. 3
©2009 Baylor Health Care System

4. 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
4
©2009 Baylor Health Care System

5. 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
5
©2009 Baylor Health Care System

6. “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 6
Technology Assessment in Health Care. 2009; 25 (Supplement 1): 281-284.
©2009 Baylor Health Care System

7. 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
7
©2009 Baylor Health Care System

8. Texas Map
Dallas-Fort
Worth
Metroplex:
Location of
Baylor Health
Care System
8
©2009 Baylor Health Care System

9. 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
9
©2009 Baylor Health Care System

10. 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)
10
©2009 Baylor Health Care System

11. 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
11
©2009 Baylor Health Care System

12. Health Care Quality
 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
Source: Institute of Medicine. Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001. 12
©2009 Baylor Health Care System

13. 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
13
©2009 Baylor Health Care System

14. 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
14
©2009 Baylor Health Care System

15. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe X
Timely
Effective
Equitable
Efficient
Patient
Centered
15
©2009 Baylor Health Care System

16. Isolated Coronary Artery Bypass Surgery at
Micro (Individual Surgeon) Level:
Safety
2010 Isolated CABG - Volume and Observed Mortality
100,0 120
90,0
100
80,0
70,0
Mortality Percentage
80
60,0
Volume
50,0 60
40,0
40
30,0
20,0
20
10,0
0,0 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
Volume Observed Mortality 16
©2009 Baylor Health Care System

17. Isolated Coronary Artery Bypass Surgery at
Micro (Individual Surgeon) Level:
Safety
2010 Isolated CABG - Volume and Risk Adjusted
Mortality
40,0 120
35,0
100
Mortality Percentage
30,0
80
Volume
25,0
20,0 60
15,0
40
10,0
20
5,0
Society
of
Thoracic
Surgeons
=
1.9
0,0 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
17
Volume RAM
©2009 Baylor Health Care System

18. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely X
Effective
Equitable
Efficient
Patient
Centered
18
©2009 Baylor Health Care System

19. Isolated Coronary Artery Bypass Surgery at
Micro (Individual Surgeon) Level:
Timeliness
2010 Isolated CABG - Volume and Average Post
Operative Ventilation Hours
500 120
450
Post-Operative Ventilation Hours
100
400
350
80
Volume
300
250 60
200
40
150
100
20
50
0 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
Volume PostOp Vent Hrs 19
©2009 Baylor Health Care System

20. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective X
Equitable
Efficient
Patient
Centered
20
©2009 Baylor Health Care System

21. Isolated Coronary Artery Bypass (CABG)
Surgery at Micro (Individual Surgeon) Level:
Effectiveness
2010 Isolated CABG Internal Mammary Artery Use and
Volume
100% 120
90%
100
Internal Mammary Artery Use
80%
70%
80
60%
Volume
50% 60
40%
40
30%
20%
20
10%
0% 0
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
Volume IMA Usage 21
©2009 Baylor Health Care System

22. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable X
Efficient
Patient
Centered
22
©2009 Baylor Health Care System

23. 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
23
©2009 Baylor Health Care System

24. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient X
Patient
Centered
24
©2009 Baylor Health Care System

25. Isolated Coronary Artery Bypass (CABG)
Surgery at Micro (Individual Surgeon) Level:
Efficiency
2010 Isolated CABG Average Post Operative Length of
Stay (LOS) and Volume
12 120
Post-Operative Length of Stay (Days)
10 100
8 80
Volume
6 60
4 40
2 20
0 0
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
25
Volume PostOp LOS (days)
©2009 Baylor Health Care System

26. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient
Patient X
Centered
26
©2009 Baylor Health Care System

27. Isolated Coronary Artery Bypass (CABG)
Surgery at Micro (Individual Surgeon)
Level: Patient Centeredness
CABG Patient Satisfaction
Likelihood to Recommend Mean Score: A Hypothetical Example
100,0 120
90,0
100
80,0
Likelihood to Recommend Score
70,0
80
60,0
Volume
50,0 60
40,0
40
30,0
20,0
20
10,0
0,0 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
27
Volume Likelihood to Recommend Mean Score
©2009 Baylor Health Care System

28. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe X
Timely
Effective
Equitable
Efficient
Patient
Centered
28
©2009 Baylor Health Care System

29. Isolated Coronary Artery Bypass
Surgery at Meso Level: Safety
2010 All Isolated CABG - Risk Adjusted Mortality Rates
5
4.1
4
3.3
3
Percentage
2.6
2.5
2.2
2
Society of Thoracic Surgeons = 1.9
1
0.0
0
Irving Garland Grapevine BASMC BUMC THHBP
Hospital (N=4/149)
29
(N=1/57)
(N=0/64)
(N=3/94)
(N=10/340)
(N=7/408)
©2009 Baylor Health Care System

30. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely X
Effective
Equitable
Efficient
Patient
Centered
30
©2009 Baylor Health Care System

31. Isolated Coronary Artery Bypass
Surgery at Meso Level: Timeliness
2010 Isolated CABG Average Total Post Operative
Ventilation Hours
40
35 33,8
30
25
21,2
Hours
20
17,5
Society
of
Thoracic
Surgeons
=
20.6
14,8
15
10,8
9,5
10
5
0
Irving Garland Grapevine BASMC BUMC THHBP
Hospital (N=149)
31
(N=57)
(N=64)
(N=94)
(N=340)
(N=408)
©2009 Baylor Health Care System

32. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective X
Equitable
Efficient
Patient
Centered
32
©2009 Baylor Health Care System

33. Isolated Coronary Artery Bypass
Surgery at Meso Level: Effectiveness
2010 All Isolated CABG Internal Mammary Artery Use By
Hospital
(re-operations excluded from denominator)
100% 96,8% 98,2% 96,8%
95,3%
90% 90,9% 89,1%
Society
of
Thoracic
Surgeons
=
95.0%
80%
70%
60%
Percent
50%
40%
30%
20%
10%
0%
Irving Garland Grapevine BASMC BUMC THHBP
Hospital (N=142/149)
33
(N=51/55)
(N=61/63)
(N=82/94)
(N=318/323)
(N=365/377)
©2009 Baylor Health Care System

34. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable X
Efficient
Patient
Centered
34
©2009 Baylor Health Care System

35. Isolated Coronary Artery Bypass
Surgery at Meso Level: Equity
2010 Isolated CABG Mortality Percentage by Race:
p-value = 0.27
3,50%
3,25%
3,00%
2,75%
2,50%
2,25%
2,00%
1,75%
1,50%
1,25%
1,00%
0,75%
0,50%
0,25%
0,00%
N = 20/877 N = 5/232
White Other
35
©2009 Baylor Health Care System

36. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient X
Patient
Centered
36
©2009 Baylor Health Care System

37. Isolated Coronary Artery Bypass
Surgery at Meso Level: Efficiency
2010 All Isolated CABG Average PostOp Length Of Stay
7
6,9
Society
of
Thoracic
Surgeons
=
6.8
6,8
6,6
6,5
6,4
6,3
6,2
Days
6
5,9
5,8 5,8
5,8
5,6
5,4
5,2
Irving Garland Grapevine BASMC BUMC THHBP 37
Hospital
©2009 Baylor Health Care System

38. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient
Patient X
Centered
38
©2009 Baylor Health Care System

39. Isolated Coronary Artery Bypass Surgery
at Meso Level: Patient Centeredness
BHCS Cardiovascular Patient Satisfaction
“Likelihood to Recommend” FY10
100
90
80
70
60
50
40
30
20
10
0
Baylor Medical Center Baylor Medical Center Baylor All Saints Medical Baylor Regional Medical Baylor University Medical The Heart Hospital
Irving (N=272) Garland (N=280) Center (N=369) Center Grapevine Center (N = 570) Baylor Plano (N=1067)
(N=452)
39
Mean Score Percentile Ranking
©2009 Baylor Health Care System

40. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe X
Timely
Effective
Equitable
Efficient
Patient
Centered
40
©2009 Baylor Health Care System

41. Isolated Coronary Artery Bypass Surgery at
Macro (Texas) Level: Safety
41
©2009 Baylor Health Care System

42. Isolated Coronary Artery Bypass Surgery at
Macro (Texas, Dallas-Fort Worth, and BHCS)
Level: Safety
42
©2009 Baylor Health Care System

43. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely X
Effective
Equitable
Efficient
Patient
Centered
43
©2009 Baylor Health Care System

44. Isolated Coronary Artery Bypass Surgery at
Macro (BHCS and US) Level: Timeliness
2010 Isolated CABG Average Total Post Operative
Ventilation Hours
30
20,6
19,6
20
Hours
10
0
BHCS Overall United States
44
Note: Data at DFW hospital level is not available.
©2009 Baylor Health Care System

45. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective X
Equitable
Efficient
Patient
Centered
45
©2009 Baylor Health Care System

46. Isolated Coronary Artery Bypass Surgery at
Macro (BHCS and US) Level: Effectiveness
2010 Isolated CABG Internal Mammary Artery Usage
(excludes re-operations)
100,0%
90,0%
96,0% 95,0%
80,0%
70,0%
60,0%
50,0%
40,0%
30,0%
20,0%
10,0%
0,0%
BHCS Overall United States
Note: Data at DFW hospital level is not available. 46
©2009 Baylor Health Care System

47. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable X
Efficient
Patient
Centered
47
©2009 Baylor Health Care System

48. Isolated Coronary Artery Bypass Surgery at
Macro (Texas, Dallas-Fort Worth, and BHCS)
Level: Equity
48
©2009 Baylor Health Care System

49. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient X
Patient
Centered
49
©2009 Baylor Health Care System

50. Isolated Coronary Artery Bypass Surgery at
Macro (Texas, Dallas-Fort Worth, and BHCS)
Level: Efficiency
50
©2009 Baylor Health Care System

51. Micro, Meso, and Macro Levels and the
STEEEP Domains of Health Care Quality
Micro Meso Macro
Safe
Timely
Effective
Equitable
Efficient
Patient X
Centered
51
©2009 Baylor Health Care System

52. Isolated Coronary Artery Bypass Surgery at
Macro (BHCS, Texas, and US) Level:
Patient Centeredness
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
Note: These data do not exist specifically at the level of the procedure. 52
©2009 Baylor Health Care System

53. 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
53
©2009 Baylor Health Care System

54. Dallas-Fort Worth Distribution of CABG Volume
Cardiovascular Surgery Utilization: Open Heart Facilities and CY2011 Case Volume
Color Legend 54
Decreasing Volume from ‘09
No Change
Increasing Volume from ‘09 ©2009 Baylor Health Care System

55. Health Care Policy Implications
• 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
55
©2009 Baylor Health Care System

56. Health Care Policy Implications
• 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?
56
©2009 Baylor Health Care System

57. Health Care Policy Implications
• 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?)
57
©2009 Baylor Health Care System

58. Adjusted Mortality Rate and
Italy–Texas Comparison
Volume Jan 02 – Sep 04
Summary Statistics –isolated CABG
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
58
©2009 Baylor Health Care System

59. Adjusted Mortality Rate and
Italy–Texas Comparison
Volume Jan 02 – Sep 04
Adjusted Mortality Rate and Monthly Volume
59
©2009 Baylor Health Care System

60. Adjusted Mortality Rate and
Italy–Texas Comparison
Volume Jan 02 – Sep 04
Estimated Adjusted Mortality Rate and Monthly Volume
60
©2009 Baylor Health Care System

61. Adjusted Mortality Rate and
Italy–Texas Comparison
Volume Jan 02 – Sep 04
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
61
©2009 Baylor Health Care System

62. Adjusted Mortality Rate and
Italy–Texas Comparison
Volume Jan 02 – Sep 04
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
62
©2009 Baylor Health Care System

63. 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?
63
©2009 Baylor Health Care System