The New Paradigm of Value-Driven Care in Cardiothoracic Surgery: Defining and Achieving "Perfect Care" for Patients Following Coronary Artery Bypass Surgery to Promote Cost-Effectiveness
Jason P Glotzbach, Vikas Sharma, *David Bull, *Aaron Eckhauser, Joseph Tonna, *Stephen McKellar, *Thomas Varghese, *Craig Selzman
University of Utah, Salt Lake City, UT
OBJECTIVES: The Centers for Medicare and Medicaid Services (CMS) have announced their intention to implement a bundled payment model for coronary artery disease that will emphasize quality of care instead of quantity of care. Given this impending change in the regulatory environment, cardiothoracic surgeons must develop systems and methods to define achievable clinical metrics that are correlated with costs of care. This will allow surgeons to measure, track, and improve quality and value of care in order to successfully build and maintain a practice within the new CMS payment structure. Using unique tools merging costing and our electronic data warehouse, we sought to determine the cost-effectiveness and value of achieving "perfect" post-operative care in patients undergoing CABG. We report the results of our iterative value driven process as a model for cardiothoracic surgeons to adapt individual practices and health care systems to flourish in this new environment.
In the first phase of the study, we tracked seven Society of Thoracic Surgery Database-derived measures of quality, including (1) antibiotics delivered within one hour prior to surgery, (2) antibiotics discontinued between 24-48 hours post-operatively, (3) antiplatelet prescribed at hospital discharge, (4) anti-lipid prescribed at discharge, (5) use of internal mammary artery, (6) no reintubation, and (7) beta-blockers prescribed at hospital discharge. In the second phase of our protocol-driven process, we tracked (8) discontinuation of inotrope use within 24 hours, and (9) use of < 500mL of albumin for resuscitation. All data were collected directly from our institution's electronic medical record using automated systems. "Perfect care" was defined as achieving ALL nine metrics per patient episode. Costs were calculated as the mean of total, as well as by categories including but not limited to facility utilization, supplies, pharmacy, laboratory, and imaging.
Over a 26-month period, 381 consecutive, risk-unadjusted patients undergoing isolated CABG were analyzed. Perfect care was successfully achieved in 257 patients (67%). There were no observed differences in mortality between patient groups. In examining causes for not meeting perfect care, failure to extubate within 24 hours, reintubation, failure to wean inotrope therapy off within 24 hours, and failure to use less than 500mL of albumin most commonly displayed variable compliance, whereas pass rates for the other 6 metrics were above 95%. In this cohort, total cost for patients with perfect care was 45% less than those without perfect care. The largest reductions in costs were related to facility utilization and respiratory therapy services.
When perfect care is achieved in patients undergoing CABG, significant cost-reductions can be obtained. Innovative tools linking automated tracking of quality metrics to costing provide significant opportunities for focused interventions (e.g. ventilator weaning protocols) that increase quality, decrease costs, and thereby enhance the value of CABG for our patients and healthcare system. This study provides evidence for the effectiveness of a systematic approach to define, measure and modulate the drivers of value for cardiothoracic surgery patients.
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