Value-driven cardiac surgery: Achieving "perfect care" after coronary artery bypass grafting

Moving the Brazilian Ischemic Stroke Pathway to a Value-Based Care: Introduction of a Risk-Adjusted Cost Estimate Model for Stroke Treatment

The unsustainable increases in healthcare expenses and waste have motivated the migration of reimbursement strategies from volume to value. Value-based health care requires detailed comprehension of cost information at the patient level. This study introduces a clinical risk- and outcome-adjusted cost estimate model for stroke care sustained on time-driven activity-based costing (TDABC). In a cohort and multicenter study, a TDABC tool was developed to evaluate the costs per stroke patient, allowing us to identify and describe differences in cost by clinical risk at hospital arrival, treatment strategies, and modified Rankin Score (mRS) at discharge. The clinical risk was confirmed by multivariate analysis and considered patients' National Institute for Health Stroke Scale and age. Descriptive cost analyses were conducted, followed by univariate and multivariate models to evaluate the risk levels, therapies, and mRS stratification effect in costs. Then, the risk-adjusted cost estimate model for ischemic stroke treatment was introduced. All the hospitals collected routine prospective data from consecutive patients admitted with ischemic stroke diagnosis confirmed. A total of 822 patients were included. The median cost was I$2,210 (IQR: I$1,163-4,504). Fifty percent of the patients registered a favorable outcome mRS (0-2), costing less at all risk levels, while patients with the worst mRS (5-6) registered higher costs. Those undergoing mechanical thrombectomy had an incremental cost for all three risk levels, but this difference was lower for high-risk patients. Estimated costs were compared to observed costs per risk group, and there were no significant differences in most groups, validating the risk and outcome adjusted cost estimate model. By introducing a risk-adjusted cost estimate model, this study elucidates how healthcare delivery systems can generate local cost information to support value-based reimbursement strategies employing the data collection instruments and analysis developed in this study.

Defining value in cardiac surgery: A contemporary analysis of cost variation across the United States

Objective

Isolated coronary artery bypass grafting and aortic valve replacement are common cardiac operations performed in the United States and serve as platforms for benchmarking. The present national study characterized hospital-level variation in costs and value for coronary artery bypass grafting and aortic valve replacement.

Methods

Adults undergoing elective, isolated coronary artery bypass grafting or aortic valve replacement were identified in the 2016-2018 Nationwide Readmissions Database. Center quality was defined by the proportion of patients without an adverse outcome (death, stroke, respiratory failure, pneumonia, sepsis, acute kidney injury, and reoperation). High-value hospitals were defined as those with observed-to-expected ratios less than 1 for costs and greater than 1 for quality, whereas the converse defined low-value centers.

Results

Of 318,194 patients meeting study criteria, 71.9% underwent isolated coronary artery bypass grafting and 28.1% underwent aortic valve replacement. Variation in hospital-level costs was evident, with median center-level cost of $36,400 (interquartile range, 29,500-46,700) for isolated coronary artery bypass grafting and $38,400 (interquartile range, 32,300-47,700) for aortic valve replacement. Observed-to-expected ratios for quality ranged from 0.2 to 10.9 for isolated coronary artery bypass grafting and 0.1 to 11.7 for isolated aortic valve replacement. Hospital factors, including volume and quality, contributed to approximately 9.9% and 11.2% of initial cost variation for isolated coronary artery bypass grafting and aortic valve replacement. High-value centers had greater cardiac surgery operative volume and were more commonly teaching hospitals compared to low-value centers, but had similar patient risk profiles.

Conclusions

Significant variation in hospital costs, quality, and value exists for 2 common cardiac operations. Center volume was associated with value and partly accounts for variation in costs. Our findings suggest the need for value-based care paradigms to reduce expenditures and optimize outcomes.

Quality of Life and Social Functioning of Patients After Cardiosurgical Interventions

The objective: to study the quality of life (QOL) and social functioning of patients who underwent cardiosurgery intervention (CSI) with the use of artificial circulation (AR) in the postoperative period, to determine and improve the system for further medical, psychological and social rehabilitation. Materials and methods. 700 patients who underwent CSI with the use of AR were treated at the Heart Institute of the Ministry of Health of Ukraine. 86 patients had cerebral infarction (CI), 217 patients with signs of postoperative encephalopathy, and 504 patients with signs of cognitive dysfunction. The level of QOL and social functioning in patients with this pathology was analyzed. Statistical analysis of differences in the quantitative values of indicators was performed using the nonparametric Mann-Whitney test. Results. It was found that patients after CSI had generally low levels of QOL in all fields, namely in the indicators of psychological (emotional) well-being, general perception of life, ability to work, physical well-being, personal realization, selfcare and independence; interpersonal interaction. The presence of ischemic and neurological complications in patients after CSI significantly reduces the QOL indicators in all areas, with differences in the quantitative values of such patients statistically significant (p<0,01) compared to the groups of patients without such complications. The most significant deterioration of QOL is found in patients with cerebral infarction in the postoperative period, slightly less significant – in patients with signs of postoperative encephalopathy, and the smallest changes – in patients with signs of cognitive dysfunction. Conclusions. The main task of modern cardiac surgery is not only to save the patient from death, but also to improve the quality of life (QOL). At the same time, patients after cardiac surgery are at risk of developing ischemic, neurological complications that significantly reduce QOL in all areas of life. That is why it is necessary to take into account the findings of the study in the development of treatment and rehabilitation programs and preventive measures for such patients.

Value-Based Healthcare Initiatives in Practice: A Systematic Review

EXECUTIVE SUMMARY

Value-based initiatives are growing in importance as strategic models of healthcare management, prompting the need for an in-depth exploration of their outcome measures. This systematic review aimed to identify measures that are being used in the application of the value agenda. Multiple electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials) were searched. Eligible studies reported various implementations of value-based healthcare initiatives. A qualitative approach was used to analyze their outcome measurements. Outcomes were classified according to a tier-level hierarchy. In a radar chart, we compared literature to cases from Harvard Business Publishing. The value agenda effect reported was described in terms of its impact on each domain of the value equation. A total of 7,195 records were retrieved; 47 studies were included. Forty studies used electronic health record systems for data origin. Only 16 used patient-reported outcome surveys to cover outcome tiers that are important to patients, and 3 reported outcomes to all 6 levels of our outcome measures hierarchy. A considerable proportion of the studies (36%) reported results that contributed to value-based financial outcomes focused on cost savings. However, a gap remains in measuring outcomes that matter to patients. A more complete application of the value agenda by health organizations requires advances in technology and culture change management.

Evaluating Quality in Adult Cardiac Surgery

National and institutional quality initiatives provide benchmarks for evaluating the effectiveness of medical care. However, the dramatic growth in the number and type of medical and organizational quality-improvement standards creates a challenge to identify and understand those that most accurately determine quality in cardiac surgery. It is important that surgeons have knowledge and insight into valid, useful indicators for comparison and improvement. We therefore reviewed the medical literature and have identified improvement initiatives focused on cardiac surgery. We discuss the benefits and drawbacks of existing methodologies, such as comprehensive regional and national databases that aid self-evaluation and feedback, volume-based standards as structural indicators, process measurements arising from evidence-based research, and risk-adjusted outcomes. In addition, we discuss the potential of newer methods, such as patient-reported outcomes and composite measurements that combine data from multiple sources.

The Value of Managing Acute Pancreatitis With Standardized Order Sets to Achieve "Perfect Care"

OBJECTIVES

We aimed to define perfect care index (PCI) metrics and to evaluate whether implementation of standardized order sets would improve outcomes without increasing hospital-based charges in patients with acute pancreatitis (AP).

METHODS

This is a retrospective, pre-post, observational study measuring clinical quality, processes of care, and hospital-based charges at a single tertiary care center. The first data set included AP patients from August 2011 to December 2014 (n = 219) before the implementation of a standardized order set (Methodist Acute Pancreatitis Protocol [MAPP]) and AP patients after MAPP implementation from January 2015 to September 2018 (n = 417). The second data set included AP patients (n = 150 in each group) from January 2013 to September 2014 (pre-MAPP) and January 2018 to September 2019 (post-MAPP) to evaluate perfect care between the 2 cohorts after controlling for systemic inflammatory response syndrome at baseline. Length of stay, PCI, and hospital-based charges were measured.

RESULTS

The post-MAPP cohort had a significantly shorter length of stay (median, 3 days vs 4 days; P = 0.01). In the second data set, PCI significantly increased after implementation of MAPP order sets (5.3%-35.3%, P < 0.0001).

CONCLUSIONS

The MAPP order sets increased the value of care by improving clinical outcomes without increasing hospital-based charges.

Advancing the Culture of Patient Safety and Quality Improvement

The American health care system has many great successes, but there continue to be opportunities for improving quality, access, and cost. The fee-for-service health care paradigm is shifting toward value-based care and will require accountability around quality assurance and cost reduction. As a result, many health care entities are rallying health care providers, administrators, regulators, and patients around a national imperative to create a culture of safety and develop systems of care to improve health care quality. However, the culture of patient safety and quality requires rigorous assessment of outcomes, and while numerous data collection and decision support tools are available to assist in quality assessment and performance improvement, the public reporting of this data can be confusing to patients and physicians alike and result in unintended negative consequences. This review explores the aims of health care reform, the national efforts to create a culture of quality and safety, the principles of quality improvement, and how these principles can be applied to patient care and medical practice.

Determinants of Value in Coronary Artery Bypass Grafting

Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to $10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation >24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay >14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P<0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with $45 526 at high-value hospitals (P<0.001), driven by higher readmission ($3675 versus $2177, P=0.005), professional ($7462 versus $6090, P<0.001), postacute care ($7315 versus $5947, P=0.031), and index hospitalization payments ($33 474 versus $30 800, P<0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus $752, P<0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P<0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services.