David J. Ballard, MD, PhD, MSPH, FACP Senior Vice President and Chief Quality Officer Baylor Health Care System Dallas, Texas, USA 4 th National Conference of the Italian Society of Health Technology Assessment Udine, Italy November 19, 2011 Impact of Health Care Performance Measurements on the Development of Health Technology Assessment at the Micro, Meso, and Macro Levels
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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
Impact of Health Care Performance Measurements on the Development of Health Technology Assessment at the Micro, Meso, and Macro Levels
“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 Technology Assessment in Health Care. 2009; 25 (Supplement 1): 281-284.
• 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
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)
Source: Institute of Medicine. Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001.
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
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
Isolated Coronary Artery Bypass Surgery at Macro (BHCS, Texas, and US) Level: Patient Centeredness
Note: These data do not exist specifically at the level of the procedure.
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
• 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?)
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
• 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?