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New York State Cardiac Surgery Reporting System Presentation – Hospital Public Reporting Summit May 26, 2004

New York State Cardiac Surgery Reporting System Presentation – Hospital Public Reporting Summit May 26, 2004 Donna R. Doran Regulatory and Oversight Environment Regulation in NYS provides broad powers to the Department of Health

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New York State Cardiac Surgery Reporting System Presentation – Hospital Public Reporting Summit May 26, 2004

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  1. New York State Cardiac SurgeryReporting SystemPresentation – Hospital Public Reporting SummitMay 26, 2004 Donna R. Doran

  2. Regulatory and Oversight Environment • Regulation in NYS provides broad powers to the Department of Health • Certificate of Need (CON) governs approval of cardiac surgery and cardiac cath in NYS. (10NYCRR 709.14) • Defines minimum standards for existing specialty services and provides authority to monitor compliance (10NYCRR 405.22) • Regulation also gives the New York State Cardiac Advisory Committee the responsibility and authority to advise the Commission on any matter relating to cardiac services – including review of existing and potential cardiac surgery programs. (10NYCRR 405.22)

  3. NYS Cardiac Advisory Committee (CAC) • Roots in the 1950s • Established formally as a Commissioner’s advisory body in 1974 • Comprised of practicing cardiologists, cardiac surgeons, and experts from other pertinent disciplines. Both in-state and out-of-state members are included on the Committee • Chair- Dr. Kenneth Shine

  4. Function and Scope of CAC • Provides a forum for serious and frank discussion of issues • Known for innovative and effective QI initiatives • Recent Policies and Initiatives Include: • Guidelines for Credentialing of RPAs in Cardiac Surgery • Guidelines and Policy on PCI in Non-Surgery Centers • Guidelines for Cardiac Cath Lab CON Reviews • Guidelines for Implementation of Hospital-Based Heart Disease Prevention Programs • Acute MI Initiatives

  5. CAC Policies & Initiatives Cont’d Major interest in Access • Study on utilization differential by race and gender1 • 1997 Workshop • Access-related conditions on CON Approvals • Cardiac Surgery Demo to Enhance Access • Access Initiative to Ensure Appropriate Referrals from Cath Lab 1 Hannan, van Ryan, Burke et al. Access to Coronary Artery Bypass Surgery by Race/Ethnicity and Gender Among Patients Who Are Appropriate for Surgery,” Medical Care, 1999; 37(1):68-77.

  6. Perhaps best known for NYS DOH Cardiac Reporting Systems

  7. History of NY’s CSRS • CAC Use of Data Benchmarking dates to early 1970s • CSRS - Result of Frustration in Using Aggregate Data to Assess Hospital Quality for CABGSurgery (Describe) • Developed in Conjunction with NYS Cardiac Advisory Committee as a System for QI • First Release – December 1990 • Cooperative Model Backed by Authority to Implement

  8. Who Participates and How • All hospitals approved through CON to perform cardiac surgery in NYS must participate. • All cases involving surgery on the heart or great vessels are reported. • Data elements include demographic, procedural, clinical and outcomes information. • Each hospital must have a designated data manager with clinical expertise trained in specific CSRS clinical criteria and authorized to ensure accurate and timely reporting.

  9. Data Collection Process • Data Entered on Form by Hospital Cardiac Surgery Departments • Transferred Using Secure DOH Website • Forwarded to DOH for Data Quality Checks and Analysis

  10. Data Quality Assurance • Cross check with DOH Admin Data to be sure all cases and all deaths are reported • Sample of Medical Records Audited by DOH’s Utilization Review Agent • Unusual reporting frequencies generate focused reviews • Discrepancies identified are corrected

  11. Tools Supplied to Hospitals • Software to Predict Probability of Mortality for Each Patient • Software to Provide Risk-Adjusted Mortality for Each Surgeon for Specified Time Periods, to monitor program outcomes and to tabulate cases by various criteria • Tables That Compare Frequencies and Mortality Rates for Each Risk Factor

  12. Information Supplied to Hospitals and the Public • Annual Report With Risk-Adjusted Mortality Rates for Hospitals • Report Includes Risk-Adjusted Mortality for Surgeons for Latest Three Years Combined • Report Identifies Significant Risk Factors and Provides Logistic Regression Data

  13. Albany Medical Center Ellis Hospital Lenox Hill Maimonides Montefiore-Moses Montefiore-Weiler Mount Sinai New York Hospital - Cornell New York Hospital - Queens NYU Medical Center Presbyterian St. Luke's - Roosevelt St. Peter's St. Vincent's Univ. Hospital of Brooklyn Westchester County 12.0 0.0 2.0 4.0 6.0 8.0 10.0 2.44 New York State Average

  14. Hospital/Surgeon Efforts to Improve Quality • Investigation of Process/Outcome Links • Reduction in the Percentage of Low-Volume Surgeons and Patients Operated on by Low-Volume Surgeons • Redistribution of Procedures Among Surgeons

  15. Changes in Processes of Care • Treatment and Timing of Surgery for Shock/AMI Patients • Monitoring of Post-Op. and ICU Care • Reduction of Return to Surgery for Post-Op. Bleeding There is at least anecdotal evidence that these changes would not have occurred without the public release of data

  16. DOH/CAC Efforts to Improve Outcomes • Software provided to enable ongoing self-assessment/improvement • Alert letters • Comprehensive Site Visits by highly respected clinical experts • Quality Improvement recommendations from CAC surveyors accompanied by monitoring and follow up. • Technical and analytical assistance.

  17. Does it Work???

  18. NY Versus US Changes in CABG Surgery Mortality • The overall CABG mortality rate declined by 28% among NY Medicare pts. between 1989 and 19921 • The overall mortality rate declined by 13% among US Medicare pts. between 1989 and 19921 • NY CABG mortality declined significantly faster (p<.01).1 1 Peterson et al., The Effects of New York State’s Bypass Surgery Provider Profiling on Access to care and Patient Outcomes in the Elderly, JACC 1998;32:993-9).

  19. NY CABG Mortality vs. US: Continued • NY had lowest CABG mortality rate in country in 1992 • NY was among top 3 in mortality rate decrease between 1989 and 1992

  20. New York State CABG SurgeryObserved Mortality Rates (%): 1989-1998

  21. NY CABG Mortality vs. US:More Recently: 1994-1999 Comparing states/regions with QI/Public Dissemination to remainder of Country. Conclusion - Public dissemination of outcomes data/regional QI initiatives appear to be associated with lower RAMR for CABG. (1994-1999 Medicare data) NY adjusted odds ratio for mortality (vs. US): .67 (significant each year and in total, but relatively constant) PA also significant each year with overall adjusted OR=.80 2 Hannan EL, Vaughn Sarrazin MS, Doran DR et al., Provider Profiling and Quality Improvement Efforts in Coronary Artery Bypass Graft Surgery: The Effect on Short-Term Mortality Among Medicare Beneficiaries. Med Care 2003;411:1164-1172.

  22. Conclusions Regarding NY’sCABG System • Mortality of CABG Surgery has decreased tremendously in NY, seemingly at least in part because of the dissemination of outcomes3 • Mortality reduction has not been accomplished by shifting of patients to hospitals with better outcomes4 3 Hannan EL, Kilburn H, Lindsey ML et al.., Improving the Outcomes of Coronary Artery Bypass Surgery in New York State. JAMA 1994;271:761-766 • Hannan EL, Kumar D, Racz M, et al., New York State’s Cardiac Surgery Reporting System: Four Years Later. ATS 1994;58:1852-1857

  23. There is no compelling evidence that ‘appropriate” high-risk patients are losing access to CABG surgery6,2 (as evidenced by changes in risk profile or by transfers out-of-state) • There is evidence of several quality improvement initiatives having been undertaken • The advantage in risk-adjusted mortality relative to the country expanded tremendously during the first five years and has remained constant since then2 • Hannan EL, Siu AL, Kumar D, et al., Assessment of CABG Surgery Performance in NYS: Is There a Bias Against Taking High-Risk Patients? Medical Care 1997;35:49-56. 2 Hannan EL, Sarrazin MSV, Doran DR, Rosenthal GE. Provider Profiling and Quality Improvement Efforts in CABG Surgery: The Effects on Short-Term Mortality Among Medicare Beneficiaries, Medical Care, 2003;41(10):1164-1172..

  24. Other Related “Report Cards”in NY • Percutaneous Coronary Interventions • Valve Surgery, now added to CABG Surgery Report • Pediatric Cardiac Surgery

  25. Conclusions Relating to Public Release of Risk Adjusted Outcomes for Assessing Quality • Impressive Results with CABG Surgery. However, clinical databases are resource intensive – application probably limited to major procedures/disease categories • Administrative Databases have promise in reducing resource requirements, but much work needs to be done on assuring completeness and accuracy • General reorientation toward Systems and IT approach is a positive • Ideally, Mortality Should be Supplemented By Other Outcomes

  26. Conclusions Relating to Public Release of Risk Adjusted Outcomes for Assessing Quality, Cont’d. • Difficult Because of Resource Reqs. To Obtain Accurate and Complete Data, e.g., Complications Data Difficult to Obtain • Other Possible Measures Include Readmissions7 and Emergency Interventions.8 Need more (complications, pt. satisfaction). • Also, Need to Have More Process Data Available 7. Hannan EL, Racz MJ, Walford G, Ryan TJ, Isom OW, Bennett E, Jones RH. Predictors of Readmission for Complications of Coronary Artery Bypass Graft Surgery in New York State, Journal of the American Medical Association, 2003;290:773-780. 8. Hannan EL, Racz M, Ryan TJ, McCallister BD, Johnson LW, Arani DT, Guerci AD, Sosa , Topol EJ. "Coronary Angioplasty Volume-Outcome Relationships for Hospitals and Cardiologists", Journal of the American Medical Association 1997;277(11):892-898.

  27. Lessons Learned Why Does it Work? Results are credible • Direct involvement and oversight by respected clinicians • Objective data validated to alleviate concerns that others may be gaming the system • Respected analysts • Infrastructure in NYS (regulatory and collaborative) provides mechanisms to ensure compliance

  28. Why Does it Work? (cont’d) The system is functional/clinically relevant • Provides tools for hospitals to self-evaluate • Part of an overall system of cooperative quality improvement • Feed-back from providers used to enhance system • Multiple uses

  29. Why Does it Work? (cont’d) Results are Available to Public • Administrators and program directors respond to public releases • Informed Public Asks Good Questions Cooperative and Committed Providers • Collaboration and commitment on part of providers/researchers/regulators

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