Ann Thorac Surg 1996;61:499-510
© 1996 The Society of Thoracic Surgeons
Presidential Address
The Bright Future of Cardiothoracic Surgery in the Era of Changing Healthcare Delivery
Frederick L. Grover, MD
University of Colorado Health Sciences Center, Denver, Colorado
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Abstract
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We are currently at a crossroads in our specialty and in the American healthcare delivery system. The manner in which we approach the next 5 to 10 years will deeply affect the future of our specialty. Thoracic surgery has had many accomplishments during my 35-year career that have improved the healthcare for the American public and others. As cardiothoracic surgeons, we have a legacy to be proud of, and the future promises to be every bit as exciting. In spite of these tremendous advances and the potential for future scientific achievements, there has been considerable uncertainty and pessimism because of the changing structure of healthcare in the United States. This has largely been stimulated by increasing healthcare expenditures leading to the development of health maintenance organizations in the hopes of curtailing expenses by competition and capitation. In addition to cost containment, managed care is likely to have an impact on the future workforce of cardiothoracic surgeons. Much of our future will be determined by how well we adapt to the changing environment and take charge of our destiny. The demand for performance information for managed care plans will be much greater than it has been in the past. It is, therefore, imperative that we collect data to reflect the quality and value of our work to ensure that significant quality is not being sacrificed for cost containment. We cardiothoracic surgeons must develop our own information management strategies so that we can be in control of our future. If we do this, I am confident that the future of cardiothoracic surgery will be a bright one indeed.
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Introduction
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We are currently at a crossroads in our specialty and in the American healthcare delivery system and are facing many of the challenges that other industries in the United States (US) faced as far back as the 19th century. We are experiencing an industrial revolution in medicine, as noted recently in the Wall Street Journal [1]. It is a watershed time for all of us, and the manner in which we approach the next 5 to 10 years will deeply affect the future of our specialty. It is not unlike the opportunity that confronted the railroad industry at the beginning of this century when it continued to perceive itself as only a railroad industry and not a transportation industry. Because of lack of vision, opportunities to expand into the air, trucking, and busing industries were missed, rendering this industry somewhat obsolete. This is similarly a period for cardiothoracic surgeons that requires considerable vision to continue the productive and innovative work that has been characteristic of our specialty over the past several decades.
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Acknowledgments
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Before delving further into this, I would like to acknowledge those people who have been particularly important in my life and career and have made it possible for me to be selected as your President, an honor that I take very seriously and deeply cherish. First, I would like to acknowledge the contribution of my parents who instilled those American values that we hear so much about today: hard work, hopefully integrity and honesty, and a strong dose of humility. Next, I would like to thank and acknowledge the tremendous support I have had from my wife, Carol, beginning in high school, then college, and then marriage, which included medical school and residency on through to the present time. Everyone understands the tremendous sacrifices that spouses make for their husbands or wives who are in the field of cardiothoracic surgery. In addition, I would like to acknowledge the support of my two sons, Fred Jr and Richard, who have also been very understanding of my time commitments and and have been a source of pride and pleasure for both Carol and me.
There are numerous people who we can all look back on as very influential in our career development. Doctor Ivan Brown, who was Professor of Surgery at Duke when I was a medical student, was a major influence in my decision to enter into cardiothoracic surgery. Doctor Brown, along with his colleague, Will Sealy, another major influence for me, were pioneers in the area of hypothermia and cardiac surgery beginning in the 1950s. Glenn Young, a master technician and exemplary surgeon, pointed out the importance of surgical excellence. Billy Peete, a general surgeon at Duke, taught me about relationships with patients and their families as well as fastidious surgical technique. Doctor David Sabiston set the example of combining academic excellence, a sense of surgical history, and an inquisitive mind in the surgical laboratory as well as total dedication to his profession. Doctor William Waddell served as the Department Chairman at Colorado when I was a resident. He taught me how to think in the operating room, be flexible, and adjust planned procedures as necessary. Doctor Thomas Starzl exemplified what can be accomplished with a combination of extraordinary brilliance, hard work, practical thinking, and the ability to take what is learned in the laboratory to the clinical arena. Doctor Ben Eiseman exemplified superb teaching, the ability to stimulate young people, and strong leadership. Doctor Bruce Paton not only taught me how to do cardiothoracic surgery but also taught me to keep a sense of humor and not take myself too seriously. Doctor David Ashbaugh was instrumental in my learning the techniques of pulmonary surgery, and Dr Henry Swan brought a wealth of historical perspective from the pioneering era of cardiothoracic surgery. I would also like to acknowledge the importance of Dr Robert Lanning, who as Chief of Surgery in the Veterans Affairs (VA) Central Office, appointed me to the VA Cardiac Surgery Consultants Committee and is largely responsible for my interest in outcomes research.
My 19-year stay in San Antonio was a very significant experience in my life, and I can thank my colleague, Dr Kent Trinkle, for his allowing me to develop independence during that period, and for his demonstration of innovativeness, risk-taking, honesty, and practicality. I would also like to acknowledge the contributions of Dr Brad Aust, the San Antonio Department Chair, who supported me and allowed me freedom to develop programs without interference, and Dr Don Campbell for his infinite wisdom in general thoracic surgery. From Denver I am indebted to the same type of support from Alden Harken, who embodies the well-rounded academic surgeon who is excellent in clinical surgery, research, education, and administration. I would also like to acknowledge the support of my long-time friend and colleague, Dr Marvin Pomerantz, who was willing to give up a very successful private practice in Denver to join our university and bring to it strength and depth in the area of general thoracic surgery.
I also must acknowledge the tremendous support and influence of all of my faculty colleagues and residents during my career. I sincerely believe I learn more from them than they learn from me. Finally, I want to express my appreciation to our secretaries, administrators, and nurse coordinators, many of whom are in the audience today from both Denver and San Antonio.
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Historical Perspectives
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Thoracic Surgery has had many accomplishments that have occurred during the 35 years of my career. Allow me to review a few of these, realizing that there are many more. Doctor Albert Starr made possible valve replacements in a reliable and reproducible fashion with the development of the first widely used valve prostheses in the early 1960s. There were major contributions by Dr Viking Björk in the area of valvular disease as well as congenital heart disease, and Dr Barrett-Boyes and Sir Donald Ross in the area of homograft valves and the Ross procedure, as reviewed by Dr Ronald Elkins in his Presidential Address last year. Doctor Chardack inserted the first successful, totally implantable pacemaker, starting an era of advances in pacemaker technology eventually leading to automatic internal defibrillators. Doctor David Sabiston performed the original coronary artery bypass operation, which Drs Favaloro, Loop, and Green popularized in the mid-1960s. Doctor Norman Shumway and his colleagues developed the technique for orthotopic cardiac transplantation and helped to bring about the commonplace use of this technique and therapy. Doctor Bruce Reitz developed the technique for combined heart/lung transplantation and has made this treatment a reality. Doctors Carpentier, Duran, Spencer, Cosgrove, Oury, Miller, and others have developed and refined the techniques for mitral valve repair. Doctor Cooley has made many contributions in all areas of cardiac and vascular surgery emphasizing technique and simplicity. Doctors DeBakey and Crawford have made numerous contributions in cardiac surgery and surgery for thoracic aortic aneurysms. Doctors Sealy, Harken, and Cox developed many innovative techniques in the area of electrophysiologic surgery. Doctors Kolff, Pierce, Pennington, and others have contributed much to the development of ventricular assist devices and totally implantable artificial hearts. Doctor Jatene developed the arterial switch for transposition of the great vessels. Doctor Norwood developed the staged correction of hypoplastic left heart syndrome. Doctor Castañeda has popularized total correction of complex congenital heart defects in infancy. Doctors Gay and Ebert revolutionized myocardial protection techniques by advocating cardioplegia. Doctors Wechsler, Buckberg, and others have produced numerous experimental and clinical studies refining the techniques of myocardial preservation. Doctor Jamieson has refined the techniques for pulmonary thromboendarterectomy for chronic pulmonary emboli. Doctor Bailey has developed the techniques for infant and pediatric heart transplantation.
In the area of general thoracic surgery, Drs Pearson and Grillo have been pioneers in the development of techniques for tracheal resection, and Dr Deslauriers in the area of sleeve lobectomy and pneumonectomy. Doctors Holmes and Ginsburg have led numerous multiinstitutional studies advancing our knowledge in adjuvant and neoadjuvant therapy for lung cancer. Doctor Cooper performed the first successful human lung transplantation. Doctor Trinkle made further contributions in this area by simplifying some of these techniques and demonstrating excellent results. Doctor Patterson deserves much credit for developing the bilateral sequential lung transplant technique. Doctor Cooper has successfully reintroduced lung reduction for patients with end-stage chronic obstructive pulmonary disease as an alternative to lung transplantation. Doctor Pomerantz has contributed much to the development of surgical treatment for patients with drug-resistant and atypical tuberculosis. Doctors Skinner, Belsey, and Orringer have made numerous contributions in surgery for esophageal disease. Doctors Roth and Pass are investigating the molecular biology of cancer of the lung, esophagus, and mesothelioma. Doctors Urschel and Roos have contributed to the surgical approach for thoracic outlet syndrome. Doctors Miller, Daniel, and many others have developed techniques for thoracoscopy and have better defined the indications for the use of this new and innovative technique. In the areas of outcomes research, my long-time friend and colleague, Dr Karl Hammermeister, developed the methodology for the VA Risk Assessment Study and continues to make innovative contributions. Also with important contributions are Drs Richard Clark and Fred Edwards for The Society of Thoracic Surgeons (STS) Database, Drs Bill Nugent and Steve Plume for the Northern New England Cardiac Surgery Database, and Dr Bob Jones with the Duke Database. Finally, there are those who are making major contributions in the area of healthcare administration, such as Dr Jack Matloff.
As cardiothoracic surgeons, we, therefore, have much to be proud of in terms of accomplishments over the past 35 years that have resulted in improved life expectancy and quality of life for hundreds of thousands of patients. The future promises to be every bit as exciting. The field of transplantation is still in its infancy. Results continue to be improved as new antirejection drugs and regimens are being discovered and developed. We are not far away from the use of xenograft solid organ transplants, and much of this is going to result from genetic research and engineering. Gene therapy strategies are being developed for the treatment of cardiovascular disease, including atherosclerosis risk factors, prevention or retardation of vascular disease, and prevention of myocardial infarction [2]. The area of minimally invasive surgery is still in its infancy. Pump oxygenators are continually improving, and many advances in the field of left ventricular assist devices and totally implantable hearts are in progress. The areas of molecular biology in cardiac, pulmonary, and esophageal disease are wide open. In addition, advances in the field of immunology continue with evaluation of chimerism as one example that may lead to improved results for transplantation [2]. These are just a few of the many exciting areas that remain in the future of our specialty.
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The ``Industrial Revolution'' in Healthcare
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In spite of the tremendous advances and the potential for future advances in our specialty, there has been great uncertainty and some widespread pessimism over the past several years because of the changing structure of healthcare in the US. We are experiencing an industrial revolution in the healthcare industry stimulated by rapidly increasing costs to the point where the general population deemed that the cost was out of control and could no longer be tolerated.
An article in the New York Times in December 1993 noted that for the first time healthcare expenditures in the US were expected to exceed $1 trillion dollars in the following year [3]. It noted that health care spending would rise $118 billion to $1.06 trillion, and would account for 15% of the nation's total output of goods and services (a 12.5% increase), and that healthcare expenditures were projected to rise by an average annual rate of 13.5% during the next 5 years and would account for 18% of the gross domestic product by the year 2000. This article reported that much of the care in the US might be unneeded, with estimates of unnecessary tests and procedures at $130 billion per year. The article reported that from 1987 to 1992, health maintenance organization (HMO) enrollments rose to 41.4 million from 29.3 million. The breakdown of healthcare spending predicted for 1994 is shown in Figure 1
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Fig 1. . Health spending, as a percentage of gross national product, has consistently increased from 1981 to 1994 from 9.6% to 15%, or $1.06 trillion dollars. Physician services account for only 18% (194.9 trillion dollars). (Reprinted with permission from New York Times, December 29, 1993:A12).
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A Wall Street Journal article [1] reported that, ``The federal movement to reform healthcare began unraveling the moment the health care system started to show real signs of reforming itself.'' Its author likens the changes in our healthcare delivery system to ``medicine's industrial revolution.'' He notes that the healthcare industry is moving to rationalize healthcare delivery by measuring the costs and benefits of treatments and by comparing the outcomes of different providers. He believes that the cost crisis awakened the healthcare purchasing community to the fact that an unscrutinized or unsupervised system means unlimited cost increases and that certain treatments, ``regardless of how scientifically compelling, are not worth the money.'' Matloff [4] noted that the complex social and medical environment in our society is ``characterized by increased costs, variable excess, uncertain and unequal quality, and bioethical concerns about what it is we are doing and for whom.'' He notes that 15% of the population may be using up to 70% of the resources and that by the year 2010 healthcare expenditures will likely be 18% of the gross national product and that by 2030 it could be 25%. It is projected that the current health care insurance cost of $4,000 per employee per year could grow to $17,000 by the year 2000 if current trends continue.
Johnson [5] calls the current era of healthcare the ``economic era.'' He describes three historical eras of the health care industry in this century: the charitable era, the technological era, and the new economic era of competition. He notes that the charitable era began at the turn of this century and lasted for approximately 50 years ending shortly after World War II. After World War II, the technologic era came into being because of the many advances in medicine; this resulted in specialization, and many of the not-for-profit hospitals were transformed from charitable institutions into a ``technological enterprise.'' With the introduction of management systems into hospitals, governing boards no longer relied on donations and fund-raising drives, and by the end of the 1980s the transformation to the economic era had taken place. This involved consolidation and competition, with the ``free standing hospital and solo practitioner being replaced with systems of hospitals and group practices of physicians as they aggregate their services.'' Johnson believes that 20 years from now the end result will be a for-profit, organized delivery system composed of hospitals, primary care physicians, specialists, and a prepayment plan.
Eisenberg [6] reported that 75% of physicians had at least one managed care contract in 1993. DelBanco and Smith [7] report that according to the Group Health Association of America by the end of 1994 more than 50 million people were receiving their care in approximately 574 managed care organizations (Fig 2). This represented an increase of almost 50% since 1988 and 300% since 1983, with the highest group being seen on the West Coast, New England, and in the mountain states (Table 1). One of the major goals of managed care is to control healthcare costs partially by controlling inappropriate utilization of resources. The methods by which these organizations tend to control costs is through intensive utilization review, feedback to physicians and health care providers on practice patterns, financial incentives for physicians to behave in a certain manner, and the development of practice guidelines to standardize treatment. The managed care organizations also attempt to eliminate any incentives for over-treatment, knowing that fee for service inherently offers incentives for providers to do more rather than less. DelBanco and Smith note that the potential disadvantages of managed care are that a healthcare provider could be pressured by the organization to withhold services, providers might also be subject to doctrines or political or financial bias' from the management of the HMO, there is an incentive to undertreat, and there will undoubtedly be conflicts between cost-effectiveness and quality.
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Fig 2. . Note the increase in the number of Americans who are receiving their healthcare from a health maintenance organization (HMO) from 1976 to 1994. (Reprinted with permission from Patterns in HMO enrollment. 4th ed. Washington, DC: Group Health Association of America, 1995:7.)
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Utilization review is an integral part of managed care [8] and includes analyses of physician practice patterns. It requires sophisticated management information systems to allow for determination of true costs and analysis of use patterns as well as quality of care. Mechanic [9] notes that utilization review management will result in denial of some care that would be beneficial but that this needs to be balanced against the risks of unnecessary procedures, which also can involve risks to the patients as well as increase costs.
Weil [10] in a provocative article notes that there is a ``paucity of available evidence of the potential cost savings when establishing networks or implementing capitated payment.'' He, therefore, believes that the use of managed care as a key force in controlling health care expenditures should be viewed as a relatively temporary solution with a projected window of 3 to 5 years. He notes that managed care plans by their micromanagement have generally achieved a one-time 7% to 10% overall cost reduction. He is concerned that too many managed care plans will select lower quality and lower cost providers who are dominated mainly by fiscal incentives rather than protecting their patients' best interest and in spite of this will have difficulty in decreasing administrative and related overhead expenses.
The issue is, therefore, economic, with the provider wanting to protect income and the payor wanting to limit expenditures, but underlying all of this is a concern by the providers as to how the economics may affect their ability to provide quality care. For years physicians have been taught to place the patient's well-being first and to somehow take care of the finances as a secondary matter. Now as physicians we are being told, along with the other providers, to bear all of the risk and the prepayment organization now is primarily a conduit for financing.
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Limitation of Resource Utilization
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Miller and Luft [11] found that when compared with indemnity plans HMOs had lower hospital admission rates, shorter hospital lengths of stay, the same or more physician visits per person, less use of procedures and tests, and greater frequency of preventive services. Some lessons regarding limitation of resource utilization by managed care can be gleaned from comparing the Canadian experience with the US experience. Naylor (personal communication) notes that the age-adjusted rate for coronary artery bypass grafting in New York in 1989 was 88 per 100,000 adults compared with 63 per 100,000 Canadians in Ontario and 57 per 100,000 in British Columbia. Also the rate of coronary angiography in Canada was approximately 250 per 100,000 adults compared with 397 per 100,000 adults in New York State. Among those undergoing angiography, 19% were noted to have insignificant disease in Canada as compared with 33% in New York. However, more patients in New York were identified as having serious coronary artery disease needing intervention, some of whom had left main disease. It therefore follows that the Canadians were missing some patients with left main disease because of not being as aggressive in their catheterization indications. This demonstrates, however, that managed care does decrease resource utilization.
Mark and colleagues [12] evaluated the use of medical resources and quality of life after acute myocardial infarction in Canada and the US. They found that the Canadian patients had a 1 day greater length of hospital stay than US patients but a much lower rate of cardiac catheterization (25% versus 72%; p < 0.001), coronary angioplasty (11% versus 29%; p < 0.001), and coronary bypass grafting (3% versus 14%; p < 0.001). By 1 year, 53% of US patients and only 24% of Canadian patients had undergone angioplasty or coronary artery bypass grafting. However, the Canadians had more visits to physicians during that year but fewer visits to specialists. At 1 year the US patients had a significantly improved functional status as compared with the Canadian patients. It is reasonable to conclude that with increased managed care in the US with the emphasis on cost containment and decreased resource utilization there will be trade-offs in terms of patient functional status and quality of life. It is important, therefore, that we surgeons collect data to assure that significant quality is not being sacrificed for cost containment.
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Effects on Academic Centers
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The effect of managed care in the changing healthcare environment on academic centers has been reviewed very nicely in four key articles. Goldman [13] notes the tremendous scientific developments that have resulted from some of our research intensive academic centers but at the same time these centers are in jeopardy of losing their central role, particularly in those geographic areas that have been most affected by managed care. This has resulted from the fact that the major incentives now are on cost containment and the limitation of consultants, procedures, admissions, etc. The challenge will be to maintain the commitment to teaching and research while at the same time incorporating practical changes to survive in the current marketplace. This is going to require a change of attitude of many of the medical school faculty where they must devote more time to practice that is cost-effective. Epstein [14] notes that on the average teaching hospitals have 20% higher costs than nonteaching hospitals even after adjustment for patient case mix and that these costs are generally related to the number of trainees. Part of these excess costs have historically been paid by Medicare in the form of $4.2 billion covering the indirect costs of medical education and $1.9 billion covering the direct costs of medical education. The remaining difference is distributed to private insurers, who pay teaching hospitals approximately 20% more than they pay community hospitals. The current changes in the healthcare environment threaten to upset this precarious financial funding. Rogers and associates from Duke [15] report attempts to change a large academic institution to meet the challenges of the managed care environment. Department chairs no longer can make important decisions on their own in a vacuum, but these must be made together as a group and must be closely coordinated. The potential conflicts between the goals of an academic institution and the hospital have to be worked out as well as refocusing from providing almost all tertiary care to providing managed care. These changes have forced the physicians to share in utilization review concepts and practice guidelines. Billi and colleagues [16] studied the requirements for HMO support of the 1992 levels of faculty and activity in the University of Michigan specialty areas and estimated that it would require an enrollment of more than 250,000 persons to keep even.
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Workforce Issues
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Iglehart [17] projected that the supply of physicians providing direct patient care will outstrip the number required by 30%, meaning a surplus of approximately 165,000 practicing physicians, virtually all specialists. Ritchie and colleagues [18] studied workforce issues in cardiology and noted a 50% increase in the production of adult cardiologists since 1975, but the number of cardiothoracic surgeons certified yearly from 1974 to 1993 had actually decreased (Fig 3). Sheldon [19] reported that between 1960 and 1988 the US physician/population ratio increased by more than 70%, and between 1988 and 2020 the ratio is projected to increase modestly. The United Kingdom, which is organized somewhat comparable to a large HMO, has 54 generalists per 100,000 population, whereas the US currently has 65 generalists per 100,000 population. The HMO staffing patterns have been suggested to be 56 generalists per 100,000. It would, therefore, appear that we have a current generalist workforce adequate to meet the needs of the changing healthcare environment. The US ratio of practicing physicians per 100,000 population has increased from 157 in 1970 to 233 in 1990 and will probably be greater than 292 by the year 2010. The market place may trigger adjustments, however, as noted in the 1995 match for anesthesiology resident positions. Sheldon [19] notes that specialties that are likely in balance are general internal medicine, family practice, general pediatrics, obstetrics and gynecology, general surgery, otolaryngology, and thoracic surgery. Specialties in excess are those in internal medicine except geriatrics. Cohn and colleagues [20] surveyed 3,049 thoracic surgeons and found that 65% were still practicing on fee for service, with 76% doing both general thoracic and cardiac surgery, 12% cardiac only, 10% general thoracic only, and 2% pediatric cardiac only. Of interest was the relatively even age distribution of practicing cardiothoracic surgeons from age 30 to 60 years, with only a moderate decrease (18%) in the 60- to 70-year-old group, and the distribution of the volume of adult cardiac (18% performed 50 or fewer cases and 36% 100 or fewer) and general thoracic cases (30% performed 0 to 25 cases). Cohn and colleagues were reluctant to make predictions on future workforce needs because of the rapidly changing healthcare environment coupled with scientific advances.
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Fig 3. . The number of cardiothoracic surgeons who are certified annually is shown: Note the slight decline since 1974. (Reprinted with permission from the American College of Cardiology [J Am Coll Cardiol 1994;24:275–328].)
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The Need for Quality Performance Data
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It is quite evident that managed care has arrived and that there will be considerable rough water to navigate through during the next several years as we take on the challenge of changing healthcare management and economics. Much of our future will be determined by our attitude and how well we take charge of our destiny and adapt to the changes. It is often helpful to look at other disciplines for hints on how to manage in changing and challenging times. Harvard economist Rosabeth Moss Kanter, in her book entitled World Class: Thriving Locally in the Global Economy [21], states that:
As the world's last super power, is the United States stuck in the past or creating the future?...Americans are living in a time of contradictions, a time of role reversal, and a time in which old expectations are violated so frequently that new expectations cannot form.... But excellence is no longer to be taken for granted nor future success guaranteed by past performance. Customers are more informed about choices available elsewhere, because of the power of information technology and world communication systems.
Thus, similar changes and opportunities are taking place in the global economy area compared with medicine and in thoracic surgery. But as Kanter states, if one uses information technology and is open to change, there is the opportunity for success.
Ramsey [22], in an article called ``Revolution in Real Time; Physician Practice Management in the 21st Century,'' defines medical informatics as involving ``the conversion of data into information that allows the physician manager to direct outcomes, quality and costs.'' He defines quality management as ``empowering employees and physicians to participate in improving the overall performance of the practice.''
DesHarnais and colleagues [23] note that no matter what the outcome of healthcare reform may be, the information systems will continue to progress and change accordingly to meet the needs. They note that information from comparative databases will be obtained on hospital performance and physician performance, as well as information to meet business and community demands. Risk-adjusted data will be necessary for both internal and external use in monitoring performance. Methods of measuring processes and structures need to be developed as well as further refinements of these monitoring tools. DesHarnais and colleagues predict that the demand for performance information for managed care plans is ``likely to be much more encompassing than it has been.'' In addition, they note that ``health care providers need to start now to develop information management strategies that permit us to build on a current structure for information management while anticipating the changes that will be needed in the new environment of health care reform and managed care.''
Matloff's group [24] notes that our healthcare system is under great pressure to cut costs but at the same time maintain quality. This system will require large quantities of data to ensure optimal medical and financial decision making. They make a strong point that for providers to be successful in the managed care environment they must be able to demonstrate that they are delivering high-quality care at a competitive price. To do this, it is mandatory that they have very useful clinical, administrative, and financial information databases. They note that the managed care organizations are primarily interested in four categories of information: ``medical outcomes, methods to assess for quality of medical decisions, systems for continuous quality improvement, and financial outcomes.'' They further note, as have others, that mortality, morbidity, quality of life, and patient satisfaction are the major outcomes of interest as a measurement of the quality of the processes of care, and emphasize that as capitation becomes more prevalent the managed care organizations will be interested in long-term outcomes not just single episodes in a patients' healthcare history. All of this leads to individual physician profiling to determine not only the quality of care that the physician gives but the cost-effectiveness of his or her care. Matloff's group concludes that those who have sophisticated informatics will be at a very large economic advantage. Because major decisions in the changing healthcare environment will be made on the basis of cost and quality measurement data, it behooves all of us to be absolutely sure that these data are collected and analyzed in a most accurate and representative fashion.
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The Current Status of Outcomes Databases
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I have had a major interest over the past 10 years in measuring outcomes in cardiothoracic surgery and will review my personal thoughts on this topic with you. The criteria by which healthcare is measured are quality, accessibility, and cost-effectiveness [25]. Doctor Galen Barbour, the former Head of Quality Assurance in the VA system, also includes patient feedback. Quality of care is defined as the degree to which health services increase the likelihood of a desired outcome. Outcomes that are generally measured are mortality, morbidity, functional health status, utilization, cost, and patient satisfaction. Dimensions of risk include age; sex; acute clinical stability; principal diagnosis; the severity of the principal disease; co-morbidities; preoperative functional status; psychological, psychosocial, and socioeconomic characteristics; patient compliance; and many other attitudinal and cognitive parameters. If patient risk factors are adjusted for, the outcome is generally determined by the processes or structures of care or by random chance. Because random chance is relatively constant, if one properly controls for the risk, the changes in quality should be related to the processes and structures of care. A structure of care refers to the facilities, equipment, services, and the care-givers' credentials and qualifications. Processes of care include the care and services provided and the process by which patients are moved through the system.
There are several factors that limit the reliability of our current risk-adjusted database systems. These include the source from which the data are collected, ie, clinical or administrative, whether they are collected prospectively or retrospectively, the experience of the data collectors, the lack of standardization of definitions between and within databases, and whether enough patients and outcomes are present so that statistical analyses can be appropriately run. There is always the potential of gaming of data and also the problem of how to handle missing data. Rare high-risk factors may not be part of the risk model, and therefore mortality for patients with such risks may be under-predicted. Most of these models have not been rigorously validated or have not had their reliability determined. Currently the reliability, as determined by the C-index, is about 0.7 for most of the databases, halfway between random chance and total predictability.
There are currently several large cardiac surgical databases. My colleague, Dr Karl Hammermeister, and our Cardiac Surgery Consultants Committee with the support of Dr Galen Barbour and Dr Gerald McDonald, Acting Director of VA Surgery, began the VA risk assessment cardiac surgery database in 1987 and have entered approximately 7,000 patients per year. Ten to 12 preoperative risk factors were found by logistic regression analysis to be important predictors of operative mortality. From these data the expected mortality for a patient can be calculated as well as odds ratio for operative death (Table 2). Observed to expected mortality ratios can also be calculated (Fig 4). In the VA system this is done every 6 months and these data are communicated back to the 43 VA cardiac surgical program directors so that they can evaluate their performance relative to their peer group and hopefully improve care. Over the past 7 years using this methodology there has been a significant decrease in the risk-adjusted mortality in the VA system (Fig 5). Similar decreases have also been seen in the New York, Northern New England, and STS databases and are likely due to a greater awareness and recording of risk factors, perhaps better selection of patients, better surgical technique, and the continual feedback of these data.
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Fig 4. . The observed to expected mortality ratios are shown for each of the 43 Department of Veterans Affairs cardiac surgery programs. This graph is distributed to each cardiac surgery program director every 6 months. (Reprinted with permission from The Society of Thoracic Surgeons [Ann Thorac Surg 1994;58:1845–51].)
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Fig 5. . The Veterans Affairs observed to expected (O/E) mortality ratios for 6-month periods from 1987 to 1995 are shown. There has been a significant decrease in risk-adjusted mortality over this period.
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The STS Database was also started in 1990 and includes more than 500 groups and approximately 750,000 patients [26]. The database has been chaired very ably by Dr Richard Clark, with the statistical analysis being directed by Dr Fred Edwards. This large database also allows the estimation of operative mortality from group to group and calculation of observed to expected mortality ratios. The New York State Database began in 1987 under the direction of Dr Edward Hannen [27]. The risk stratification technique is similar to the VA's. The Northern New England Cardiovascular Study Group was also organized in 1987 and measures adjusted mortality rates, which were found to vary between hospitals more than could be explained on case mix alone [28]. This is a voluntary database and serves as an excellent example of several groups of surgeons getting together in an attempt to improve their quality of care using carefully collected data. Outcomes have been expanded to include patient satisfaction and functional health status items.
In spite of all of the progress that has been made in risk modeling, the perfect risk stratification model to judge quality and cost will probably never exist, and even with continued refinement it is doubtful that one will achieve outcome predictability of greater than 80% to 85% (C-index). It is therefore recommended that these risk-adjusted outcomes be used only as relative measurements to trigger internal review for quality improvement and cost-effectiveness.
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The Need for Cost and Cost-Effectiveness Data
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Iezzoni and Greenberg [29] note that purchasers believe that because of the great increases in healthcare costs over the past several decades that providers must become accountable for what they produce, that other industries are forced to measure the quality of their products and to justify their outputs, and that the healthcare industry should be no exception. Schwartz [30] emphasizes the importance of striking a balance between cost and quality so that quality is maintained. Noting that managed competition must have reliable, solid information on both quality and cost, he makes the very important comment that, ``in the absence of valid, reliable, and relevant information on quality and outcomes of care, decisions will be made on the basis of the cost alone.'' Ungerleider speaks of value in healthcare and notes that value is related to quality and cost with the equation V = Q/C. At the current time, most third-party carriers and HMOs appear to be assuming that quality is relatively uniform across centers, and therefore when using the above equation quality becomes a constant, or V = K/P. If this is the assumption, then the only way to increase value from the perspective of the third-party carriers is to decrease price.
For costs or charges to be appropriately analyzed, however, it is mandatory that patients be risk stratified so that costs can be predicted according patient risk factors. This is important not only for physicians and hospitals to predict the costs based on their patient population, but also so that they can negotiate mutually satisfactory contracts. In an attempt to stratify for risk, Dudley and co-authors [31] found that a lower ejection fraction and older age were independent predictors of increased cost for coronary bypass grafting. Weintraub and colleagues [32] found that wound infection, pneumonia, arrhythmias, age, neurologic events, postoperative infarction, and ejection fraction were predictors of increased hospital length of stay after coronary bypass operations.
The STS Database currently estimates predicted length of stay based on preoperative risk of death sextile [33] (Fig 6). Similarly, my colleagues Shroyer and MaWhinney have performed risk-adjusted length of stay estimates in the VA system and express this as observed to expected length of stay (Fig 7). Although length of stay is a gross predictor of cost and charges, it also is an indicator of both the efficiency and cost-effectiveness of an individual hospital or surgeon. It is imperative that in the near future we tie the risk-adjusted outcome databases to the cost databases to measure not only lengths of stay but actual hospital costs and charges in terms of factors such as laboratory and diagnostic studies, operating room charges, and pharmacy charges. It is only by obtaining this type of data that true cost will be known and used for contract negotiations and be used as a tool to become more efficient and cost-effective.
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Fig 6. . This graph shows the estimated length of stay (LOS) according to estimated risk of death after coronary artery bypass grafting (n = 95,504) from The Society of Thoracic Surgeons database. Length of stay can be used as an indicator for cost. Patients missing dates are censored. (S.E. = standard error.) (Reprinted with permission from The Society of Thoracic Surgeons Database Report, January 1995.)
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Fig 7. . Observed postoperative length of stay (LOS) for coronary artery bypass grafting patients is compared with a risk-calculated length of stay giving an observed to expected (O/E) length of stay ratio for each of the 43 Veterans Affairs Medical Centers performing cardiac operations (4/1/94 to 9/30/94; preliminary analysis, 8/17/95).
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Use of Databases for Developing Policy
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The power of a database to answer questions that arise in the development of healthcare policies should not be underestimated. For example, we have recently had inquiries regarding the minimal volume of operations necessary to maintain both quality and cost-effectiveness directed to us in both the VA and private sector through the STS. When analyzing the VA, STS, and New York State Databases it became evident that the minimal group or hospital minimal volume of cases for comparable outcomes was approximately 100 to 125 cases per year [34–36] (Fig 8). This was in contrast to some of the guidelines that have been set by the American College of Cardiology and the American Heart Association. Guidelines for individual surgeons could not be determined because of a lack of surgeon-specific data in the VA and STS databases. In addition, the question has been asked, is there a critical volume of operations that must be performed by a hospital or a surgeon to result in cost-effective care? At the VA we have compared risk-adjusted stratification for volume and length of stay (as an indicator of cost) and have found no relationship.
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Fig 8. . The observed to expected (O/E) ratios for mortality are plotted against hospital annual volume for the 43 Veterans Affairs cardiac surgical programs over a 5-year period. There is less variability among the higher volume hospitals as compared with lower volume hospitals, but there are numerous hospitals with excellent O/E ratios in the lower volume group. Threshold analysis revealed a significantly higher mortality in those centers performing fewer than 100 cases per year. (Reprinted with permission from The Society of Thoracic Surgeons [Ann Thorac Surg 1996;61:17–20].)
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Another use of databases is in evaluating accessibility of care. Carroll and colleagues [37] investigated the waiting times by country for elective and urgent coronary angiography and coronary bypass grafting. Carroll and colleagues measured waiting times for elective coronary bypass grafting in the US non-VA population, the US VA population, Canada, Sweden, and the United Kingdom (Fig 9) and measured the same for urgent coronary artery bypass grafting. It is interesting that both US systems reflected greater accessibility than did the more socialized/managed systems. When accessibility problems are identified, measures can be taken to correct them as has been done in Canada by increasing the number of catheterizations and interventional procedures.
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Fig 9. . The distribution of waiting times by country for elective coronary artery bypass grafting is shown as a measure of accessibility of care. The waiting time is shortest for non-Veterans Affairs (VA) United States hospitals, next shortest for United States VA hospitals, and longest for Canada, Sweden, and the United Kingdom. (Reprinted with permission from the American College of Cardiology [J Am Coll Cardiol 1995;25:557–63].)
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Large databases can also compare relative efficiencies of hospitals so that one can monitor the effectiveness of changes in processes and structures of healthcare. For example, in Figure 10, lengths of stay of the Denver VA cardiac surgical patients compared with other VA hospitals before and after a fast-track protocol was installed are shown, reflecting a shortened length of stay because of a change in a process of care.
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Fig 10. . Unadjusted postoperative length of stay for coronary artery bypass grafting in the 43 Veterans Affairs (VA) hospitals before (A) and after (B) Denver began a fast-track protocol. Note the shorter length of stay at the Denver VA hospital as compared with the peer group by changing this process of care.
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Another use of a large database is to develop practice guidelines and clinical pathways. Doctor Karl Hammermeister has almost completed the development of a very sophisticated computer-based practice guideline and clinical pathway for ischemic heart disease. This involves interaction with the healthcare providers at computer terminals located in various clinical areas of the hospital and provides clinical decision aids in the form of clinical practice guidelines, predicted cost, and predicted outcomes in real time as the physician is making clinical decisions on individual patients. The decisions made and treatment given will be captured as well as the eventual outcome of the patient so that the database outcomes analysis can be continually updated and may be used as a ``standard of treatment.''
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Ethical Implications
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Robert Sade [38], in his Southern Thoracic Surgical Association Presidential Address in 1991, touched on ethics in the current healthcare environment including the fact that the current environment is forcing us, as thoracic surgeons, to become ``double agents,'' where we are supposed to be the patient's advocate, but at the same time are thrust into cost control and containment. Potential conflicts may arise when we are dealing with severely ill patients who are high risk, needing potentially high-cost procedures with a marginal chance of long-term benefit. What is the right choice? How do we balance these conflicting demands? These are difficult issues that we need to discuss and confront honestly and openly as we move through this changing healthcare environment, but we must rely on accurate data to make ethically responsible decisions.
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Conclusions
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This is indeed medicine's industrial revolution, and during the next decade our generation of thoracic surgeons will be measured on our ability to navigate through these challenging waters to keep the course of maintaining quality while at the same time becoming more efficient. In the process, we must incorporate the emerging discipline of healthcare informatics into our everyday practice so that we can track the effectiveness of our different therapies for different groups of patients both in the areas of quality and cost, including long-term quality of life and functional status. Doctor Kenneth Shine, President of the Institute of Medicine, recently said in an address, ``Quality is the anchor piece on which we can focus during these changing health care times.'' Let us, as the current generation of cardiothoracic surgeons, accept these challenges and successfully carry the proud and productive tradition of our noble specialty into the 21st century.
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Acknowledgments
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Abstract
Introduction
