Transcript Who is Vancouver Coastal Health?
Slide 1
Using Health Economic
Framework to Determine the
Benefits of Participating in a
Surgical Outcomes Measurement
Program
Linda Dempster, RN MA
Quality and Patient Safety
Vancouver Coastal Health Authority
Slide 2
disclosures
• Nothing to disclose
Slide 3
Objectives
• Vancouver Coastal Health and B.C.
Healthcare
• National Surgical Quality Improvement
Program (NSQIP)
• Health Economic Framework
• Applying the Framework
• Evaluating the Program
• Conclusion
Slide 4
How does the BC
healthcare system
operate?
Slide 5
BC Health
Authorities
Slide 6
Vancouver Coastal Health
Population
Health and
Wellness
Primary
Health
Care
Home and
Community
Services
Mental
Health and
Addictions
Acute Care
Slide 7
Vancouver Coastal Health
VCH serves 25%
of BC’s population
(over 1 million
people) in 17
Municipalities and
15 First Nations
Communities.
Slide 8
Who is Vancouver Coastal Health?
22,000 staff, 2,500 physicians and 5,000
volunteers working at 556 locations
including 13 hospitals, and 15 community
health centres.
Slide 9
Every day in VCH region we see:
914 patients in our emergency departments
5 life or threatened organ cases
316 surgery patients in our operating rooms (5 days a week)
2,065 ambulatory patients
1,961 inpatient days
175 people in the community for occupational or physical
therapy (PT/OT)
891 home care nursing visits
6,240 residential care clients
891 assisted living tenants
5,121 home support hours
http://www.vch.ca/about_us/quick_facts/
Slide 10
Economic Burden of Adverse Events*
The rate of
AE
7.5 %
The total number of
discharges per year
84,043 (VCHA)
Additional
attributable acute
care days per AE
6 days**
Of which 37 %
are
preventable
Economic burden of
preventable AE
$ 15,329,475
Median cost per
acute care day
$ 1,100
Economic burden of
AE
$ 41,601,285
7.5% AE x 84.043
discharges x 37%=
2,332 preventable AE per
year
Resources:
* Baker, N. et al.: The Canadian Adverse Events Study. CMAJ. 2004. Vol. 170(11): 1678-86.
**Etchells, E. et al.: The Economics of Patient Safety in Acute Care. Canadian Patient Safety Institute. 2012.
10
Slide 11
Reducing surgical events
• We had limited data on our surgical events
so invested in participating in the ACSNSQIP program
• A significant investment
• No risk-adjusted data for 2 years
Slide 12
National Surgical Quality Improvement
Program (ACS NSQIP)
• International measurement program that allows
>400 hospitals to accurately compare
complication rates
• American College of Surgeons
• preoperative, perioperative and 30 day
postoperative variables
• 24 sites in BC
• PHC/VCH started in 2011 with 6 sites
• Identifies areas to focus on
12
Slide 13
VCH NSQIP by Numbers
13
Slide 14
Health Economic Evaluation
Health Economic Evaluation
•
•
•
•
Competition between resource scarcity and providing the best possible care
Economic outcome measurement, efficient use of resources
Patient focused
Long-term evaluation
Cost-Benefit Analysis
•
•
•
Evaluation of costs and
consequences in
monetary units
Opportunity Costs
Cost Avoidance
System Access
•
Translate results into
improved access to the
system, e.g.
• Bed days / Patient
days
• Wait times
• Patient Volume
Projection Analysis
• Assess the potential of a
quality improvement
initiative before
implementation
Is an intervention
worthwhile?
Acknowledgement; Stefanie Raschka health economist
14
Slide 15
Evaluation Framework
Stefanie Raschka, Health Economist
1.
2. Productivity & Efficiency
Quality Outcomes
• Length of Stay
• Admissions / Readmissions
• Work Flow / Surgical Volume
• Employee Turnover and Staff Absence
• Patient/Employee Satisfaction and
Experiences
• Adverse Events / Occurrences
• Healthcare Acquired Infections
• Mortality & Morbidity
Making
“Cents“
4. Program Costs / Investments
3. Health Economics
• Operational costs
• Implementation costs
• Training and Education
• Consultancy Support
• Cost-Benefit Analysis
• Return-on-Investment
• Cost Avoidance
• Access (e.g. additional patient days, beds freed)
15
Slide 16
Patient Experience
Patient Experience
Mean Surgical Patient Satisfaction VCH
•30 Day Follow-up:
5
4.8
4.6
4.4
4.3
4.16
4.2
4.03
4
3.8
4.34
4.34
4.36
Use of overall satisfaction
question:
“How would you rate your
overall surgical experience
on a scale of 1 (being the
worst) and 5 (being the best)
at…”
• Including Open
Comments
16
Slide 17
Physician & Staff Feedback
“The way the data is collected forces surgeons to believe
it. We can’t debate on standardized, risk-adjusted
outcomes. We can’t hide or run away anymore!”
“We are all speaking the same language”
17
Slide 18
Strong belief that NSQIP will improve the
quality of surgical care
“It provides us with powerful data we never had before”
“It is bringing the idea of quality improvement to the frontline, right into the OR”
18
Slide 19
Using your own data to make the case
Potential by Occurrence
VCH - Patient Day Opportunity
Patient Day Opportunity (per year)
10,000
9,219
9,000
If we reduce adverse events
rate by 100%:
8,000
7,000
6,000
4,609
5,000
• VCH: highest potential for
SSI (2,693 pd),
Pneumonia (2,079 pd),
Ventilator>48hrs (1,577 pd)
4,000
3,000
2,305
2,000
1,000
0
25% Reduction
50% Reduction
100% Reduction
19
Slide 20
More Predictions
Patient Case Opportunities
VCH - Patient Case Opportunities
Patient Case Opportunities (per year)
1,600
1,415
1,400
1,200
If we reduce adverse events
rate by 100%:
1,000
800
• VCH: highest potential for
General Surgery (522 cases),
Orthopedics (254 cases)
707
600
400
354
200
0
25% Reduction
50% Reduction
100% Reduction
20
Slide 21
Economic Burden of our Surgical
Adverse Events
Adverse Event
Cardiac events
Pneumonia
Unplanned Intubation
Ventilator . 48 hours
DVT/PE
Renal Failure
UTI
SSI
Total
Patient Cases
per Year
89
300
47
205
108
119
123
422
1,415
Patient Days
per Year
575
2,079
376
1,577
558
690
671
2,693
9,219
Costs per Surgical
Cost for the treatment of
Adverse Event
surgical adverse events
$ 7,789
$ 695,558
[$ 10,019 - $ 57,158]
$ 3,009,708
$ 10,019
$ 2,524,788
$ 18,310
[$ 18,414 - $ 25,219]
$ 942
$ 15,331
$ 1,971,987
$ 2,196,790
$ 116,149
$ 6,474,281
$ 16,989,260
1,415 adverse events out of 21,680 annual inpatient cases (7%)
Acknowledgement: AnalysisWorks, Vancouver B.C.
21
Slide 22
Enhanced Recovery After Surgery
Projection Analysis - Using ERAS to Reduce Length of Stay
Number of
cases
Bed days
ALOS
Reduction
of LOS
Bed days
avoided
Additional
patients treated
General Surgery
3,235
28,843
9
2 days
6,198
885
Cardiac Surgery
Gyn/urological
Surgery
951
10,256
11
4 days
3,599
514
2,748
8,428
4
2 days
2,932
1,466
Total
6,934
47,527
12,729
2,866
Service
*The analysis is based on a one year period (2011/12).
The occurrence rate for complication is based on NSQIP data reports.
22
Slide 23
Cost Benefit Analysis
with Targets
Scenario 1: 25% - 10% - 10%
Program Costs
T1 = 2011/12 T2 = 2012/13
$762,319
$1,327,842
Special Projects (ERAS)
T3 = 2013/14
$1,327,842
T4 = 2014/15
$1,414,027
T5= 2015/16
$1,456,448
$120,000
Cost Avoidance
∆ 25 % in T3
$0
$0 ∆ 345 cases $4,247,315
∆ 10 % in T4
$1,275,196
∆ 10 % in T5
∆ 95 cases $1,143,900
Profit
-$762,319
-$1,327,842
$2,799,473
-$138,831
-$312,548
∑
-$762,319
-$2,090,161
$709,312
$570,481
$257,933
23
Slide 24
So- what have we done!
We continue to receive ongoing funding…
Slide 25
VCH Quality Initiatives
Urinary Tract
Infections
VGH Cardiac
Events
Review
Pneumonia
(VGH & RH)
Enhanced
Recovery
After Surgery
Surgical
Quality
Improvement
Normothermia
QI
Committees
VGH Cardiac
UBC OR
Surgical Site
Infections
(VGH &LGH)
25
Slide 26
SSI Prevention
26
Slide 27
General Surgery Pneumonia
Decrease of GS Pneumonia non risk rates from 3.5% to 2.3%
Avoided 32 cases of pneumonia at $10,000/case = $320,000 in cost avoidance which actually allows access to others
ICOUGH Pneumonia Prevention
27
Slide 28
Pneumonia Prevention Project
0 pneumonias in last 420 charts reviewed!
28
Slide 29
Cardiac Surgery
QI Committee: Started May 2012
Team: Nurse champions, Infection
Control Practitioner, Nurse
Practitioner, Anesthetists, Surgeons,
Pharmacy, Nursing leaders, Quality
Coordinators and Educators from
Operating Room (OR), Preoperative
Unit and Surgical Units.
Current Projects
Pneumonias
SSI
Intubation times
Urinary tract infections
29
Slide 30
Major Values of NSQIP
Worth the ongoing investment!!
• Benchmarking
• Regional collaboration and conversation:
• Awareness and self-education about best practices
• Trends over time
• Includes the patient perspective
• Standardized risk-adjusted data collection
• The program bundles resources
• Integration of pre- and post op outcomes
30
Slide 31
Conclusion
• Using a health economic evaluation
framework can assist in proving the worth
and value of a program
• It can help to predict value over time to
support the initial investment
Slide 32
Thank you!
Using Health Economic
Framework to Determine the
Benefits of Participating in a
Surgical Outcomes Measurement
Program
Linda Dempster, RN MA
Quality and Patient Safety
Vancouver Coastal Health Authority
Slide 2
disclosures
• Nothing to disclose
Slide 3
Objectives
• Vancouver Coastal Health and B.C.
Healthcare
• National Surgical Quality Improvement
Program (NSQIP)
• Health Economic Framework
• Applying the Framework
• Evaluating the Program
• Conclusion
Slide 4
How does the BC
healthcare system
operate?
Slide 5
BC Health
Authorities
Slide 6
Vancouver Coastal Health
Population
Health and
Wellness
Primary
Health
Care
Home and
Community
Services
Mental
Health and
Addictions
Acute Care
Slide 7
Vancouver Coastal Health
VCH serves 25%
of BC’s population
(over 1 million
people) in 17
Municipalities and
15 First Nations
Communities.
Slide 8
Who is Vancouver Coastal Health?
22,000 staff, 2,500 physicians and 5,000
volunteers working at 556 locations
including 13 hospitals, and 15 community
health centres.
Slide 9
Every day in VCH region we see:
914 patients in our emergency departments
5 life or threatened organ cases
316 surgery patients in our operating rooms (5 days a week)
2,065 ambulatory patients
1,961 inpatient days
175 people in the community for occupational or physical
therapy (PT/OT)
891 home care nursing visits
6,240 residential care clients
891 assisted living tenants
5,121 home support hours
http://www.vch.ca/about_us/quick_facts/
Slide 10
Economic Burden of Adverse Events*
The rate of
AE
7.5 %
The total number of
discharges per year
84,043 (VCHA)
Additional
attributable acute
care days per AE
6 days**
Of which 37 %
are
preventable
Economic burden of
preventable AE
$ 15,329,475
Median cost per
acute care day
$ 1,100
Economic burden of
AE
$ 41,601,285
7.5% AE x 84.043
discharges x 37%=
2,332 preventable AE per
year
Resources:
* Baker, N. et al.: The Canadian Adverse Events Study. CMAJ. 2004. Vol. 170(11): 1678-86.
**Etchells, E. et al.: The Economics of Patient Safety in Acute Care. Canadian Patient Safety Institute. 2012.
10
Slide 11
Reducing surgical events
• We had limited data on our surgical events
so invested in participating in the ACSNSQIP program
• A significant investment
• No risk-adjusted data for 2 years
Slide 12
National Surgical Quality Improvement
Program (ACS NSQIP)
• International measurement program that allows
>400 hospitals to accurately compare
complication rates
• American College of Surgeons
• preoperative, perioperative and 30 day
postoperative variables
• 24 sites in BC
• PHC/VCH started in 2011 with 6 sites
• Identifies areas to focus on
12
Slide 13
VCH NSQIP by Numbers
13
Slide 14
Health Economic Evaluation
Health Economic Evaluation
•
•
•
•
Competition between resource scarcity and providing the best possible care
Economic outcome measurement, efficient use of resources
Patient focused
Long-term evaluation
Cost-Benefit Analysis
•
•
•
Evaluation of costs and
consequences in
monetary units
Opportunity Costs
Cost Avoidance
System Access
•
Translate results into
improved access to the
system, e.g.
• Bed days / Patient
days
• Wait times
• Patient Volume
Projection Analysis
• Assess the potential of a
quality improvement
initiative before
implementation
Is an intervention
worthwhile?
Acknowledgement; Stefanie Raschka health economist
14
Slide 15
Evaluation Framework
Stefanie Raschka, Health Economist
1.
2. Productivity & Efficiency
Quality Outcomes
• Length of Stay
• Admissions / Readmissions
• Work Flow / Surgical Volume
• Employee Turnover and Staff Absence
• Patient/Employee Satisfaction and
Experiences
• Adverse Events / Occurrences
• Healthcare Acquired Infections
• Mortality & Morbidity
Making
“Cents“
4. Program Costs / Investments
3. Health Economics
• Operational costs
• Implementation costs
• Training and Education
• Consultancy Support
• Cost-Benefit Analysis
• Return-on-Investment
• Cost Avoidance
• Access (e.g. additional patient days, beds freed)
15
Slide 16
Patient Experience
Patient Experience
Mean Surgical Patient Satisfaction VCH
•30 Day Follow-up:
5
4.8
4.6
4.4
4.3
4.16
4.2
4.03
4
3.8
4.34
4.34
4.36
Use of overall satisfaction
question:
“How would you rate your
overall surgical experience
on a scale of 1 (being the
worst) and 5 (being the best)
at…”
• Including Open
Comments
16
Slide 17
Physician & Staff Feedback
“The way the data is collected forces surgeons to believe
it. We can’t debate on standardized, risk-adjusted
outcomes. We can’t hide or run away anymore!”
“We are all speaking the same language”
17
Slide 18
Strong belief that NSQIP will improve the
quality of surgical care
“It provides us with powerful data we never had before”
“It is bringing the idea of quality improvement to the frontline, right into the OR”
18
Slide 19
Using your own data to make the case
Potential by Occurrence
VCH - Patient Day Opportunity
Patient Day Opportunity (per year)
10,000
9,219
9,000
If we reduce adverse events
rate by 100%:
8,000
7,000
6,000
4,609
5,000
• VCH: highest potential for
SSI (2,693 pd),
Pneumonia (2,079 pd),
Ventilator>48hrs (1,577 pd)
4,000
3,000
2,305
2,000
1,000
0
25% Reduction
50% Reduction
100% Reduction
19
Slide 20
More Predictions
Patient Case Opportunities
VCH - Patient Case Opportunities
Patient Case Opportunities (per year)
1,600
1,415
1,400
1,200
If we reduce adverse events
rate by 100%:
1,000
800
• VCH: highest potential for
General Surgery (522 cases),
Orthopedics (254 cases)
707
600
400
354
200
0
25% Reduction
50% Reduction
100% Reduction
20
Slide 21
Economic Burden of our Surgical
Adverse Events
Adverse Event
Cardiac events
Pneumonia
Unplanned Intubation
Ventilator . 48 hours
DVT/PE
Renal Failure
UTI
SSI
Total
Patient Cases
per Year
89
300
47
205
108
119
123
422
1,415
Patient Days
per Year
575
2,079
376
1,577
558
690
671
2,693
9,219
Costs per Surgical
Cost for the treatment of
Adverse Event
surgical adverse events
$ 7,789
$ 695,558
[$ 10,019 - $ 57,158]
$ 3,009,708
$ 10,019
$ 2,524,788
$ 18,310
[$ 18,414 - $ 25,219]
$ 942
$ 15,331
$ 1,971,987
$ 2,196,790
$ 116,149
$ 6,474,281
$ 16,989,260
1,415 adverse events out of 21,680 annual inpatient cases (7%)
Acknowledgement: AnalysisWorks, Vancouver B.C.
21
Slide 22
Enhanced Recovery After Surgery
Projection Analysis - Using ERAS to Reduce Length of Stay
Number of
cases
Bed days
ALOS
Reduction
of LOS
Bed days
avoided
Additional
patients treated
General Surgery
3,235
28,843
9
2 days
6,198
885
Cardiac Surgery
Gyn/urological
Surgery
951
10,256
11
4 days
3,599
514
2,748
8,428
4
2 days
2,932
1,466
Total
6,934
47,527
12,729
2,866
Service
*The analysis is based on a one year period (2011/12).
The occurrence rate for complication is based on NSQIP data reports.
22
Slide 23
Cost Benefit Analysis
with Targets
Scenario 1: 25% - 10% - 10%
Program Costs
T1 = 2011/12 T2 = 2012/13
$762,319
$1,327,842
Special Projects (ERAS)
T3 = 2013/14
$1,327,842
T4 = 2014/15
$1,414,027
T5= 2015/16
$1,456,448
$120,000
Cost Avoidance
∆ 25 % in T3
$0
$0 ∆ 345 cases $4,247,315
∆ 10 % in T4
$1,275,196
∆ 10 % in T5
∆ 95 cases $1,143,900
Profit
-$762,319
-$1,327,842
$2,799,473
-$138,831
-$312,548
∑
-$762,319
-$2,090,161
$709,312
$570,481
$257,933
23
Slide 24
So- what have we done!
We continue to receive ongoing funding…
Slide 25
VCH Quality Initiatives
Urinary Tract
Infections
VGH Cardiac
Events
Review
Pneumonia
(VGH & RH)
Enhanced
Recovery
After Surgery
Surgical
Quality
Improvement
Normothermia
QI
Committees
VGH Cardiac
UBC OR
Surgical Site
Infections
(VGH &LGH)
25
Slide 26
SSI Prevention
26
Slide 27
General Surgery Pneumonia
Decrease of GS Pneumonia non risk rates from 3.5% to 2.3%
Avoided 32 cases of pneumonia at $10,000/case = $320,000 in cost avoidance which actually allows access to others
ICOUGH Pneumonia Prevention
27
Slide 28
Pneumonia Prevention Project
0 pneumonias in last 420 charts reviewed!
28
Slide 29
Cardiac Surgery
QI Committee: Started May 2012
Team: Nurse champions, Infection
Control Practitioner, Nurse
Practitioner, Anesthetists, Surgeons,
Pharmacy, Nursing leaders, Quality
Coordinators and Educators from
Operating Room (OR), Preoperative
Unit and Surgical Units.
Current Projects
Pneumonias
SSI
Intubation times
Urinary tract infections
29
Slide 30
Major Values of NSQIP
Worth the ongoing investment!!
• Benchmarking
• Regional collaboration and conversation:
• Awareness and self-education about best practices
• Trends over time
• Includes the patient perspective
• Standardized risk-adjusted data collection
• The program bundles resources
• Integration of pre- and post op outcomes
30
Slide 31
Conclusion
• Using a health economic evaluation
framework can assist in proving the worth
and value of a program
• It can help to predict value over time to
support the initial investment
Slide 32
Thank you!