Using value-based analysis to influence outcomes in complex surgical systems.
BACKGROUND
Value-based analysis (VBA) is a management strategy used to determine changes in value (quality/cost) when a usual practice (UP) is replaced by a best practice (BP). Previously validated in clinical initiatives, its usefulness in complex systems is unknown. To answer this question, we used VBA to correct deficiencies in cardiac surgery at Memorial Healthcare System.


METHODS
Cardiac surgery is a complex surgical system that lends itself to VBA because outcomes metrics provided by the Society of Thoracic Surgeons provide an estimate of quality; cost is available from Centers for Medicare and Medicaid Services and other contemporary sources; the UP can be determined; and the best practice can be established.


RESULTS
Analysis of the UP at Memorial Healthcare System revealed considerable deficiencies in selection of patients for surgery; the surgery itself, including choice of procedure and outcomes; after care; follow-up; and control of expenditures. To correct these deficiencies, each UP was replaced with a BP. Changes included replacement of most of the cardiac surgeons; conversion to an employed physician model; restructuring of a heart surgery unit; recruitment of cardiac anesthesiologists; introduction of an interactive educational program; eliminating unsafe practices; and reducing cost.


CONCLUSIONS
There was a significant (p < 0.01) reduction in readmissions, complications, and mortality between 2009 and 2013. Memorial Healthcare System was only 1 of 17 (1.7%) database participants (n = 1,009) to achieve a Society of Thoracic Surgeons 3-star rating in all 3 measured categories. Despite substantial improvements in quality, the cost per case and the length of stay declined. These changes created a savings opportunity of $14 million, with actual savings of $10.4 million. These findings suggest that VBA can be a powerful tool to enhance value (quality/cost) in a complex surgical system.
Georgetown University School of Medicine, Washington, DC. Electronic address: Jrkcdk1@aol.com.
John R
JR
Kirkpatrick
Memorial Healthcare System, Hollywood, FL.
Stanley
S
Marks
Memorial Healthcare System, Hollywood, FL.
Michele
M
Slane
Memorial Healthcare System, Hollywood, FL.
Donald
D
Kim
Memorial Healthcare System, Hollywood, FL.
Lance
L
Cohen
Memorial Healthcare System, Hollywood, FL.
Michael
M
Cortelli
Memorial Healthcare System, Hollywood, FL.
Juan
J
Plate
Memorial Healthcare System, Hollywood, FL.
Richard
R
Perryman
Georgetown University School of Medicine, Washington, DC.
John
J
Zapas
D006348:Cardiac Surgical Procedures / Q000706:statistics & numerical data*; D017046:Cost Savings; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D017721:Hospital Costs / Q000706:statistics & numerical data; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008484:Medicaid / Q000191:economics; D006278:Medicare / Q000191:economics; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D014481:United States