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VA Center for Clinical Management Research VA Ann Arbor Healthcare System*

VA Center for Clinical Management Research VA Ann Arbor Healthcare System*. Profiling Hospital Differences in the Quality of CABG Surgery Using Quality-Adjusted Life Expectancy. Justin W. Timbie, PhD* David M. Shahian, MD Joseph P. Newhouse, PhD

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VA Center for Clinical Management Research VA Ann Arbor Healthcare System*

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  1. VA Center for Clinical Management Research VA Ann Arbor Healthcare System* Profiling Hospital Differences in the Quality of CABG Surgery Using Quality-Adjusted Life Expectancy Justin W. Timbie, PhD* David M. Shahian, MD Joseph P. Newhouse, PhD Meredith B. Rosenthal, PhD Sharon-Lise T. Normand, PhD Funding: Alfred P. Sloan Foundation

  2. Outline • Context: Summary measures of quality • Framework: Use 10 quality measures to estimate survival and utility outcomes. • Illustration: Estimate QALY outcomes for 14 hospitals performing CABG surgery. • Discussion: How to generalize the approach

  3. Background: Composite Measures Main issues: 1) Weights have limited (or no) clinical basis. 2) Assigning “importance” weights is a challenge. 3) Weighting of mortality vs. other measures is conceptually weak.

  4. Rationale for QALY composite measure • QALY = Quality-Adjusted Life Year • Incorporates mortality and morbidity effects (via utility) of poor quality. • Time horizon is one year. QALYs address main issues: 1) Weights are based on clinical outcomes. 2) Weights determined by fitting survival model and utility weights from literature. 3) Mortality/morbidity tradeoff determined by utility.

  5. CABG Quality Measures Source: Massachusetts Data Analysis Center (Mass-DAC), 2004.

  6. Utilities for CABG complications

  7. Estimating QALYs

  8. Estimating QALYs

  9. Estimating QALYs

  10. Estimating QALYs Incremental QALY = P(S)*EU – P(S)*EU Hospital i Any hospital

  11. Key findings • Incorporating longer-term survival and utilities can change inferences on outliers. • Low incidence of major complications. • Limitations: • Process measures had negligible survival effects. • Disagreement on utility estimates and aggregation method.

  12. Generalizing the QALY approach • Consider excluding some process measures from QALY composite. • Surgical: • Mortality and complications are key measures. • Medical: • 30-day mortality is current standard. • Readmission, functional status measures on horizon. • Safety: • NQF “Safe Practices”: Large quality problem, high morbidity.

  13. QALY composites for diabetes • Measures: • BP < 130/80 mmHg • A1c < 7% • LDL < 100 mg/dL • QALYs summarize implications of current risk factor levels relative to goals. • Survival outcomes simulated via Markov model. • Utilities reflect future complications and cardiac events. • Medical Care 2007;45:315-321. 5-fold greater odds of mortality (over 10 years)

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