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

2. disclosures Nothing to disclose

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

4. How does the BC healthcare system operate?

5. BC Health Authorities

6. Vancouver Coastal Health Population Health and Wellness Primary Health Care Home and Community Services Mental Health and Addictions Acute Care

7. VCH serves 25% of BC’s population (over 1 million people) in 17 Municipalities and 15 First Nations Communities. Vancouver Coastal Health

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.

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/

10. Economic Burden of Adverse Events* 10 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** Median cost per acute care day $ 1,100 Economic burden of AE $ 41,601,285 Economic burden of preventable AE $ 15,329,475 Of which 37 % are preventable 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. 7.5% AE x 84.043 discharges x 37%= 2,332 preventable AE per year

11. Reducing surgical events We had limited data on our surgical events so invested in participating in the ACS- NSQIP program A significant investment No risk-adjusted data for 2 years

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

13. VCH NSQIP by Numbers 13

14. 14 Evaluation of costs and consequences in monetary units Opportunity Costs Cost Avoidance  Is an intervention worthwhile? Cost-Benefit Analysis Competition between resource scarcity and providing the best possible care Economic outcome measurement, efficient use of resources Patient focused Long-term evaluation Health Economic Evaluation Translate results into improved access to the system, e.g. Bed days / Patient days Wait times Patient Volume Assess the potential of a quality improvement initiative before implementation Projection Analysis Health Economic Evaluation System Access Acknowledgement; Stefanie Raschka health economist

15. Evaluation Framework Stefanie Raschka, Health Economist 15 3. Health Economics Cost-Benefit Analysis Return-on-Investment Cost Avoidance Access (e.g. additional patient days, beds freed) 1.Quality Outcomes Patient/Employee Satisfaction and Experiences Adverse Events / Occurrences Healthcare Acquired Infections Mortality & Morbidity 4. Program Costs / Investments Operational costs Implementation costs Training and Education Consultancy Support 2. Productivity & Efficiency Length of Stay Admissions / Readmissions Work Flow / Surgical Volume Employee Turnover and Staff Absence Making “Cents“

16. Patient Experience 16 Patient Experience 30 Day Follow-up: 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

17. 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”

18. 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 front- line, right into the OR”

19. Using your own data to make the case 19 Potential by Occurrence If we reduce adverse events rate by 100%: VCH: highest potential for SSI (2,693 pd), Pneumonia (2,079 pd), Ventilator>48hrs (1,577 pd)

20. 20 Patient Case Opportunities If we reduce adverse events rate by 100%: VCH: highest potential for General Surgery (522 cases), Orthopedics (254 cases) More Predictions

21. 21 1,415 adverse events out of 21,680 annual inpatient cases (7%) Economic Burden of our Surgical Adverse Events Adverse Event Patient Cases per Year Patient Days per Year Costs per Surgical Adverse Event Cost for the treatment of surgical adverse events Cardiac events89575 $ 7,789 $ 695,558 Pneumonia3002,079 [$ 10,019 - $ 57,158] $ 3,009,708 Unplanned Intubation47376 $ 10,019 $ 2,524,788 Ventilator. 48 hours2051,577 DVT/PE108558 $ 18,310 $ 1,971,987 Renal Failure119690 [$ 18,414 - $ 25,219] $ 2,196,790 UTI123671 $ 942 $ 116,149 SSI4222,693 $ 15,331 $ 6,474,281 Total1,4159,219 $ 16,989,260 Acknowledgement: AnalysisWorks, Vancouver B.C.

22. 22 Service Number of cases Bed daysALOS Reduction of LOS Bed days avoided Additional patients treated General Surgery3,23528,84392 days6,198885 Cardiac Surgery95110,256114 days3,599514 Gyn/urological Surgery2,7488,42842 days2,9321,466 Total6,93447,527 12,7292,866 Projection Analysis - Using ERAS to Reduce Length of Stay Enhanced Recovery After Surgery *The analysis is based on a one year period (2011/12). The occurrence rate for complication is based on NSQIP data reports.

23. 23 Scenario 1: 25% - 10% - 10%T1 = 2011/12T2 = 2012/13T3 = 2013/14T4 = 2014/15T5= 2015/16 Program Costs$762,319$1,327,842 $1,414,027$1,456,448 Special Projects (ERAS) $120,000 Cost Avoidance ∆ 25 % in T3$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 Cost Benefit Analysis with Targets

24. So- what have we done! We continue to receive ongoing funding…

25. VCH Quality Initiatives Surgical Quality Improvement Urinary Tract Infections Enhanced Recovery After Surgery QI Committees VGH Cardiac UBC OR Surgical Site Infections (VGH &LGH) Normothermia Pneumonia (VGH & RH ) VGH Cardiac Events Review 25

26. SSI Prevention 26

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 27 ICOUGH Pneumonia Prevention

28. Pneumonia Prevention Project 28 0 pneumonias in last 420 charts reviewed!

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

30. 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

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

32. Thank you!