“Medically Ready Force…Ready Medical Force” Managing the Challenge of the Relationship between Low Volume Surgery and Quality ~ AMSUS 2016 ~ Paul R. Cordts, MD, FACS Military Health System Functional Champion Defense Health Agency December 2016 “Medically Ready Force…Ready Medical Force”

Agenda Background MHS Volume Data MHS Quality Data Mitigation Strategies Public Reporting of Volumes Summary

Military Health System (MHS) Overview The MHS is a large healthcare system whose mission is to provide optimal health services in support of our nation’s military mission. $48B organization Serves over 9.4M beneficiaries Payer and provider Facilities 55 Hospitals (41 in US) 373 Clinics (315 in US) 251 Dental Clinics (201 in US) 253 Veterinary Facilities (198 in US) The MHS Quadruple Aim – better health, better care, lower cost, and readiness – reflects the system’s vision of providing a coordinated continuum of preventive and curative services while supporting the Services’ warfighter needs. MHS Quadruple Aim

Leapfrog Surgeon Volume Factsheet Volume and Mortality Studies have demonstrated that high volume facilities and surgeons have considerably lower mortality rates than their lower volume counterparts. Pancreatectomy for cancer: low volume hospitals have 4x mortality rate of highest volume hospitals Vascular surgery: higher operator volume correlates with lower rate of mortality and complications Lung cancer resection: mortality rates are significantly higher in low volume facilities, and 2x higher in non-teaching facilities Leapfrog Surgeon Volume Factsheet

Minimum Procedure Volumes Minimum procedure volume guidelines addressing the importance of surgeon volume have been developed in an effort to improve patient safety. American College of Surgeons: set minimum volume standards in its credentialing process for “Centers of Excellence” in bariatric surgery Aetna and Blue Cross: developed annual volume standards for surgeries such as transplants, bariatric, orthopedic, and spinal surgery The Leapfrog Surgical Volume Standard4 Johns Hopkins, University of Michigan, and Dartmouth-Hitchcock Medical Center: decided to establish “minimum volume standards”

Health systems set minimum volume standards Procedure Minimum hospital annual volume Bariatric staple surgery 40 Esophagus cancer resection 20 Lung cancer resection Pancreatic cancer resection Rectal cancer resection 15 Carotid artery stenting 10 Complex abdominal aortic aneurysm repair Mitral valve repair Hip replacement 50 Knee replacement Three prominent healthcare systems Dartmouth-Hitchcock Medical Center Johns Hopkins Medicine University of Michigan Hospital Sets minimum volume standards for hospitals (and physicians) in their system

Complex Procedures Procedure Surgeon Volume-Outcome Association? Hospital Volume-Outcome Association? Sources Esophageal Cancer Resection N/A (no study identified) Weak (mortality); None (LOS and complications) Kozower and Stukenborg (2012); Meguid et al (2009) Lung Cancer Resection N/A Weak (longer term mortality); None (inpatient mortality) Rosen et al (2014); Kozower and Stukenborg (2011); Cheung et al (2009) Pancreatic Cancer Resection Strong (mortality, LOS) Swanson et al (2014); Hollenbeck et al (2007) Rectal Cancer Resection Weak (mortality) Etzioni et al (2014); Baek et al (2013); Ho et al (2006) Carotid Artery Stenting Modest (mortality and complications) Weak (mortality, stroke, AMI) Badheka et al (2014); Modrall et al (2014); Sidawy et al (2009) AAA Repair Modest (mortality) None Modrall et al (2011); McPhee et al (2011); LaPar et al (2012) Mitral Valve Repair Kidher et al (2010); Gammie et al (2007)

13 Years of Continuous Learning

Deployment Effect Skills eroded after 6 months (perceived) 1-6 months to re-acquire complete comfort 3-6 month deployments best Ideal time between deployments not asked Most discomfort with cognitive skills (not technical)

Military Surgeon Case Volumes

DRAFT - PREDECISIONAL

MHS Performance: Mortality and Morbidity   July '12-June '13 July '13-June '14 Jan '14-Dec '14 Jan '15-Dec '15 Mortality Morbidity Medical Center 1 * Community Hospitals * Exceeds Standards 1 Meets Standards Needs Improvement   Data Unavailable

Low Volume High Acuity Surgical Procedures based on NSQIP – MHS vs. CIV Complication Rates Complication Rate AAA BAR CEA COL ESO LUN PAN PRO THA TKA AVE MHS(%) 1.65 1.2 1.5 0.5 1.8 2 1.3 1.1 1.4 CIVIL(%) 2.1 1.7 2.6 1.9 1.6 Survival Rates Survival Rate  AAA BAR CEA COL ESO LUN PAN PRO THA TKA AVE MHS(%) 100 99.9 98.3 99 99.4 94 99.8 98.7 CIVIL(%) 86.2 96.7 96.4 98.6 98 99.3 97.3 Takeaways: Represents 85% of complex surgical cases performed in MHS (MTFs >5 years with NSQIP) Complication/survival rates comparable to civilian rates. Procedure Index: AAA = abdominal aortic aneurysm; BAR = bariatric surgery; CEA = carotid stenting; ESO = esophagectomy; LUN = lung cancer resection PAN = pancreatic cancer surgery; PRO = rectal cancer surgery; THA = total hip arthroplasty; TKA = total knee arthroplasty; AVE = average

Mitigation Strategies Facility capabilities: 24/7 ICU coverage with critical care trained nurses 24/7 Interventional Radiology capability 24/7 in-house skilled provider(s) to reduce risk of Failure to Rescue Surgeon/surgical team capabilities: Part-time practice in, or rotation to, high volume facilities Inform recapture strategy with KSAs required of expeditionary surgeon/team MTFs attain Trauma Center designation Enhanced MSMs as a readiness platform

From ProPublica Surgeon’s Scorecard

From ProPublica Surgeon’s Scorecard

Summary Professional societies, insurance plans and some healthcare systems do consider volume Healthcare systems may regionalize specific high risk procedures and those requiring advanced technology Factors other than volume play a role in patient outcome Increasing demand for public reporting of volumes Must ensure “Ready Medical Force”, while ensuring Patient Safety, robust training programs and volume/complexity of procedures to maintain staff proficiency