CCSIP 2015 update: TAVR taking a bite out of SAVR?

The CCSIP reporting website was updated through 2014, now including a breakdown of aortic valve replacement procedures between transcatheter AVR (TAVR) and surgical AVR (SAVR).  At several sites where significant volumes of TAVR are being performed, SAVR volumes have decreased.  For example, at Cedars Sinai Medical Center, SAVR has decreased by 50%:

Statewide, TAVR represented 30% of all isolated AVRs during 2013-2014.  However, overall, isolated SAVR volume has not yet been affected; 7074 AVRs were performed in 2011-2012 and 7022 in 2013-2014.  Further details about CABG, PCI and Heart valve volumes and outcomes are available at the CCSIP reporting website.

Public Reporting of PCI and Valves Moves Along (SB 830)

James MacMillan attended a hearing in Sacramento last week at which Senate Bill 830 was presented and discussed.  Dr. MacMillan submitted a letter of support and made a presentation to the committee hearing.  He described the changes that have occurred in cardiovascular procedures since the beginning of public reporting of CABG more than ten years ago.  The incidence of CABG has decreased, and there are now 4 times more PCI’s than CABG procedures performed in California.  Heart Valve procedures have increased relative to CABG, now representing more that half of the cardiac surgeres performed at most hospitals.  Outcomes for CABG and valve surgery have improved, and recent data shows that PCI accounts for more deaths and complications than cardiac surgery.  His presentation was well received and there appears to be little opposition to the expansion of public reporting.

CASTS update March 2014

CASTS board members had an informal luncheon meeting at the STS in Orlando.  The primary topic of conversation was related to the update of the mandatory public reporting law SB 680.  The update, known as SB 830, is in draft form and currently being prepared by James MacMillan of CASTS and Bill Bommer of CAACC.  The legislation will allow reporting of PCI and Valve outcomes beginning in 2015.  CASTS is also preparing an update to its reporting site www.californiacardiacsurgery.com which will provide an examples of information that may be presented in future public reports.  The new reports are designed similar to those in New York, which provide aggregated isolated valve and valve-CABG groups as well as CABG and PCI.   The reports will be available at the end of March to qualified users.

Amendment of SB 680

James MacMillan is planning a meeting with CA State Senator Cathleen Galgiani next month in Sacramento.  She has agreed to sponsor the amendments to SB 680.  We also have contacted Elizabeth (Betsy) Imholz, who is head of the west coast health team for the Consumers Union.  Betsy was part of the group that sponsored the original bill in 2001.   She indicated that the bill mandated OSHPD to report on all surgical and obstetrical procedures and that she was surprised that this hadn’t happened.  CU will help with an update to make more reports available to the public.  CASTS and CAACC will be soliciting ideas from members about the reporting process.

Public Reporting of CABG-Valve Data

Thanks to all for responses to the notice that the CCORP will begin reporting CABG-valve cases sometime in the near future (the earliest would be the end of 2014). Of about 20 surgeons who responded, most agreed with Fred Grover’s parting recommendation that no further cardiac surgery reporting be undertaken without reporting of PCI. While this is not surprising, some also pointed out that we surgeons have been in the forefront of public reporting and should continue to support it. Unfortunately the law (SB 680) that established CABG reporting included ALL CABG, not just isolated CABG. Further, from a statistical point of view, the greater number of outcomes (deaths) provides improved significance to the reports. Clearly the law needs to be updated and this time around the CASTS must play a more active role in the legislative process.

A few quotes from the responses:

“Reporting needs to happen now, with cardiology and cath lab stats–there needs to be “skin in the game” and take advantage of their stronger lobbying power.”

“…until cardiologists agree to report their interventions, cardiac surgeons should simply tell their hospital administrations, that they will no longer act as back up for interventions that are undertaken without accountability.”

“I also agree with Dr. Grover’s wise remark not to participate in any State sponsored reporting until the Cardiologists are forced being accountable of their work. I see too many PCIs with poor intermediate and long term outcomes. The standing recommendation to refer a patient for CABG with 3 vessel disease and significant LV dysfunction is violated on a daily basis.”

“We need to develop a strategy to get a law to get PCI publicly reported. This will also require funding. Perhaps the CA ACC could step up. We can fight the extended CABG reporting, I predict without success. Instead, I recommend making the case for PCI reporting. The concerns that lead to the original law to report CABG is totally applicable to lead the quest to report PCI.”

“……if the ultimate intent of the reporting is to elevate the level of cardiovascular health care delivery then it must include defining what has appeared by some observers (myself included) to be an egregious inappropriate excess…reporting pci results is essential …. if mechanisms to force the issue are necessary then they should be used…double standards are hard to defend.”

“I disagree with Fred Grover. Cardiac surgery public reporting for cabg has reduced operative mortality since introduction. Expanding to valves and cabg valves would undoubtedly have a similar influence. Our specialty has had unusual strength of character and integrity making our leadership by example more powerful than debate.”

“The caveat for me is that this next level has to be more than just a linear extension of the mechanics of studying CABG to valve/CABG. There is more that we need from the data management since we have learned how it drives surgical, post surgical and nonsurgical behavior. Although I agree with Dr. Grover’s wish to have PCI also reported, I disagree that we should wait for that to happen before we move further forward. CABG data has dramatically improved outcomes even though the public does not know how to interpret these numbers. They none the less have been beneficiaries.”

“Historically, cardiac surgeons were initially dragged into a position of accountability insofar as risk-adjusted outcomes data for CABG surgery. Now, after three decades, the profession is admired by its peers and by the public for its foresight and clarity of purpose . The accurate reportage of our results has had beneficial effects in terms of better outcomes and has served as a useful guidepost for our patients in selecting whom they want as a surgeon. I can only see benefits in extending this accountability to the practice of valve/cabg surgery and possibly eventually robotic surgery.”

“We need to use this energy to point out the value of CASTS. I will certainly work on my state senator and assemblyman to get some legislation going. Also CMA can help push it once it gets going. The Consumers Union would be hypocritical if they didn’t support it also.”