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Editorial

Toward Cost-Effective Data Utopia

Providence Health and Services, Cardiovascular Disease Study Group, Portland, Oregon

^_* Address correspondence to Dr Grunkemeier, 9155 SW Barnes Rd, LL33, Portland, OR 97225 (Email: gary.grunkemeier{at}providence.org).

In the societal drive to determine the best and most cost-effective treatment for any disease entity, we have traditionally turned to outcomes research. When two competing therapies exist to treat one disease entity, research is needed on comparative outcomes. Comparative outcomes must take into account not only in–hospital morbidity and mortality, but it must also include long-term survival, re-admission and re-treatment of the initial disease, the occurrence of long-term sequelae of the original treatment, and the societal cost of the entire episode of the disease-related care.

To produce the research from scratch on comparative outcomes would require the creation of an all-encompassing, colossal, over-reaching database that would include demographic, risk factor, and treatment variables, and then link them to short-term, mid-term, and long-term outcome data points, including survival and financial data. It would require an army of data collectors, it would take years to construct, and it would likely exhaust all funding or bankrupt the system before arriving at an answer.

The construction of such an information warehouse would enable a "data utopia," or a database that would encompass so much pertinent medical, financial, and social data that answers to both medical-related and healthcare system-related questions could be answered with near-definitive conclusions. This database is a need we must fulfill to be able to answer the difficult healthcare-related questions of our times, and of the future for the proposed new world of universal healthcare. But how do we get there? Also, how do we do so in a cost-effective and resource-effective manner?

	A Bit of History

Top Introduction A Bit of History To The Future ...... References

 
Fifty years ago, Dr Albert Starr began a series of mitral valve replacement surgeries, and he insisted from the outset on conducting "outcomes research," long before this specific term was invented [1]. He registered every cardiac surgery patient into a free lifetime follow-up service. He considered this as an essential aspect of his surgical practice; not doing so would be, as he said, "... practicing surgery in an intellectual vacuum." The result is the world's longest-term follow-up cardiac surgery database, currently (i.e., in 2010) housing 65,000 patients and 230,000 follow-up contacts. Starr and his research team (of which we are current members) were able to publish the 40-year results of valve replacement surgery [2], and we are currently embarked on producing a 50-year publication.

Our follow-up system typically confirms the status of approximately 85% of the outstanding patients. The usual statistical survival method censors lost patients at the time of last contact. To see what effect this had on survival estimates, we acquired the National Death Index (NDI) information on a group of 14,000 patients, thus raising our completeness percentage to 98%, and we found that survival estimates and the results of Cox regression models did not differ between the original and the NDI-augmented data [3].

The estimated costs of our follow-up service (exclusive of in-hospital data entry) are approximately $10 to $15 per patient per year. The cost of the NDI method was cheaper, but we acquired information on all complications (eg, deaths, strokes, embolic events, bleeding events, myocardial infarctions, repeat interventions, readmissions, infections, hospitalizations, and so forth), whereas the NDI method only provides information on deaths. These follow-up costs if extrapolated to the tens-of-millions of patient records contained within both The Society of Throracic Surgeons (STS) and the National Cardiovascular Data Registry (ie, the American College of Cardiology [ACC] clinical database) would be astronomical on an annual basis, and would make the probability of achieving Data Utopia prohibitive.

	To The Future ... And Beyond!

Top Introduction A Bit of History To The Future ...... References

 
However, as evidenced by the article by Jacobs and colleagues [4], and as supported by the ACC, the Centers for Medicare Services, and The STS, there may be a better and more efficient pathway to data utopia for the treatment of cardiac disease. For the past 2 years, the joint leadership of both The STS and the ACC have come together in an effort to merge our respective databases along with those from the Centers for Medicare Services and the Social Security Death Index to create a cardiac data utopia out of pre-existing building blocks. This modular design, if it can be successfully accomplished on taxonomical and technical levels, will provide a cost-effective, rapid development pathway to the creation of data utopia.

Thus, the article by Jacobs and colleagues [4] signifies an enormously important step in advancing database technology and innovation for comparative effectiveness analyses to get the best therapy to the right patients. We, as surgeons, following the visionary national database leadership of Dr Richard Clark, bought into the concept of continuous quality improvement through comparing risk-adjusted outcomes years ago with the creation of The STS National Database. This single-specialty database has spurred innumerable active drives toward continuous quality outcomes-based improvements on the local level. As a profession, our collective outcomes have improved, whereas the difficulty of the cases we have performed has increased.

However, now the time has come to take the next step toward data utopia in order to answer some of the more difficult societal questions, perhaps lay to rest some controversies, and perhaps create more, ever deeper-probing treatment-effectiveness queries. Both we, as surgeons, and our cardiologist colleagues feel that our "way" is the best way (ie, medically, socially and financially) to treat coronary artery disease. We may soon have the same or similar questions regarding the treatment of aortic valve disease, mitral valve disease, the closure of intracardiac defects, the treatment of aortic aneurysmal disease, and others. There is only one way to find out the answers to these important questions, and that is, data utopia.

Cardiologists and the Centers for Medicare Services have now bought into the idea of data utopia, as well, and have partnered with us (the surgeons) to find the answers. They too understand both the professional and societal importance of this quest. As the executive director of the ACC recently wrote in his weekly blog to the ACC leadership [5]: "Physician accountabilities beyond leadership in the governance of health care institutions and systems must primarily focus on systematically improving quality of care, patient safety, prevention and health care return on investment. To do that, we need to wisely invest in health information technology systems, clinical decision support, and engagement in registries and participate in lifelong learning and continuous patient-centered clinical quality improvement. This is the value-add to the systems of tomorrow that also will protect the financial viability and attractiveness of physician practice. At the same time we are working in this quality improvement arena, which ironically will be the best way to reduce the cost curve of health care spending, we need to be the leaders in promoting the advancement of science, research and continuous innovation that will continue to greatly contribute to the economic wellbeing of the nation."

Well-said, Jack! Jack "gets it," the cardiologists are beginning to "get it," and we, the surgeons "get it." So, as the saying goes: "The truth is out there." Well then, let's go find it!

	References

Top Introduction A Bit of History To The Future ...... References

 

1. Starr A, Edwards ML. Mitral replacement: clinical experience with a ball-valve prosthesis Ann Surg 1961;154:726-740.[Medline]
2. Gao G, Wu YX, Grunkemeier GL, Furnary AP, Starr A. Heart valve replacement with Starr-Edwards prostheses: 40 year survival J Heart Valve Dis 2004;13:91-96.[Medline]
3. Wu YX, Furnary AP, Grunkemeier GL. Using the National Death Index to validate the noninformative censoring assumption of survival estimation Ann Thorac Surg 2008;85:1256-1260.[Abstract/Free Full Text]
4. Jacobs JP, Edwards FH, Shahian DM, et al. Successful linking of The Society of Thoracic Surgeons Adult Cardiac Surgery Database to Centers for Medicare and Medicaid Services Medicare data Ann Thorac Surg 2010;90:1150-1157.[Abstract/Free Full Text]
5. Lewin JC. "The Lewin Report," sent via e-mail, May 15, 2010.

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