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Gender Differences in Hospital Survival Rates For Medicare Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter. Steven D. Culler, PhD Associate Professor Rollins School of Public Health Emory University April Simon MRN President

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Gender Differences in Hospital Survival Rates For Medicare Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

Steven D. Culler, PhD

Associate Professor

Rollins School of Public Health

Emory University

April Simon MRN

President

Cardiac Data Solutions

Atlanta GA


Study objectives
Study Objectives Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • To report on gender differences in risk-adjusted mortality rates by hospital performance classes based on CABG outcomes among Medicare beneficiaries.

  • To identify the number of female Medicare beneficiary deaths that could be avoided by improving outcomes in bottom tier hospitals.


Methods data sources
Methods: Data Sources Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Medicare Provide Analysis and Review File (MedPAR): An administrative database containing demographic information, 9 diagnostic and 6 procedure (ICD-9-CM) codes, and the discharge status of all Medicare beneficiaries admitted to any U.S. hospital.


Methods study period
Methods: Study Period Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Study Period: October 1, 2002 to September 30, 2004 (Fiscal Years 2003 & 2004).


Methods study population
Methods: Study Population Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

Inclusion Criteria:

  • All Medicare beneficiaries undergoing a CABG surgery (Procedure codes of 36.10-36.19 and 36.2).

    Exclusion Criteria:

  • Patients having any concomitant valve surgery (Procedure codes of 35.00-35.04; 35.10-35.14; 35.20-35.28; & 35.31-35.39).

  • All patients in hospitals performing less than 52 surgeries per year or less than 17 surgeries on females per year.


Methods study sample
Methods: Study Sample Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter


Methods analytic approach
Methods: Analytic Approach Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Step 1: Annual Risk-Adjusted Mortality:

    A logistic regression equation (controlling for up to 25 demographic and co-morbid conditions) was estimated to predict each Medicare beneficiary’s probability of experiencing in-hospital mortality for each fiscal year.


Methods analytic approach1
Methods: Analytic Approach Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Step 2: Annual Hospital Performance Tiers:

    Hospitals were annually ranked into quartiles based on the number of lives saved (or lost) - the difference between a hospital’s risk adjusted expected number of deaths and its observed number of deaths during the fiscal year.


Methods analytic approach2
Methods: Analytic Approach Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Step 3: Annual Hospital Risk-Adjusted Mortality Rate by Gender:

    A male and female risk-adjusted mortality rate was calculated for each hospital for each fiscal year.


Results risk adjusted cabg mortality
Results: Risk-Adjusted CABG Mortality Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter


Results risk adjusted cabg mortality1
Results: Risk-Adjusted CABG Mortality Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter


Results gender difference between top and bottom tier
Results: Gender Difference Between Top and Bottom Tier Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter


Issues alternative goals for bottom tier hospitals
Issues: Alternative Goals for Bottom Tier Hospitals Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • The females and males have the same risk-adjusted mortality rate in bottom tier hospitals;

  • The female risk-adjusted mortality rate in bottom tier hospitals improves to the average female risk-adjusted mortality rate; and

  • The female risk-adjusted mortality rate in bottom tier hospitals improves to the female risk-adjusted mortality rate in top tier hospitals.


Goal three bottom tier equals top tiers
Goal Three: Bottom Tier Equals Top Tiers Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter


Summary
Summary: Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Female Medicare beneficiaries had significantly higher risk-adjusted hospital mortality rates than males.

  • As one moves from the top quartile to the bottom quartile, the gender disparity in the risk-adjusted mortality rate increases.


Summary1
Summary: Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Improvement Goal:

    85.3% of expected female beneficiaries deaths could be avoided if bottom tier hospitals achieved the same risk-adjusted outcomes as top tier CABG hospitals.


Limitations
Limitations: Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

  • Risk-adjusted models are based on co-morbid conditions identified from ICD-9-CM codes reported in an administrative dataset.

  • Gender differences for Medicare beneficiaries may not reflect gender differences for CABG surgery among younger patients.


Conclusion
Conclusion Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter

Female Medicare beneficiaries should be much more selective in choosing where to have their CABG surgery performed!


The end
The End Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter


Goal one no gender difference in bottom tier hospitals
Goal One: No Gender Difference in Bottom Tier Hospitals Beneficiaries Undergoing Coronary Artery Bypass Graft Surgery: Does Hospital Performance Ranking Matter



Methods analytic approach3
Methods: Analytic Approach Female Rate

Risk-Adjustment: Demographic Variables:


Methods analytic approach4
Methods: Analytic Approach Female Rate

Risk-Adjustment: History of Prior Procedures or Conditions:


Methods analytic approach5
Methods: Analytic Approach Female Rate

Risk-Adjustment – Co-Morbid Conditions:


Methods analytic approach6
Methods: Analytic Approach Female Rate

Risk-Adjustment: Co-Morbid Conditions


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