Founded in 1996, CASTS has served as a professional society for cardiothoracic surgeons in California. The Board of Directors and staff have promoted communications by hosting meetings and other activities. The California Healthcare Foundation awarded CASTS a grant in 2003, the California Cardiac Surgery Initiative (CCSI), in partnership with the California chapter of the American College of Cardiology to enhance the effectiveness of the mandatory reporting law, SB-680. Phase I of the project (2003-2005) focused on assisting providers in complying with data collection requirements and developing infrastructure for reporting outcomes and evaluating processes of care.
Phase II expanded the project to include all cardiac surgery procedures and interventional cardiology, now known as the California Cardiac Surgery and Intervention Project (CCSIP). Additional support from the Blue Shield of California Foundation facilitated CASTS’ efforts to publish outcomes from the OSHPD Patient Discharge Dataset on its web site, develop a regional STS report for members, and conduct site visits and information exchanges on best practices for quality improvement. CASTS has contributed expertise for the CCORP Clinical Advisory Panel and technical support to OSHPD for the startup of the public reporting program. CASTS has engaged in outreach efforts with surgeons, CCORP staff, information technology vendors, and hospital clinical data managers. The latter have attended workshops on enhancing data integrity through training and cross-hospital dialogue.
Jeffrey C. Milliken, MD, Chief, Division of Cardiothoracic Surgery, U.C. Irvine Medical Center, served as president of CASTS from 2009 through 2014. During this time the CCSIP, under the management of Beate Danielsen PhD, developed a sophisticated website reporting 30 and 90 day outcomes of all CABG, Valve and PCI procedures. Dr. Junaid Khan, CASTS President succeeding Dr. Milliken, presided over negotiations with Medicare and updates to Title 22 and the CCSIP program. Subsequently, William Bommer MD, co-PI of the project, initiated a confidential program to report outlier status to heart hospitals, presenting encouraging results at national meetings of the ACC. The incoming CASTS president is Peyman Benharash MD of UCLA. Dr. Benharash is currently helping to develop a statewide collaborative together with representatives of OSHPD and California members of the American College of Cardiology.
Edwin Fonner, Jr., DrPH served as Executive Director for several years until his untimely death in 2014. During his tenure CASTS received support from the Blue Shield of California Foundation. Dr. Fonner achieved outreach with national groups, and developed close relationships with the STS National Database and the Data Manager groups. He organized many successful statewide meetings such as pictured above.
Dr.Fonner emphasized lofty aspirations for the CASTS, which he listed as follows:
Communications – CASTS will improve the frequency and quality of inter-disciplinary communications among data managers, clinical staff, and surgeons. Headway is being made with data managers and hospital staff. CASTS will attempt to improve rapport between the cardiac surgical community, CCORP, medical societies, payers, and the media.
Best practices and baseline data – CASTS will increase opportunities for sharing information on care processes that improve patient outcomes. Specific protocols and evidence-based guidelines will be posted on the web site and discussed at CASTS meetings. Better baseline data will be available for measuring improved processes and outcomes.
Cost effectiveness – Cost savings should emerge with opportunities to improve post-operative outcomes. Favorable returns on investment can be earned by pursing initiatives like reducing blood use with adherence to new JCAHO guidelines on blood management.
Collaboration – Participants in CASTS workshops, web forums, and conference calls will share information on improving patient care and data integrity. Opportunities for surgeons to exchange ideas via web forums and conference calls will strengthen voice and promote cooperation.
Health information technology – Available tools and comparative data should improve decision-making. CASTS will provide outcomes data from STS and administrative sources with web-based dashboards. Online forums, a clinical data abstraction tool, and idea exchanges will improve learning. The comparability of data for public reporting will accrue from collaboration by data mangers and CCORP.
Improved Health Literacy – A patient education module, if effectively disseminated, will inform patients, family, and care givers about relative risks and benefits of treatment alternatives. It will be a breakthrough if CASTS is able to create a communications bridge between surgeons, cardiologists, and primary care focusing on appropriateness of CABG versus stent.
The Heart Team
The “heart team ” concept has provided a platform to bring together cardiovascular specialists from various disciplines in the patient care process. New procedures such as transcather aortic valve replacement have required the integration of surgeons and interventialists to make decisions concerning indications and approaches. Guidelines for coronary interventions require concordant decision-making by cardiologists, surgeons and caregivers for patients with advanced disease. Establishing a dialogue, an action plan, and a QI agenda involving multiple heart programs, practices and heart team members will favorably impact standards of care. Defining a model quality agenda for the state’s cardiac surgical community is a CASTS priority.
The CASTS therefore would like to encourage all heart team members to participate in society activities–physician assistants, perfusionists, nurses, operating room staff, data managers and administrative personnel. However, the process of accomplishing this laudable goal has not be easy or obvious. Ed Fonner, before his unitmely death, proposed that data managers and other heart team members be offered full membership in CASTS, with privileges to become officers or directors of the corporation. This proposal was not well received by CASTS physicians and directors, who felt that it was not consistent with the goals of CASTS as a society of surgeons.
California Data Managers have proposed the formation of a new, all inclusive organization to pursue quality improvement goals. The mission of this organization is very similar to the CASTS:
“The California Cardiothoracic Surgery Collaborative (CCSC) is organized to improve decisions affecting the cardiothoracic surgical community, to ensure fairness, accuracy, and completeness of publicly-reported healthcare information, to encourage adoption of evidence-based best practices, and to better manage patient outcomes data with training opportunities and peer-to-peer information exchange. Its objectives are to improve advocacy, enhance communications, pursue quality improvements, and support sound decision-making.
1. Collect, share, and analyze patient data concerning safety, quality of care, and process innovations in the cardiac surgery area to improve decision-making on quality and cost management issues;
2. Create a collaborative infrastructure which can monitor and analyze outcomes, develop best practice care processes, and through process improvement enhance the quality of care in cardiac surgery;
3. Facilitate communications and educational activities in the cardiac surgical community to ensure the integrity of publicly-reported healthcare information and address relevant issues facing the cardiac surgical community in California;
4. Support education initiatives aimed at improving patient health literacy, informed patient choice, and medical decision-making.”
The described goals are consistent with the mission of the CASTS as articulated by Dr. Fonner. While it is true that the creation of the CASTS was influenced by the need to monitor pubic reporting initiatives and ensure the quality of outcomes data, the interests and goals of surgeons and heart team members go well beyond these areas. In order to further collaboration and collegiality among heatlhcare professionals and stakeholders in cardiac and thoracic surgery, the CASTS would like to establish a dialogue to move the process of organizing heart team members in the correct direction. At present (summer 2019) a “California Cardiovascular Collaborative” program is under development by OSHPD, in concert with CASTS, California members of the ACC, and other members of the heart team including the data managers association.