Public Reporting of Cardiac Surgery Performance: Part 2—Implementation

Public reporting for coronary artery bypass graft surgery: The quest for the optimal scorecard

OBJECTIVE

A number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices.

METHODS

Composite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. News & World Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for Medicare & Medicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated.

RESULTS

Correlations between Society of Thoracic Surgeons star rating and U.S. News & World Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for Medicare & Medicaid Services 30-day mortality (r = -0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. News & World Report CABG ratings (r = 0.33) and with Centers for Medicare & Medicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed.

CONCLUSIONS

Correlations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center's clinical practice and to better inform patients.

Public disclosure of hospital clinicians' performance data: insights from medical directors

Objective This study gathered information from public hospital chief medical officers to better understand underlying mechanisms through which public reporting affects institutional behavioural change and decision making towards quality improvement. Methods This qualitative study used thematic analysis of 17 semistructured, in-depth interviews among a peak group of medical directors representing 26 health services in Victoria, Australia. Results The medical directors indicated a high level of in-principle support for public reporting of identifiable, individual clinician-level data. However, they also described varying conceptual understanding of what public reporting of performance data is. Overall, they considered public reporting of individual clinicians' performance data a means to improve health care quality, increase transparency and inform consumer healthcare decision making. Most identified caveats that would need to be met before such data should be publicly released, in particular the need to resolve issues around data quality and timeliness, context and interpretation and ethics. Acknowledgement of the public's right to access individual clinician-level data was at odds with some medical directors' belief that such reporting may diminish trust between clinicians and their employers, thus eroding rather than motivating quality improvement. Conclusions Public reporting of identifiable individual healthcare clinicians' performance data is an issue that merits robust research and debate given the effects such reporting may have on doctors and on hospital quality and safety. What is known about the topic? The public reporting of individual clinician-level data is a mechanism used in some countries, but not in Australia, for increasing health care transparency and quality. Clinician-level public reporting of doctors' performance attracts contention and debate in Australia. What does this paper add? This paper informs debate around the public reporting of individual clinician-level performance data. Among a discrete cohort of senior hospital administrators in Victoria, Australia, there was strong in-principle support for such public reporting as a means to improve hospital quality and safety. What are the implications for practitioners? Before public reporting of individual clinician performance data could occur in Australia, resolution of issues would be required relating to legality and ethics, data context and interpretation, data quality and timeliness.

Public Reporting of Cardiac Outcomes for Patients With Acute Myocardial Infarction: A Systematic Review of the Evidence

BACKGROUND

Percutaneous coronary intervention (PCI) is recognized by both the American Heart Association and the American College of Cardiology as an optimal therapy to treat patients experiencing acute myocardial infarction (AMI) with ST-segment elevation myocardial infarction. A health policy aimed at improving outcomes for the patient with AMI is public reporting of whether a patient received a PCI.

OBJECTIVE

A systematic review was conducted to evaluate the effect of public reporting for patients with AMI, specifically for those patients who receive PCI.

METHODS

EMBASE, MEDLINE, Academic Search Premier, Google Scholar, and PubMed were searched from inception through August 2017. Articles were selected for inclusion if researchers evaluated public reporting and included an outcome for whether a patient received a PCI during hospitalization for an AMI. Methodological quality of the included studies was evaluated, and findings were synthesized.

RESULTS

Eight studies of high methodological quality were included in the review. Most studies found that, in areas of public reporting, patients were less likely to undergo a PCI and high-risk patients did not undergo a PCI. Researchers also found that patients with AMI had lower in-hospital mortality after the implementation of public reporting, but only if these patients received a PCI.

CONCLUSIONS

Although public reporting may have had intentions of improving care, there is strong evidence that this policy did not result in more timely PCIs or improved mortality of patients with AMI. In fact, public reporting resulted in unintended consequences of not providing care for the most vulnerable patients in fear of an adverse outcome.

Risk Aversion in Cardiac Surgery: 15-Year Trends in a Statewide Analysis

BACKGROUND

With a rising emphasis on public reporting, we hypothesized that select hospitals are becoming increasingly risk-averse by avoiding high-risk operations. Further, we evaluated the association between risk-averse practices, outcomes, and publicly reported quality measures.

METHODS

Clinical data from 78,417 patients undergoing cardiac surgery (2002-2016) from a regional consortium was paired with publicly available reimbursement and quality data. High-risk surgery was defined as predicted risk of mortality ≥5%. Hospital risk aversion was defined as a significant decrease in both high-risk volume and proportion, with cases stratified by hospital risk aversion status for univariate analysis.

RESULTS

The rate of high-risk cases decreased from 17.9% in 2002 to 12.6% in 2016. Significant risk aversion was seen in 39% of hospitals, which had a 59% decrease in high-risk volume vs a 16% decrease at non-risk-averse hospitals. In the last 5 years, declining high-risk cases at risk-averse hospitals were driven by fewer cases from transfers (19.2% vs 28.1%, P < .001) and the emergency department (17.6% vs 19.2%, P = .001). Only non-risk-averse hospitals had mortality rates lower than expected (risk-averse: 0.97 [95% confidence interval, 0.91-1.03], P = .30; non-risk-averse: 0.88 [95% confidence interval, 0.83-0.94], P = .001). There were no differences by risk aversion status in reported ratings or financial incentives (all P > .05).

CONCLUSIONS

Over 60% of hospitals continue to operate on high-risk patients, with concentration of care driven by transfer patterns. These non-risk-averse hospitals are high-performing with better-than-expected outcomes, particularly in high-risk cases. Transparency and objectivity in reporting are essential to ensure continued access for these high-risk patients.

Risk Adjustment of the Modified Low Back Pain Disability Questionnaire and Neck Disability Index to Benchmark Physical Therapist Performance: Analysis From an Outcomes Registry

BACKGROUND

Patient-reported outcomes (PROs) have been touted as the ultimate assessment of quality medical care and have been proposed as performance measures after appropriate risk adjustment. Although spine conditions represent the most common orthopedic disorders, the most used PROs for disabilities related to the back and neck-the Modified Low Back Pain Disability Questionnaire (MDQ) and the Neck Disability Index (NDI)-have not been evaluated as performance measures.

OBJECTIVE

The objective of this study was to benchmark physical therapists' performance in the management of spine conditions not involving surgery through the use of risk-adjusted MDQ and NDI outcomes.

DESIGN

This was a retrospective observational study.

METHODS

Data were accessed for patients seeking physical therapy with no history of related surgery for back or neck pain (315,274 treatment episodes) between January 2015 and June 2018. Patients with complete data, including initial and matched final MDQ or NDI, were considered for analysis (182,276 patients; 2799 physical therapists). Linear models controlling for baseline PRO and patient characteristics predicted PRO change for each patient. An aggregated performance ratio of actual PRO change to predicted PRO change was calculated for each physical therapist, and then empirical bootstrapping was used to develop the median performance ratio and its confidence intervals. Physical therapists who met a 40-patient threshold for either cohort (MDQ or NDI) were classified as "outperforming," "meeting expectations," or "underperforming" relative to predicted values using these 95% confidence intervals.

RESULTS

Performance ratios indicated that 10% and 11% of physical therapists outperformed, 79% and 78% met expectations, and 11% and 11% underperformed relative to the risk-adjusted predicted change in the MDQ (1240 therapists; 97,908 patients) and NDI (461 therapists; 26,123 patients), respectively. To demonstrate the clinical importance of risk adjustment, clinical performance was evaluated in the seemingly homogeneous subset of 208 physical therapists within 0.5 SD of the median baseline MDQ and the median actual change in the MDQ. Following risk adjustment, 2 physical therapists were classified in each of the outperforming and underperforming cohorts.

LIMITATIONS

The secondarily obtained observational data used were not collected for research purposes. Additionally, the analyses were limited by missing baseline information and follow-up PROs.

CONCLUSIONS

The risk-adjusted performance ratios for the MDQ and NDI resulted in disparate conclusions regarding the quality of care compared with the raw, unadjusted change scores. According to the baseline and unadjusted change in the MDQ, even physical therapists in the most homogeneous sample were differentiated following appropriate risk adjustment. Clinically important improvements in actual PROs were observed in the outperforming but not in the underperforming physical therapists. Clinically meaningful differences in the performance ratio are unknown and are a limitation to clinical application and an opportunity for future research.

Association of Surgeon Case Numbers of Pancreaticoduodenectomies vs Related Procedures With Patient Outcomes to Inform Volume-Based Credentialing

IMPORTANCE

Despite growing interest from various surgical societies and patient safety organizations, concerns remain that volume-based credentialing standards are arbitrary and may fail to recognize a surgeon's full scope of practice.

OBJECTIVE

To evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone.

DESIGN, SETTING, AND PARTICIPANTS

This proof-of-concept cohort study used the all-payer State Inpatient Databases from 6 geographically diverse states to identify all operations for surgeons who performed at least 1 pancreaticoduodenectomy from January 1, 2012, to December 31, 2014. Each surgeon's mean annual volume for pancreaticoduodenectomies and related complex hepatopancreatobiliary (HPB) procedures was calculated. Outcomes for surgeons above and below a threshold of 12 pancreaticoduodenectomies per year were evaluated. Whether related HPB procedure volume was also associated with better outcomes for surgeons not meeting the procedure-specific threshold was also evaluated. Data were analyzed from March 2 through 20, 2019.

MAIN OUTCOMES AND MEASURES

Thirty-day mortality and complications.

RESULTS

The study cohort included 176 043 patients, of whom 92 064 were female (52.3%), with a mean (SD) age of 59 (17) years. Within 270 hospitals, only 54 of 1028 surgeons (5.3%) met the mean pancreaticoduodenectomy volume threshold from 2012 to 2014. In-hospital mortality after pancreaticoduodenectomy was lower for surgeons who performed 12 or more procedures per year (1.8% [95% CI, 1.1%- 2.4%] vs 4.7% [95% CI, 4.0%-5.4%]; odds ratio, 0.32; 95% CI, 0.21-0.50). However, in-hospital mortality varied 7-fold among surgeons who did not meet the threshold (1.2% [95% CI, 0.8%-1.6%] to 8.4% [95% CI, 7.9%-8.9%]). Increasing HPB case volume was associated with better outcomes for pancreaticoduodenectomy in this group. For example, surgeons performing 2 or fewer pancreaticoduodenectomies annually would need to perform an additional 27 related HPB procedures to match the in-hospital mortality rate of surgeons performing 12 or more pancreaticoduodenectomies.

CONCLUSIONS AND RELEVANCE

In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The findings suggest that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.

Risk Stratification for Transcatheter Aortic Valve Replacement

Risk assessment models developed from administrative and clinical databases are used for clinical decision making. Since these models are derived from a database, they have an inherent limitation of being as good as the data they are derived from. Many of these models under or overestimate certain clinical outcomes particularly mortality in certain group of patients. Undeniably, there is significant variability in all these models on account of patient population studied, the statistical analysis used to develop the model and the period during which these models were developed. This review aims to shed light on development and application of risk assessment models for cardiac surgery with special emphasis on risk stratification in severe aortic stenosis to select patients for transcatheter aortic valve replacement.

Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis

Public reporting is a tactic that hospitals and other health care facilities use to provide data such as outcomes to clinicians, patients, and payers. Although inadequate registered nurse (RN) staffing has been linked to poor patient outcomes, only eight states in the United States publicly report staffing ratios-five mandated by legislation and the other three electively. We examine nurse staffing trends after the New Jersey (NJ) legislature and governor enacted P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. We conduct a secondary analysis of reported data from the State of NJ Department of Health on 73 hospitals in 2008 to 2009 and 72 hospitals in 2010 to 2015. The first aim was to determine if NJ hospitals complied with legislation, and the second was to identify staffing trends postlegislation. On the reports, staffing was operationalized as the number of patients per RN per quarters. We obtained 30 quarterly reports for 2008 through 2015 and cross-checked these reports for data accuracy on the NJ Department of Health website. From these data, we created a longitudinal data set of 13 inpatient units for each hospital (14,158 observations) and merged these data with American Hospital Association Annual Survey data. The number of patients per RN decreased for 10 specialties, and the American Hospital Association data demonstrate a similar trend. Although the number of patients does not account for patient acuity, the decrease in the patients per RN over 7 years indicated the importance of public reporting in improving patient safety.

Frailty in the Cardiac Surgical Patient: Comparison of Frailty Tools and Associated Outcomes

BACKGROUND

Frailty measurement in cardiac surgery is poorly studied. The study purposes were to identify a simple but accurate frailty tool by comparing the simplified frailty index, Study of Osteoporotic Fractures (SOF), to a more complex frailty index, the Cardiovascular Health Study (CHS), and outcomes of frail patients to nonfrail patients.

METHODS

Patients aged 65 years or older admitted for elective coronary artery bypass grafting (CABG), valvular surgery (valve), or a combination of CABG/valve were recruited and administered the SOF and CHS indexes. Surgical outcomes were defined by The Society of Thoracic Surgeons. A hand-held dynamometer assessed grip strength. Health-related quality of life was assessed by the 12-Item Short Form Health Survey.

RESULTS

Patients (n = 167) were primarily male (75%), white (88%), and CABG (23%), valve (50%), or CABG/valve (25%). Frailty agreement between the CHS (frail, n = 47) and SOF (frail, n = 15) was poor (κ = 0.185). SOF frail patients had poorer health, were men (67% vs 61%), had a decreased ejection fraction (0.467 vs 0.537), an increased Society of Thoracic Surgeons Risk (5.0 vs 3.5), and increased European System for Cardiac Operative Risk Evaluation score (8.2 vs 5.2). All SOF frail patients reported lack of energy vs 8.7% CHS frail patients, and 80% vs 23.9% reported an unintentional weight loss of 5% or more. SOF frail patients were significantly more likely to experience prolonged ventilation (20% vs 6.5%), pneumonia (20% vs 6.5%), prolonged intensive care unit hours (158.6 vs 85.01), and readmission within 30 days (20% vs 8.7%). All frail patients reported a significantly lower physical health-related quality of life.

CONCLUSIONS

The SOF tool better identified patients considered "frail." Frail patients had more adverse outcomes and poorer health-related quality of life.

Mandatory public reporting of cardiac surgery outcomes: The 2003 to 2014 Massachusetts experience

OBJECTIVES

Beginning in 2002, all 14 Massachusetts nonfederal cardiac surgery programs submitted Society of Thoracic Surgeons (STS) National Database data to the Massachusetts Data Analysis Center for mandatory state-based analysis and reporting, and to STS for nationally benchmarked analyses. We sought to determine whether longitudinal prevalences and trends in risk factors and observed and expected mortality differed between Massachusetts and the nation.

METHODS

We analyzed 2003 to 2014 expected (STS predicted risk of operative [in-hospital + 30-day] mortality), observed, and risk-standardized isolated coronary artery bypass graft mortality using Massachusetts STS data (N = 39,400 cases) and national STS data (N = 1,815,234 cases). Analyses included percentage shares of total Massachusetts coronary artery bypass graft volume and expected mortality rates of 2 hospitals before and after outlier designation.

RESULTS

Massachusetts patients had significantly higher odds of diabetes, peripheral vascular disease, low ejection fraction, and age ≥75 years relative to national data and lower odds of shock (odds ratio, 0.66; 99% confidence interval, 0.53-0.83), emergency (odds ratio, 0.57, 99% confidence interval, 0.52-0.61), reoperation, chronic lung disease, dialysis, obesity, and female sex. STS predicted risk of operative [in-hospital + 30-day] mortality for Massachusetts patients was higher than national rates during 2003 to 2007 (P < .001) and no different during 2008 to 2014 (P = .135). Adjusting for STS predicted risk of operative [in-hospital + 30-day] mortality, Massachusetts patients had significantly lower odds (odds ratio, 0.79; 99% confidence interval, 0.66-0.96) of 30-day mortality relative to national data. Outlier programs experienced inconsistent, transient influences on expected mortality and their percentage shares of Massachusetts coronary artery bypass graft cases.

CONCLUSIONS

During 12 years of mandatory public reporting, Massachusetts risk-standardized coronary artery bypass graft mortality was consistently and significantly lower than national rates, expected rates were comparable or higher, and evidence for risk aversion was conflicting and inconclusive.

Challenges in outlier surgeon assessment in the era of public reporting

OBJECTIVE

To assess the effect of various evaluation and reporting strategies in determining outlier surgeons, defined by having worse-than-expected mortality after cardiac surgery.

METHODS

Our study included 33 394 isolated coronary artery bypass graft (CABG) procedures performed by 136 surgeons and 12 172 surgical aortic valve replacement (SAVR) procedures performed by 113 surgeons between 2010 and 2014. Three current methodologies based on the framework of comparing observed and expected (O/E ratio) mortality, with different distributional assumptions, were examined. We further assessed the consistency of outliers detected by these three methods and the impact of using different time windows and aggregating data of CABG and SAVR procedures.

RESULTS

The three methods were consistent and detected same outliers, with the least conservative method detecting additional outliers (outliers detected for methods 1, 2 and 3: CABG 3 (2.2%), 2 (1.5%) and 8 (5.9%); SAVR 1 (0.9%), 0 (0.0%) and 11 (9.7%)). When numbers of cases recorded were low and events were rare, the two more conservative methods were unlikely to detect outliers unless the O/E ratios were extremely high. However, these two methods were more consistent in detecting the same surgeons as outliers across different time windows for assessment. Of the surgeons who performed both CABG and SAVR, none was an outlier for both procedures when assessed separately. Aggregating data from CABG and SAVR may lead to results to be dominated by the procedure that had a higher caseload.

CONCLUSIONS

The choices of outlier assessment method, time window for assessment and data aggregation have an intertwined impact on detecting outlier surgeons, often representing different value assumptions toward patient protection and provider penalty. It is desirable to use different methods as sensitivity analyses, avoid aggregating procedures and avoid rare-event endpoints if possible.

The Society of Thoracic Surgeons Congenital Heart Surgery Database Public Reporting Initiative

Three basic principles provide the rationale for the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (CHSD) public reporting initiative: (1) Variation in congenital and pediatric cardiac surgical outcomes exist. (2) Patients and their families have the right to know the outcomes of the treatments that they will receive. (3). It is our professional responsibility to share this information with them in a format they can understand. The STS CHSD public reporting initiative facilitates the voluntary transparent public reporting of congenital and pediatric cardiac surgical outcomes using the STS CHSD Mortality Risk Model. The STS CHSD Mortality Risk Model is used to calculate risk-adjusted operative mortality and adjusts for the following variables: age, primary procedure, weight (neonates and infants), prior cardiothoracic operations, non-cardiac congenital anatomic abnormalities, chromosomal abnormalities or syndromes, prematurity (neonates and infants), and preoperative factors (including preoperative/preprocedural mechanical circulatory support [intraaortic balloon pump, ventricular assist device, extracorporeal membrane oxygenation, or cardiopulmonary support], shock [persistent at time of surgery], mechanical ventilation to treat cardiorespiratory failure, renal failure requiring dialysis and/or renal dysfunction, preoperative neurological deficit, and other preoperative factors). Operative mortality is defined in all STS databases as (1) all deaths, regardless of cause, occurring during the hospitalization in which the operation was performed, even if after 30 days (including patients transferred to other acute care facilities); and (2) all deaths, regardless of cause, occurring after discharge from the hospital, but before the end of the 30^th postoperative day. The STS CHSD Mortality Risk Model has good model fit and discrimination with an overall C statistics of 0.875 and 0.858 in the development sample and the validation sample, respectively. These C statistics are the highest C statistics ever seen in a pediatric cardiac surgical risk model. Therefore, the STS CHSD Mortality Risk Model provides excellent adjustment for case mix and should mitigate against risk aversive behavior. The STS CHSD Mortality Risk Model is the best available model to date for measuring outcomes after pediatric cardiac surgery. As of March 2016, 60% of participants in STS CHSD have agreed to publicly report their outcomes through the STS Public Reporting Online website (http://www.sts.org/quality-research-patient-safety/sts-public-reporting-online). Although several opportunities exist to improve our risk models, the current STS CHSD public reporting initiative provides the tools to report publicly, and with meaning and accuracy, the outcomes of congenital and pediatric cardiac surgery.

Ethical considerations of transparency, informed consent, and nudging in a patient with paediatric aortic stenosis and symptomatic left ventricular endocardial fibroelastosis

A 9-year-old boy who was born with bicuspid aortic stenosis underwent two unsuccessful aortic valvuloplasty interventions, and by 2 years of age he developed restrictive cardiomyopathy caused by left ventricular endocardial fibroelastosis and diastolic dysfunction. The attending cardiologist referred the patient to a high-volume, high-profile congenital cardiac surgical programme 1000 miles away that has a team with considerable experience with left ventricular endocardial fibroelastosis resection and a reputation of achieving good results. Owing to problems with insurance coverage, the parents sought other options for the care of their child in their home state. Dr George Miller is a well-respected local congenital and paediatric cardiac surgeon with considerable experience with the Ross operation as well as with right ventricular endocardial fibroelastosis resection. When talking with Dr Miller, he implied that there is little difference between right ventricular endocardial fibroelastosis and left ventricular endocardial fibroelastosis resection, and stated that he would perform the operation with low mortality based on his overall experience. Dr Miller stated that the local institution could provide an equivalent surgical procedure with comparable outcomes, without the patient and family having to travel out of state. A fundamental dilemma that often arises in clinical surgical practice concerns the conduct of assessing and performing new procedures, especially in rare cases, for which the collective global experience is scant. Although Dr Miller has performed right ventricular endocardial fibroelastosis resection, this procedure differs from left ventricular endocardial fibroelastosis resection, and he cannot be sure that he will indeed be able to perform the procedure better than the high-volume surgeon. This ethical situation is best understood in terms of the principles of respect for patient autonomy, beneficence, non-maleficence, and justice. The tension between the imperatives of beneficence and the obligation to respect the autonomy of the patient by acting only with the patient's best interest in mind is discussed.

Transparency and Public Reporting of Pediatric and Congenital Heart Surgery Outcomes in North America

Health care is embarking on a new era of increased transparency. In January 2015, the Society of Thoracic Surgeons (STS) began to publicly report outcomes of pediatric and congenital cardiac surgery using the 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) Mortality Risk Model. Because the 2014 STS CHSD Mortality Risk Model adjusts for procedural factors and patient-level factors, it is critical that centers are aware of the important impact of incomplete entry of data in the fields for patient-level factors. These factors are used to estimate expected mortality, and incomplete coding of these factors can lead to inaccurate assessment of case mix and estimation of expected mortality. In order to assure an accurate assessment of case mix and estimate of expected mortality, it is critical to assure accurate completion of the fields for patient factors, including preoperative factors. It is crucial to document variables such as whether the patient was preoperatively ventilated or had an important noncardiac congenital anatomic abnormality. The lack of entry of these variables will lead to an underestimation of expected mortality. The art and science of assessing outcomes of pediatric and congenital cardiac surgery continues to evolve. In the future, when models have been developed that encompass other outcomes in addition to mortality, pediatric and congenital cardiac surgical performance may be able to be assessed using a multidomain composite metric that incorporates both mortality and morbidity, adjusting for the operation performed and for patient-specific factors. It is our expectation that in the future, this information will also be publicly reported. In this era of increased transparency, the complete and accurate coding of both patient-level factors and procedure-level factors is critical.

The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2016 Update on Outcomes and Quality

The Society of Thoracic Surgeons Congenital Heart Surgery Database is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This article summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operations performed from January 2011 to December 2014 and documenting overall discharge mortality (interquartile range among programs with more than 9 cases): off-bypass coarctation, 1.0% (0.0% to 0.9%); ventricular septal defect repair, 0.7% (0.0% to 1.1%); tetralogy of Fallot repair, 1.0% (0.0% to 1.7%); complete atrioventricular canal repair, 3.2% (0.0% to 6.5%); arterial switch operation, 2.7% (0.0% to 5.6%); arterial switch operation plus ventricular septal defect, 5.3% (0.0% to 6.7%); Glenn/hemiFontan, 2.1% (0.0% to 3.8%); Fontan operation, 1.4% (0.0% to 2.4%); truncus arteriosus repair, 9.6% (0.0 % to 11.8%); and Norwood procedure, 15.6% (10.0% to 21.4%).

Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future

BACKGROUND

The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes.

METHODS

The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership.

RESULTS

Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges.

CONCLUSIONS

Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.

Practice gaps in the care of mitral valve regurgitation: Insights from the American College of Cardiology mitral regurgitation gap analysis and advisory panel

BACKGROUND

The revised 2014 American College of Cardiology (ACC)/American Heart Association valvular heart disease guidelines provide evidenced-based recommendations for the management of mitral regurgitation (MR). However, knowledge gaps related to our evolving understanding of critical MR concepts may impede their implementation.

METHODS

The ACC conducted a multifaceted needs assessment to characterize gaps, practice patterns, and perceptions related to the diagnosis and treatment of MR. A key project element was a set of surveys distributed to primary care and cardiovascular physicians (cardiologists and cardiothoracic surgeons). Survey and other gap analysis findings were presented to a panel of 10 expert advisors from specialties of general cardiology, cardiac imaging, interventional cardiology, and cardiac surgeons with expertise in valvular heart disease, especially MR, and cardiovascular education. The panel was charged with assessing the relative importance and potential means of remedying identified gaps to improve care for patients with MR.

RESULTS

The survey results identified several knowledge and practice gaps that may limit implementation of evidence-based recommendations for MR care. Specifically, half of primary care physicians reported uncertainty regarding timing of intervention for patients with severe primary or functional MR. Physicians in all groups reported that quantitative indices of MR severity were frequently not reported in clinical echocardiographic interpretations, and that these measurements were not consistently reviewed when provided in reports. In the treatment of MR, nearly 30% of primary care physician and general cardiologists did not know the volume of mitral valve repair surgeries by their reference cardiac surgeons and did not have a standard source to obtain this information. After review of the survey results, the expert panel summarized practice gaps into 4 thematic areas and offered proposals to address deficiencies and promote better alignment with the 2014 ACC/American Heart Association valvular disease guidelines.

CONCLUSION

Important knowledge and skill gaps exist that may impede optimal care of the patient with MR. Focused educational and practice interventions should be developed to reduce these gaps.

Principles of shared decision-making within teams

In the domain of paediatric and congenital cardiac care, the stakes are huge. Likewise, the care of these children assembles a group of "A+ personality" individuals from the domains of cardiac surgery, cardiology, anaesthesiology, critical care, and nursing. This results in an environment that has opportunity for both powerful collaboration and powerful conflict. Providers of healthcare should avoid conflict when it has no bearing on outcome, as it is clearly a squandering of individual and collective political capital. Outcomes after cardiac surgery are now being reported transparently and publicly. In the present era of transparency, one may wonder how to balance the following potentially competing demands: quality healthcare, transparency and accountability, and teamwork and shared decision-making. An understanding of transparency and public reporting in the domain of paediatric cardiac surgery facilitates the implementation of a strategy for teamwork and shared decision-making. In January, 2015, the Society of Thoracic Surgeons (STS) began to publicly report outcomes of paediatric and congenital cardiac surgery using the 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) Mortality Risk Model. The 2014 STS-CHSD Mortality Risk Model facilitates description of Operative Mortality adjusted for procedural and patient-level factors. The need for transparency in reporting of outcomes can create pressure on healthcare providers to implement strategies of teamwork and shared decision-making to assure outstanding results. A simple strategy of shared decision-making was described by Tom Karl and was implemented in multiple domains by Jeff Jacobs and David Cooper. In a critical-care environment, it is not unusual for healthcare providers to disagree about strategies of management of patients. When two healthcare providers disagree, each provider can classify the disagreement into three levels: • SDM Level 1 Decision: "We disagree but it really does not matter, so do whatever you desire!" • SDM Level 2 Decision: "We disagree and I believe it matters, but I am OK if you do whatever you desire!!" • SDM Level 3 Decision: "We disagree and I must insist (diplomatically and politely) that we follow the strategy that I am proposing!!!!!!" SDM Level 1 Decisions and SDM Level 2 Decisions typically do not create stress on the team, especially when there is mutual purpose and respect among the members of the team. SDM Level 3 Decisions are the real challenge. Periodically, the healthcare team is faced with such Level 3 Decisions, and teamwork and shared decision-making may be challenged. Teamwork is a learned behaviour, and mentorship is critical to achieve a properly balanced approach. If we agree to leave our egos at the door, then, in the final analysis, the team will benefit and we will set the stage for optimal patient care. In the environment of strong disagreement, true teamwork and shared decision-making are critical to preserve the unity and strength of the multi-disciplinary team and simultaneously provide excellent healthcare.

Penetration, Completeness, and Representativeness of The Society of Thoracic Surgeons Adult Cardiac Surgery Database

BACKGROUND

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) has been successfully linked to the Centers for Medicare and Medicaid (CMS) Medicare database, thereby facilitating comparative effectiveness research and providing information about long-term follow-up and cost. The present study uses this link to determine contemporary completeness, penetration, and representativeness of the STS ACSD.

METHODS

Using variables common to both STS and CMS databases, STS operations were linked to CMS data for all CMS coronary artery bypass graft (CABG) surgery hospitalizations discharged between 2000 and 2012, inclusive. For each CMS CABG hospitalization, it was determined whether a matching STS record existed.

RESULTS

Center-level penetration (number of CMS sites with at least one matched STS participant divided by the total number of CMS CABG sites) increased from 45% in 2000 to 90% in 2012. In 2012, 973 of 1,081 CMS CABG sites (90%) were linked to an STS site. Patient-level penetration (number of CMS CABG hospitalizations done at STS sites divided by the total number of CMS CABG hospitalizations) increased from 51% in 2000 to 94% in 2012. In 2012, 71,634 of 76,072 CMS CABG hospitalizations (94%) occurred at an STS site. Completeness of case inclusion at STS sites (number of CMS CABG cases at STS sites linked to STS records divided by the total number of CMS CABG cases at STS sites) increased from 88% in 2000 to 98% in 2012. In 2012, 69,213 of 70,932 CMS CABG hospitalizations at STS sites (98%) were linked to an STS record.

CONCLUSIONS

Linkage of STS and CMS databases demonstrates high and increasing penetration and completeness of the STS database. Linking STS and CMS data facilitates studying long-term outcomes and costs of cardiothoracic surgery.

The Society of Thoracic Surgeons Composite Measure of Individual Surgeon Performance for Adult Cardiac Surgery: A Report of The Society of Thoracic Surgeons Quality Measurement Task Force

BACKGROUND

Previous composite performance measures of The Society of Thoracic Surgeons (STS) were estimated at the STS participant level, typically a hospital or group practice. The STS Quality Measurement Task Force has now developed a multiprocedural, multidimensional composite measure suitable for estimating the performance of individual surgeons.

METHODS

The development sample from the STS National Database included 621,489 isolated coronary artery bypass grafting procedures, isolated aortic valve replacement, aortic valve replacement plus coronary artery bypass grafting, mitral, or mitral plus coronary artery bypass grafting procedures performed by 2,286 surgeons between July 1, 2011, and June 30, 2014. Each surgeon's composite score combined their aggregate risk-adjusted mortality and major morbidity rates (each weighted inversely by their standard deviations) and reflected the proportion of case types they performed. Model parameters were estimated in a Bayesian framework. Composite star ratings were examined using 90%, 95%, or 98% Bayesian credible intervals. Measure reliability was estimated using various 3-year case thresholds.

RESULTS

The final composite measure was defined as 0.81 × (1 minus risk-standardized mortality rate) + 0.19 × (1 minus risk-standardized complication rate). Risk-adjusted mortality (median, 2.3%; interquartile range, 1.7% to 3.0%), morbidity (median, 13.7%; interquartile range, 10.8% to 17.1%), and composite scores (median, 95.4%; interquartile range, 94.4% to 96.3%) varied substantially across surgeons. Using 98% Bayesian credible intervals, there were 207 1-star (lower performance) surgeons (9.1%), 1,701 2-star (as-expected performance) surgeons (74.4%), and 378 3-star (higher performance) surgeons (16.5%). With an eligibility threshold of 100 cases over 3 years, measure reliability was 0.81.

CONCLUSIONS

The STS has developed a multiprocedural composite measure suitable for evaluating performance at the individual surgeon level.

The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model: Part 2-Clinical Application

BACKGROUND

The empirically derived 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model incorporates adjustment for procedure type and patient-specific factors. The purpose of this report is to describe this model and its application in the assessment of variation in outcomes across centers.

METHODS

All index cardiac operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database (January 1, 2010, to December 31, 2013) were eligible for inclusion. Isolated patent ductus arteriosus closures in patients weighing less than or equal to 2.5 kg were excluded, as were centers with more than 10% missing data and patients with missing data for key variables. The model includes the following covariates: primary procedure, age, any prior cardiovascular operation, any noncardiac abnormality, any chromosomal abnormality or syndrome, important preoperative factors (mechanical circulatory support, shock persisting at time of operation, mechanical ventilation, renal failure requiring dialysis or renal dysfunction (or both), and neurological deficit), any other preoperative factor, prematurity (neonates and infants), and weight (neonates and infants). Variation across centers was assessed. Centers for which the 95% confidence interval for the observed-to-expected mortality ratio does not include unity are identified as lower-performing or higher-performing programs with respect to operative mortality.

RESULTS

Included were 52,224 operations from 86 centers. Overall discharge mortality was 3.7% (1,931 of 52,224). Discharge mortality by age category was neonates, 10.1% (1,129 of 11,144); infants, 3.0% (564 of 18,554), children, 0.9% (167 of 18,407), and adults, 1.7% (71 of 4,119). For all patients, 12 of 86 centers (14%) were lower-performing programs, 67 (78%) were not outliers, and 7 (8%) were higher-performing programs.

CONCLUSIONS

The 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model facilitates description of outcomes (mortality) adjusted for procedural and for patient-level factors. Identification of low-performing and high-performing programs may be useful in facilitating quality improvement efforts.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: The Driving Force for Improvement in Cardiac Surgery

Initiated in 1989, the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) includes more than 1085 participating centers, representing 90%-95% of current US-based adult cardiac surgery hospitals. Since its inception, the primary goal of the STS ACSD has been to use clinical data to track and improve cardiac surgical outcomes. Patients' preoperative risk characteristics, procedure-related processes of care, and clinical outcomes data have been captured and analyzed, with timely risk-adjusted feedback reports to participating providers. In 2006, STS initiated an external audit process to evaluate STS ACSD completeness and accuracy. Given the extremely high inter-rater reliability and completeness rates of STS ACSD, it is widely regarded as the "gold standard" for benchmarking cardiac surgery risk-adjusted outcomes. Over time, STS ACSD has expanded its quality horizons beyond the traditional focus on isolated, risk-adjusted short-term outcomes such as perioperative morbidity and mortality. New quality indicators have evolved including composite measures of key processes of care and outcomes (risk-adjusted morbidity and risk-adjusted mortality), longer-term outcomes, and readmissions. Resource use and patient-reported outcomes would be added in the future. These additional metrics provide a more comprehensive perspective on quality as well as additional end points. Widespread acceptance and use of STS ACSD has led to a cultural transformation within cardiac surgery by providing nationally benchmarked data for internal quality assessment, aiding data-driven quality improvement activities, serving as the basis for a voluntary public reporting program, advancing cardiac surgery care through STS ACSD-based research, and facilitating data-driven informed consent dialogues and alternative treatment-related discussions.

Antimicrobial use metrics and benchmarking to improve stewardship outcomes: methodology, opportunities, and challenges

Measurement of antimicrobial use before and after an intervention and the associated outcomes are key activities of antimicrobial stewardship programs. In the United States, the recommended metric for aggregate antibiotic use is days of therapy/1000 patient-days. Clinical outcomes, including response to therapy and bacterial resistance, are critical measures but are more difficult to document than economic outcomes. Interhospital benchmarking of risk adjusted antimicrobial use is possible, although several obstacles remain before it can have an impact on patient care. Many challenges for stewardship programs remain, but the methods and science to support their efforts are rapidly evolving.

The impact of high-risk cases on hospitals' risk-adjusted coronary artery bypass grafting mortality rankings

BACKGROUND

Risk-adjusted mortality (RAM) models are increasingly used to evaluate hospital performance, but the validity of the RAM method has been questioned. Providers are concerned that these methods might not adequately account for the highest levels of risk and that treating high-risk cases will have a negative impact on RAM rankings.

METHODS

Using cases of isolated coronary artery bypass grafting (CABG) performed at 1002 sites in the United States participating in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from 2008 to 2010 (N = 494,955), the STS CABG RAM model performance in high-risk patients was assessed. The ratios of observed to expected (O/E) perioperative mortality were compared among groups of hospitals with varying expected risks. Finally, RAM rates during the overall study period for each site were compared with its performance in a simulated "nightmare year" in which the site's highest risk cases over a 3-year period were concentrated into a 1-year period of exceptional risk.

RESULTS

The average predicted mortality for center risk groups ranged from 1.46% for the lowest risk quintile to 2.87% for the highest. The O/E ratios for center risk quintiles 1 to 5 during the overall period were 1.01 (95% confidence interval, 0.96% to 1.06%), 1.00 (0.95% to 1.04%), 0.98 (0.94% to 1.03%), 0.97 (0.93% to 1.01%), and 0.80 (0.77% to 0.84%), respectively. The sites' risk-adjusted mortality rates were not increased when the centers' highest risk cases were concentrated into a single "nightmare year."

CONCLUSIONS

Our results show that the current risk-adjusted models accurately estimate CABG mortality and that hospitals accepting more high-risk CABG patients have equal or better outcomes than do those with predominately lower-risk patients.