OUTCOMES ANALYSIS, QUALITY IMPROVEMENT, AND PATIENT SAFETY
The Society of Thoracic Surgeons Adult
Cardiac Surgery Database: 2017 Update on
Outcomes and Quality
Richard S. D’Agostino, MD, Jeffrey P. Jacobs, MD, Vinay Badhwar, MD,
Gaetano Paone, MD, J. Scott Rankin, MD, Jane M. Han, MSW,
Donna McDonald, RN, MPH, Fred H. Edwards, MD, and David M. Shahian, MD
Department of Thoracic and Cardiovascular Surgery, Lahey Hospital & Medical Center, Burlington, Massachusetts; Division of Cardiac
Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland and Johns Hopkins All Children’s
Heart Institute, All Children’s Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, Florida; Division of
Cardiothoracic Surgery, West Virginia University, Morgantown, West Virginia; Division of Cardiac Surgery, Henry Ford Hospital,
Detroit, Michigan; The Society of Thoracic Surgeons, Chicago, Illinois; Department of Surgery, University of Florida College of
Medicine, Jacksonville, Florida; and Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital and
Harvard Medical School, Boston, Massachusetts
Established in 1989, The Society of Thoracic Surgeons
Adult Cardiac Surgery Database is one of the most
comprehensive clinical data registries in health care. It is
widely regarded as the gold standard for benchmarking
risk-adjusted outcomes in cardiac surgery and is the foundation for all quality measurement and improvement
activities of The Society of Thoracic Surgeons. This is the
second in a series of annual reports that summarizes current
aggregate national outcomes in cardiac surgery and reviews
database-related activities in the areas of quality measurement and performance improvement during the past year.
T
Overview of the ACSD
he Society of Thoracic Surgeons (STS) Adult Cardiac
Surgery Database (ACSD) was established in
response to the publication of minimally adjusted coronary artery bypass grafting (CABG) operative mortality
data by the federal government in 1986 and the recognition by STS leaders that these results did not adjust for
differences in the inherent risk of patients [1, 2]. Since its
inception in 1989, the primary goal of the ACSD has been
to provide clinically relevant and accurate information to
STS participants to assist in self-assessment and quality
improvement activities.
During the past 3 decades, the ACSD has evolved into
the most comprehensive clinical cardiac surgery data
registry in the world. Data derived from this repository of
more than 6.1 million patient records support nationally
benchmarked performance assessment and feedback,
sophisticated risk adjustment models [3–5], performance
measurement [6, 7], quality improvement initiatives, and
voluntary public reporting [8]. The ACSD has also been
linked with other registries, facilitating the development
of a platform for longitudinal outcomes assessment to
inform comparative effectiveness research, device surveillance, and health policy development. This report
summarizes current national aggregate cardiac surgical
outcomes and outlines quality measurement and performance improvement activities derived from the ACSD
during the past year.
Address correspondence to Dr D’Agostino, Department of Thoracic and
Cardiovascular Surgery, Lahey Hospital & Medical Center, 41 Mall Rd,
Burlington, MA 01805; email: richard.s.d’[email protected].
Ó 2017 by The Society of Thoracic Surgeons
Published by Elsevier
(Ann Thorac Surg 2017;103:18–24)
Ó 2017 by The Society of Thoracic Surgeons
ACSD participants submit data to the STS data warehouse and analytical center at Duke Clinical Research
Institute during four quarterly harvests each year. After
internal checks for data completeness and consistency are
conducted, analyses are performed, and the results are
disseminated quarterly to each ACSD participant. The
information is participant specific regarding risk factors
and nationally benchmarked outcomes and also contains
aggregate national results for comparison and internal
quality assurance. Semiannually, participants also receive
their performance on National Quality Forum (NQF)endorsed STS measures and composite quality scores
based on a running 12 months (CABG) and 36 months
(valve) of data ending in June or December of each year.
As of September 2016, the ACSD included 1,119
participant groups comprising 3,100 surgeons from all 50
United States states, 10 sites in Canada, and 19 participants in 7 other countries. The data set contains information on more than 6.1 million cumulative cardiac
operations worldwide. The anesthesiology module has 62
participants comprising 684 anesthesiologists. The atrial
fibrillation module has 15 participants. Linked Centers for
Medicare and Medicaid Services and ACSD CABG data
have demonstrated high ACSD patient (94%) and centerlevel (90%) penetration and 98% complete case inclusion
of Centers for Medicare and Medicaid Services CABG
cases at STS sites [9]. These findings provide reassuring
information about the representativeness and completeness of the ACSD.
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2016.11.001
Ann Thorac Surg
2017;103:18–24
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STS ACSD: QUALITY AND OUTCOMES
Abbreviations and Acronyms
ACSD
AF
AVR
CABG
CVA
DSWI
FTR
LOS
MV
MVR
MVRR
NQF
QMTF
STS
TQI
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
Adult Cardiac Surgery Database
atrial fibrillation
aortic valve replacement
coronary artery bypass grafting
cerebrovascular accident
deep sternal wound infection
failure to rescue
length of stay
mitral valve
mitral valve replacement
mitral valve repair or replacement
National Quality Forum
Quality Measurement Task Force
The Society of Thoracic Surgeons
Task Force on Quality Initiatives
Data integrity has been of paramount importance to the
ACSD since its inception. In addition to an extensive
internal validation process, beginning in 2006, STS has
randomly selected 10% of sites each year for additional
independent external audit. In 2016, 110 facilities were
audited. During an audit, submitted data are compared
with the medical record, and hospital surgical logs are
reviewed to verify that all cases are included. These
audits have shown nearly 100% of cases are appropriately
captured and that concordance rates with submitted data
elements exceed 95% [10, 11].
Some data fields have a choice of “unknown,” as an
option to be used only after every effort has been made to
ascertain the correct response. Minimizing the use of
“unknown” is particularly critical for those fields relating
to operative mortality, because they underpin the validity
of risk models, benchmarking, and composite scores. The
relevant operative mortality fields include “discharge
status,” “status at 30 days after discharge,” and “operative
death.” To assure the highest level of accuracy when
reporting operative mortality, STS has established
“missing” or “unknown” vital status thresholds to
determine eligibility to receive a composite score (star
rating). As of January 1, 2016, fields relating to operative
mortality status must have a completeness rate of 95%,
increasing to 98% for those cases performed after
December 31, 2016. Records with “unknown” or
“missing” operative mortality data are considered
incomplete. Patients of STS ACSD participants who do
not meet data completeness thresholds will not be
included in the benchmark population used for performance analyses, and these participants will not be eligible
to receive a composite score.
A key objective of the ACSD is to provide sophisticated
risk models that can be used to assess outcomes and
quality. Consequently, data elements are revised on a
3-year cycle to ensure they remain clinically relevant with
evolving surgical practice and to address suggestions
raised by data managers and surgeons. ACSD specification revision was a major focus in 2016 and entailed a
systematic review of every data field in version 2.81. With
19
each specification revision, there is always an inherent
tension between collecting every possible relevant factor
and increasing the number of data fields beyond a
pragmatic size. An expansion pressure is also created by
new technologies and procedures.
Mindful of maintaining this balance, outdated data
elements have been eliminated in the most recent specification upgrade to permit inclusion of others that better
reflect current and future practice. Most notably, the
section on aortic and aortic root procedures was rewritten
and substantially expanded to address the advances in
aortic surgery since the last iteration of the database. The
new version, which will become effective July 1, 2017, will
contain approximately 1,200 data elements, including
those data fields in the optional anesthesiology module.
This represents an increase from the 840 fields in version
2.81, although the additional fields required for any given
patient are far fewer because many of these data elements
are child fields that are only relevant if the parent is
selected; furthermore, some data elements apply only to
specific types of patients.
National Outcomes in Adult Cardiac Surgery
This report encompasses aggregate outcomes for all
operations performed during the period January 1 to
December 31, 2015, and presented in the 2016 Harvest 1
report. They are based on the data elements specified in
the current version (2.81) of the data collection
instrument.
The relative distribution of the major procedures for
which the STS ACSD has developed risk-adjustment
models [3–5] and composite quality ratings [12–15] is
shown in Figure 1. These seven procedures represent
approximately 77% of the major cardiac procedures performed nationally. Thus, 23% of procedures performed
nationally are not included in one of these seven categories and comprise procedures such as combined aortic
and mitral valve replacement, tricuspid valve repair/
replacement, arrhythmia correction operations, implantation of a ventricular assist device, and septal defect
repair, among others, that were performed in isolation or
in combination with other procedures.
Table 1 inventories the change in procedure volume
during the past decade and the past year. The number of
isolated CABG operations, although declining by 7%
during the past decade, has shown a slight increase
during the past year. This may reflect a change in the
volume or treatment strategy, or both, of diabetic patients
presenting with 3-vessel coronary disease. The volume of
aortic valve replacements performed during the past
decade has increased by 74%. However, that growth trend
was notably absent during this past year, with a 1%
decrease in the number of procedures, undoubtedly
resulting from the effect of transcatheter aortic valve
replacement as an emerging treatment option. There is a
continuing national trend in favor of mitral valve repair
over replacement [15], although the overall number of
procedures involving the mitral valve, despite showing
growth during the past decade, decreased slightly in 2015.
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Ann Thorac Surg
2017;103:18–24
Fig 1. Relative distribution of seven major cardiac operations by
procedure type: calendar year 2015. (AVR ¼ aortic valve replacement;
CABG ¼ coronary artery bypass grafting; MV ¼ mitral valve;
MVR ¼ mitral valve replacement.)
Selected aggregate national outcomes for the more
commonly performed operations in calendar year 2015
are presented in Table 2. Operative mortality for the listed
procedures remains fundamentally unchanged from last
year’s report, ranging from a high of 9.8% for mitral valve
replacement (MVR) combined with CABG (MVRþCABG)
to a low of 1.1% for mitral valve repair. MVRþCABG
continues to show the highest incidence of major
morbidity among the most commonly performed
procedures.
The incidence of new postoperative atrial fibrillation
ranges from 24% for CABG to 44.2% for MVRþCABG.
Atrial fibrillation is the most frequently encountered
complication after cardiac operations. It negatively affects
postoperative clinical outcomes and resource utilization
[16] and remains an area for quality improvement efforts.
The recognition that exposure to even small quantities
of a transfused blood product can be associated with
adverse short-term and long-term outcomes has led
many cardiac surgical programs to adopt strategies to
reduce transfusion. Table 3 details rates of blood product
use for the past 2 calendar years. Transfusion rates have
decreased for all of the seven major cardiac surgical
procedures. During the past 5 years, transfusion rates
have decreased by 10% to 15% [17]. Nevertheless, a substantial number of patients still are exposed to a blood
product, highlighting the need for further efforts in this
area.
Reducing readmissions has become a major health care
reform goal, and the Centers for Medicare and Medicaid
Services is introducing reimbursement penalties for
higher-than-expected readmission rates after CABG. In
2015, the 30-day postdischarge readmission rates ranged
from 10% for CABG to 16.1% for MVRþCABG (Table 3).
The three most common reasons for readmission are
congestive heart failure, arrhythmias, and pleural effusions requiring treatment. The STS remains proactive in
this area and has introduced a 30-day readmission measure for CABG [18] and produced a quality Webinar on
this topic in May 2016.
Quality Measurement
The development of risk models and performance measures falls under the domain of the STS Quality
Table 1. Change in Procedure Volume During the Past Decade and the Past Year
Variable
Overall procedure count
Major procedures
Isolated CABG
Isolated AVR
Isolated MVR
MV repair
AVR þ CABG
MVR þ CABG
MV repair þ CABG
AVRþMVR
Procedures not classified above
Incidence of select other procedures
Tricuspid valve
Ventricular assist device
Atrial septal defect repair
AF correction operation
Aortic aneurysm operation
Cardiac transplant
AF ¼ atrial fibrillation;
valve replacement.
2006
(No.)
2014
(No.)
2015
(No.)
267,860
284,531
286,149
7
161,733
16,957
4,498
5,092
15,540
2,648
4,838
1,163
55,391
147,918
29,810
6,987
8,858
18,362
2,632
4,283
1,908
63,773
151,474
29,462
7,027
8,764
17,570
2,681
3,862
1,808
63,501
–6
74
56
72
13
1
–20
55
15
2
–1
1
–1
–4
2
–10
–5
–0.4
5,965
1,134
3,158
14,978
9,553
978
10,014
4,742
5,895
19,422
12,635
1,718
10,137
5,274
5,756
11,354
13,113
1,687
70
365
82
–24
37
72
1
11
–2
–42
4
–2
AVR ¼ aortic valve replacement;
Change: 2006 to 2014
(%)
CABG ¼ coronary artery bypass grafting;
Change: 2014 to 2015
(%)
1
MV ¼ mitral valve;
MVR ¼ mitral
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Table 2. Selected Outcomes of the More Commonly Performed Cardiac Surgical Procedures in Calendar Year 2015
CABG
AVR
AVR þ CABG
MVR
MVR þ CABG MV Repair MV Repair þ CABG
(n ¼ 151,474) (n ¼ 29,462) (n ¼ 17,570) (n ¼ 7,027)
(n ¼ 2,681)
(n ¼ 8,764)
(n ¼ 3,862)
Outcome
In-hospital mortality, %
Operative mortality,a %
Major morbidity
Reoperation,b %
DSWI/mediastinitis, %
Permanent stroke, %
Prolonged ventilation
>24 hours, %
Renal failure, %
New-onset AF, %
Readmission 30 days
of discharge, %
Postoperative hospital LOS
Mean, days
Median, days
1.8
2.2
1.6
2.1
3.3
3.9
4.0
4.7
8.7
9.8
0.9
1.1
4.1
4.1
2.2
0.3
1.3
8.2
4.4
0.1
1.3
7.5
6.3
0.3
2.2
12.8
7.9
0.2
1.9
17.0
11.6
0.4
3.3
29.0
3.6
0.1
1.3
5.3
7.0
0.3
2.6
19.8
2.1
24.0
10.0
2.0
31.7
10.0
3.7
39.6
12.6
4.4
34.2
15.7
8.2
44.2
16.1
1.1
29.8
8.8
5.2
42.6
13.3
6.9
6.0
7.2
6.0
8.5
7.0
10.0
7.0
11.6
9.0
6.5
5.0
9.8
8.0
a
Operative mortality is defined in all three Society of Thoracic Surgeons 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
b
deaths, regardless of cause, occurring after discharge from the hospital, but before the end of postoperative day 30.
National Quality Forum
definition of reoperation.
AF ¼ atrial fibrillation;
AVR ¼ aortic valve replacement;
DSWI ¼ deep sternal wound infection;
LOS ¼ length of stay;
CABG ¼ coronary artery bypass grafting;
CVA ¼ cerebrovascular accident;
MV ¼ mitral valve;
MVR ¼ mitral valve replacement.
Measurement Task Force (QMTF) and involves close
collaboration between clinical cardiothoracic surgeons
and statisticians from Duke Clinical Research Institute.
Risk Models
A major focus of the QMTF in 2016 has been the development of new risk models for isolated CABG, isolated
valve replacement operations, and valve replacement
combined with CABG operations. Surgeons and statisticians reviewed the existing risk models and variables, as
well as new variables available in version 2.73. They
considered the clinical justification and importance of
each variable, the relative frequency of each risk factor in
the specific procedural population, the bivariate association of each variable with the nine relevant outcomes for
each procedure, and the extent of missing data (or test not
Table 3. Blood Product Use for the Seven Major Procedures:
2014 Versus 2015
Procedure
Patients Receiving Any Blood Product
During the Intraoperative and/or
Postoperative Period, %
Calendar Year
CABG
AVR
AVR þ CABG
MVR
MVR þ CABG
MV repair
MV repair þ CABG
AVR ¼ aortic valve replacement;
grafting;
MV ¼ mitral valve;
2014
44.5
50.0
67.7
69.8
84.4
34.4
71.5
2015
43.0
46.3
66.9
67.2
82.3
33.1
67.9
CABG ¼ coronary artery bypass
MVR ¼ mitral valve replacement.
performed). Candidate variables were sequentially studied using backward selection at various levels of statistical
significance, various tests of model discrimination and
calibration were performed, and final models were
developed. These new models will be published in 2017
and implemented in subsequent performance measures
and feedback reports.
Composite Performance Measures for Mitral Valve
Repair and Replacement, With or Without CABG
In 2016, STS QMTF added two new mitral composite
measures, the isolated mitral valve repair or replacement
(MVRR) composite [15] and MVRRþCABG composite [19].
Because contemporary mitral operations are frequently
performed in conjunction with concomitant procedures, the
MVRR and MVRRþCABG models were designed using
modified versions of existing risk models to account for
these additional procedures. Consequently, the STS mitral
composite measures include all isolated mitral procedures
as well as those undergoing concomitant tricuspid valve
repair (not replacement), atrial septal defect and patent
foramen ovale closure, and surgical ablation for atrial
fibrillation. The performance of these common adjunctive
procedures did not affect risk-adjusted mortality.
Because mitral valve pathophysiology can affect clinical
decision making, particularly in patients with functional
ischemic mitral regurgitation [20, 21], the MVRRþCABG
composite specifically examined the effect of mitral etiology on outcome. Etiology was found not to be an independent predictor of risk-adjusted 30-day mortality or
major morbidity and was not included in the model. This
finding does not refute the contribution of mitral etiology
to the longer-term outcomes of mitral operations. Rather,
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the lack of any specific effect of an etiology variable on
30-day outcome is likely explained by the presence of
other risk factors such as New York Heart Association
Functional Classification, ejection fraction, age, and renal
failure. The role of etiology in long-term outcomes may be
defined in future comparative investigations.
As with previously developed STS composite measures,
and in the absence of widely accepted or NQF-endorsed
process measures for mitral valve operations, the primary end points assessed were 30-day or in-hospital
mortality and the occurrence of major morbidity (reoperation, stroke, renal failure, sternal infection, or prolonged
ventilation). After exclusions, 61,201 patients from 867
participating sites who underwent operations between
July 2011 and June 2014 were identified for MVRR composite measure development [15]. The MVRRþCABG
cohort included 24,740 MVRRþCABG patients from 703
participating sites. To provide composite scores to as many
sites as possible while maintaining acceptable model
reliability, the measures include 3 years of data from
programs with at least 36 MVRR cases and at least 25
MVRRþCABG cases to arrive at a reliability of 0.58 and
0.50, respectively. For the MVRR measure, 2.6% of
participant sites were deemed to be 1 star (lower-thanexpected performance), 91.7% were 2 stars (as-expected
performance), and 5.7% were 3 stars (higher-than-expected performance). For the MVRRþCABG measure, 2%
of programs were 1 star, 95% were 2 stars, and 3% were 3
stars. Deaths and morbidity progressively declined as star
ratings increased. The MVRR and the MVRRþCABG
measures were both reviewed favorably and recommended for endorsement by the NQF Surgery Project
Standing Committee in 2016, and data from these composites will be delivered in participant feedback reports
commencing in 2017.
Failure to Rescue
Failure to rescue (FTR) is a measure of hospital performance that is receiving increasing attention. It refers to
the outcome of patients who have experienced a
complication and focuses more on the system of care
rather than the operative procedure. Superior FTR rates
suggest that an institution has the staff, structures, and
processes of care that allows it to better “rescue” patients
who have sustained serious complications.
The STS has made considerable progress in the
exploration of FTR. The STS National Database was used
to develop FTR data for a contemporary cohort of CABG
patients. Data from 604,154 patients undergoing CABG
from 2010 to 2013 were used to develop a statistical model
to predict FTR for each of four complications and for a
composite of all four complications [22]. The STS analysis
was consistent with previous studies showing that FTR
rates were more strongly correlated with death than were
overall complication rates.
Interestingly, when centers were grouped by terciles of
complication rates, lower complication rates were associated with higher FTR and higher complication rates
were associated with lower FTR. Likewise, the FTR
observed-to-expected ratio was more favorable for the
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high-complication tercile and less favorable for the lowcomplication tercile. This apparent paradox has been
addressed by the QMTF and will be explored. Each
complication tercile is to be examined for volume,
average patient risk, and other factors that may affect the
findings. This closer examination of the complication
terciles may shed light on the cause of the inverse relationship between complication rate and FTR.
Other areas to be explored are FTR rates for valve
replacement operations, FTR outcomes other than death,
and the complex determinants of FTR. As FTR studies
progress, the STS hopes that the role of FTR can be more
clearly defined and that STS members can be provided
with a valuable new quality metric.
Quality Initiatives
The STS Task Force on Quality Initiatives (TQI) has
devoted its energies primarily in three areas during the
past year: (1) the development and maintenance of NQFendorsed measures (in collaboration with the QMTF); (2)
the development of quality Webinars; and (3) providing
surgeon support for Data Manager Regional Groups.
NQF Measure Submissions
The NQF is a multistakeholder organization whose goal is
to improve health care quality through better measurement. NQF endorsement is the gold standard for health
care quality, and NQF-endorsed measures are recognized
as evidenced based and “best in class.” The STS
is committed to the development and use of such highestquality performance measures, and its 34 NQF-endorsed
measures are the largest number of any professional
society.
The submission of STS measures for NQF endorsement
is a joint effort between the TQI and QMTF. The TQI
specifically contributes information on clinical practice
guidelines and other information to demonstrate that
each measure focus is evidence based. In June 2016, the
STS submitted three previously endorsed adult cardiac
and three new adult cardiac composite measures to the
NQF for review under the NQF Surgery Project Phase 3
(Table 4). The NQF Surgery Project Standing Committee
recommended all of the STS measures for endorsement
at its August 2016 meeting, and it is anticipated that these
measures will successfully undergo the remaining steps
in the NQF measure review process, which includes
30-day NQF public and member comment period, postcomment review call, 15-day member voting period,
endorsement decision by the Consensus Standards
Approval Committee, and ratification by the NQF Board
of Directors.
STS Quality Webinars
The first Webinar in the series debuted in February 2012
and was devoted to perioperative blood conservation.
Subsequent topics have included glycemic control (April
2013), mediastinal staging of lung cancer (March 2014),
and prolonged ventilation in adult cardiac operations
(December 2014). The most recent Webinar, posted on the
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Table 4. Submitted Society of Thoracic Surgeons National
Quality Forum Measures
NQF Measure No.
New
3030
Old
3031
3032
0117
0127
0134
Measure
STS Individual Surgeon Composite Measure
for Adult Cardiac Surgery
STS MVRR Composite Score
STS MVRR þ CABG Composite Score
Beta-Blocker at Discharge
Preoperative Beta-Blockade
Use of Internal Mammary Artery in CABG
CABG ¼ coronary artery bypass grafting;
MVRR ¼ mitral valve
repair/replacement;
NQF ¼ National Quality Forum;
STS ¼ The
Society of Thoracic Surgeons.
STS Web site on May 18, 2016, focused on the increasingly important issue of 30-day readmissions after cardiac
operations. Among the areas covered was the role of the
federal government in reimbursement policy and the
potential for unintended negative consequences, controversies related to difficulties in adequately estimating
expected rates of readmission, and defining what constitutes excessive or unnecessary readmission. In addition,
Webinar speakers presented information on the most
common causes of readmission after CABG and practical
approaches to reducing their frequency. The Webinar
was very well received, as demonstrated by the 1,013
views between May and early September 2016. All presentations are available for viewing on the STS Webinar
Series page of the STS Web site (http://www.sts.org/
node/18437).
Data Manager Regional Groups
STS National Database data managers remain vital to the
ongoing success of the STS National Database. Data manager regional groups have provided a collaborative environment for peer support and guidance. There are now 20
such regional groups that span 43 states. Although surgeon
23
participation has improved in several localities during the
past year, only the groups in Virginia, Michigan, Texas/
Oklahoma, Maryland, and the Delaware Valley (consisting
of programs in Pennsylvania, Delaware, and New Jersey)
hold regular meetings attended by both surgeons and data
managers. However, surgeon support, unfortunately,
remains informal and unstructured throughout many areas
of the country. There is little or no surgeon support of
the Arkansas/Kentucky/Tennessee and Nebraska/Iowa
regional data manager groups. The ACSD Task Force takes
this opportunity to remind all cardiothoracic surgeons of
their professional obligation to provide support for these
critically important local quality improvement initiatives.
To highlight the important role of data mangers, the
June 2016 issue of STS National Database News included a
TQI article [23] that stressed the importance of data
manager and surgeon collaboration in regional groups
and featured the regional group activities in Texas and
Michigan. In addition, the TQI provides data manager
groups with expert speakers who are available to present
on topics related to quality at regional meetings and calls.
TQI surgeon members delivered presentations on quality
improvement in acute kidney injury/acute renal failure at
the August 2016 Missouri/Kansas regional group call and
on successful regional quality collaboratives at the
October 2016 Ohio regional group conference. The TQI
will continue to work with Data Managers Regional
Groups on this important initiative.
Future Initiatives
The ACSD will make operational the new specification
revision (version 2.9) effective July 1, 2017. The audit
process will use a 98% data completeness threshold for
operative mortality fields submitted on or after January 1,
2017. Data collection and reporting methodology will be
updated to better meet the needs of participants by
implementing continuous data collection in January 2017
and a Web-based report dashboard in mid-2017.
Table 5. Potential Quality Measurement Task Force Projects for 2017 to 2018
Variable
Project
Ongoing
Joint project with the STS Stroke Task Force to explore specific risk mitigation strategies for
periprocedural stroke
Volume thresholds for mitral valve repair will be explored, using data used to develop the STS mitral
composite measures
The development of risk models for short-term (periprocedural) and long-term (1-year and 5- year) costs
for CABG
Published results from states with cardiac surgery report cards will be compared with results from the
STS Adult Cardiac Surgery Database for similar periods to examine the correlation of state report cards
and STS performance ratings as well as the potential effect of public reporting on performance
A multiprocedural composite will be developed to provide a more comprehensive perspective on hospital
or group performance, based on the methodology used to develop the STS individual surgeon
performance measure
Explore the consistency of STS performance ratings over time as a potential adjunct to performance
measurement
Explore the issue of whether or not to adjust outcomes for socioeconomic status using geocoded STS data
for adult cardiac surgery
New
CABG ¼ coronary artery bypass grafting;
STS ¼ The Society of Thoracic Surgeons.
24
QUALITY REPORT
D’AGOSTINO ET AL
STS ACSD: QUALITY AND OUTCOMES
The QMTF has planned a number of Adult Cardiac
projects for the coming year. These projects are detailed
in Table 5.
Finally, the TQI continues to develop a proposal for a
site review quality-improvement program. Volunteer TQI
members have populated three workgroups focusing on
previsit preparation and the in-person visit, postvisit
reporting, and development of best practices. It is anticipated that such a program would facilitate interaction
between adult cardiac surgical programs requesting
external review and STS-approved site reviewers who
have the demonstrated skills and attributes to assist in
quality improvement. The program proposal is intended
to be presented to the STS Board in early 2017.
Summary
Cardiothoracic surgeons were among the first medical
specialists to recognize the value of comprehensive,
accurate, and granular clinical information in their
ongoing efforts to improve the care they provide to their
patients. For nearly 30 years, the STS ACSD has been the
foundation of the Society’s activities in performance
measurement, quality improvement, and outcomes
research in adult cardiac surgery. Knowledge derived
from the ACSD has advanced cardiac surgical care,
improved patient outcomes, and helped to inform public
policy. Future enhancements to the ACSD will remain
devoted to these goals.
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