The European Thoracic Database project: composite performance score to measure quality of care after major lung resection☆

Abstract

Performance measurement is an essential element of quality improvement initiatives. The objective of this study was to develop a composite performance score (CPS) incorporating processes and outcomes measures available in the European Society of Thoracic Surgeons (ESTS) Database and apply it to stratify performance of participating units. A total of 1656 major lung resections for malignant primary neoplastic disease were collected in the ESTS database from 2001 through 2003 and were analyzed. For the purpose of this study only data collected from units contributing more than 50 consecutive cases were included. Three quality domains were selected: preoperative care, operative care, and postoperative outcome. According to best available evidence the following measures were selected for each domain: preoperative care (% of predicted postoperative carbon monoxide lung diffusion capacity (ppoDLCO) measurement in patients with predicted postoperative forced expiratory volume in one second (ppoFEV1) <40%), operative care (% of systematic lymph node dissection), and outcomes (risk-adjusted cardiopulmonary morbidity and mortality rates). Morbidity and mortality risk models were developed by hierarchical logistic regression and validated by bootstrap analyses. Individual processes and outcomes scores were rescaled according to their standard deviations and summed to generate the CPS, which was used to rate units. CPS ranged from -4.4 to 3.7. Individual scores were poorly correlated with each other. Two units were negative outliers and two positive outliers (outside 95% confidence limits). Compared to the rating obtained by using the risk-adjusted mortality rates, all units changed their positions when ranked by CPS. The composite performance score methodology may support future peer-based organizational quality benchmarking initiatives and may be used for regulatory and credentialing purposes.