Society Of Thoracic Surgeons National Research Articles

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

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

Comparing Robotic Lung Resection with Thoracotomy and Video-Assisted Thoracoscopic Surgery Cases Entered into the Society of Thoracic Surgeons Database

The use of robotic lung surgery has increased dramatically despite being a new, costly technology with undefined benefits over standard of care. There is a paucity of published comparative articles justifying its use or cost. Furthermore, outcomes regarding robotic lung resection are either from single institutions with in-house historical comparisons or based on limited numbers. We compared consecutive robotic anatomic lung resections performed at two institutions with matched data from The Society of Thoracic Surgeons (STS) National Database for all open and video-assisted thoracoscopic surgery (VATS) resections. We sought to define any benefits to a robotic approach versus national outcomes after thoracotomy and VATS. Data from all consecutive robotic anatomic lung resections were collected from two institutions (n = 181) from January 2010 until January 2012 and matched against the same variables for anatomic resections via thoracotomy (n = 5913) and VATS (n = 4612) from the STS National Database. Patients with clinical N2, N3, and M1 disease were excluded. There was a significant decrease in 30-day mortality and postoperative blood transfusion after robotic lung resection relative to VATS and thoracotomy. The patients stayed in the hospital 2 days less after robotic surgery than VATS and 4 days less than after thoracotomy. Robotic surgery led to fewer air leaks, intraoperative blood transfusions, need for perioperative bronchoscopy or reintubation, pneumonias, and atrial arrhythmias compared with thoracotomy. This is the first comparative analysis using national STS data. It suggests potential benefits of robotic surgery relative to VATS and thoracotomy, particularly in reducing length of stay, 30-day mortality, and postoperative blood transfusion.

Abstract 220: Cost-effectiveness of CABG vs PCI for Treatment of Multivessel Coronary Disease among Diabetes Patients---A Secondary Analysis from ASCERT

Background: The ASCERT--American College of Cardiology Foundation (ACCF) - Society of Thoracic Surgeons (STS) Database Collaboration on the Comparative Effectiveness of Revascularization Strategies study - has demonstrated that coronary artery bypass graft (CABG) surgery was associated with reduced mortality compared to percutaneous coronary intervention (PCI) at 4 years. In this study, we examined the cost-effectiveness of CABG versus PCI for treatment of multivessel coronary disease patients among diabetes patients. Methods: Diabetes Patients age ≥65 years with stable 2 and 3-vessel disease undergoing revascularization from 2004 through 2008 were evaluated. CABG patients with diabetes were selected from the STS National Database and the PCI patient population from The ACCF National Cardiovascular Data Registry. Costs were assessed at index, study period from years 2004 to 2008 by Diagnosis Related Group for hospitalizations. The average Medicare participant per capita expenditure in 2004 was used to estimate cost beyond the study period. Effectiveness during the study period was measured via mortality rate. Costs and effectiveness were adjusted using propensity scores and inverse probability weighting to reduce treatment selection bias. The incremental cost-effectiveness ratio (ICER) was expressed as cost per LYG. Results: Among diabetes patients (24,508 of 86,244 in CABG group and 25,481 of 103,549 in PCI group) at least 65 years old with two or three vessel coronary artery disease, costs were higher for CABG by $11,013 (95% CI: $10,930 to $11,136) during the index hospitalization. Over the period from 2004 through 2008 , average total costs were $28,413 for CABG versus $20,268 for PCI, a difference of $8,145 (95% CI: $7,918 to $8,373); patients undergoing CABG gained an average of 0.1524 life-years relative to PCI; the ICER of CABG, compared to PCI, was $53,500 per LYG, with 18%, 42%, 78%, and 88% of bootstrap-derived estimates <$25,000/LYG , <$50,000/LYG , <$75,000/LYG , and <$100,000/LYG, respectively. Conclusions: This study shows that over a period of 4 years or longer, CABG is associated with better outcomes but at higher cost than PCI in patients with diabetes.

The role of the total artificial heart in the treatment of post–myocardial infarction ventricular septal defect

improved durability and performance relative to previous VADs. Our major rationale for choosing the HeartWare HVAD was its relatively small size and ability to be contained within the pericardium, thus eliminating the potential need to create a pocket or rotate the pump configuration. In addition, the device’s integrated inflow cannula could decrease the chance of inflow obstruction related to the abnormal position of the ventricles in CC-TGA. TEE guidance ensured successful selection of the optimal insertion site for the VAD inflow cannula. In summary, we report a case of successful HeartWare HVAD implantation in a patient with CC-TGA to support the function of the RV (systemic ventricle).

The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Introduction

The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 1—Coronary Artery Bypass Grafting SurgeryThe Annals of Thoracic SurgeryVol. 88Issue 1PreviewThe first version of The Society of Thoracic Surgeons National Adult Cardiac Surgery Database (STS NCD) was developed nearly 2 decades ago. Since its inception, the number of participants has grown dramatically, patient acuity has increased, and overall outcomes have consistently improved. To adjust for these and other changes, all STS risk models have undergone periodic revisions. This report provides a detailed description of the 2008 STS risk model for coronary artery bypass grafting surgery (CABG). Full-Text PDF The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 2—Isolated Valve SurgeryThe Annals of Thoracic SurgeryVol. 88Issue 1PreviewAdjustment for case-mix is essential when using observational data to compare surgical techniques or providers. That is most often accomplished through the use of risk models that account for preoperative patient factors that may impact outcomes. The Society of Thoracic Surgeons (STS) uses such risk models to create risk-adjusted performance reports for participants in the STS National Adult Cardiac Surgery Database (NCD). Although risk models were initially developed for coronary artery bypass surgery, similar models have now been developed for use with heart valve surgery, particularly as the proportion of such procedures has increased. Full-Text PDF The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 3—Valve Plus Coronary Artery Bypass Grafting SurgeryThe Annals of Thoracic SurgeryVol. 88Issue 1PreviewSince 1999, The Society of Thoracic Surgeons (STS) has published two risk models that can be used to adjust the results of valve surgery combined with coronary artery bypass graft surgery (CABG). The most recent was developed from data for patients who had surgery between 1994 and 1997 using operative mortality as the only endpoint. Furthermore, this model did not specifically consider mitral valve repair plus CABG, an increasingly common procedure. Consistent with STS policy of periodically updating and improving its risk models, new models for valve surgery combined with CABG have been developed. Full-Text PDF

The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 2—Isolated Valve Surgery

Adjustment for case-mix is essential when using observational data to compare surgical techniques or providers. That is most often accomplished through the use of risk models that account for preoperative patient factors that may impact outcomes. The Society of Thoracic Surgeons (STS) uses such risk models to create risk-adjusted performance reports for participants in the STS National Adult Cardiac Surgery Database (NCD). Although risk models were initially developed for coronary artery bypass surgery, similar models have now been developed for use with heart valve surgery, particularly as the proportion of such procedures has increased. The last published STS model for isolated valve surgery was based on data from 1994 to 1997 and did not include patients undergoing mitral valve repair. STS has developed new valve surgery models using contemporary data that include both valve repair as well as replacement. Expanding upon existing valve models, the new STS models include several nonfatal complications in addition to mortality. Using STS data from 2002 to 2006, isolated valve surgery risk models were developed for operative mortality, permanent stroke, renal failure, prolonged ventilation (> 24 hours), deep sternal wound infection, reoperation for any reason, a major morbidity or mortality composite endpoint, prolonged postoperative length of stay, and short postoperative length of stay. The study population consisted of adult patients who underwent one of three types of valve surgery: isolated aortic valve replacement (n = 67,292), isolated mitral valve replacement (n = 21,229), or isolated mitral valve repair (n = 21,238). The population was divided into a 60% development sample and a 40% validation sample. After an initial empirical investigation, the three surgery groups were combined into a single logistic regression model with numerous interactions to allow the covariate effects to differ across these groups. Variables were selected based on a combination of automated stepwise selection and expert panel review. Unadjusted operative mortality (in-hospital regardless of timing, and 30-day regardless of venue) for all isolated valve procedures was 3.4%, and unadjusted in-hospital morbidity rates ranged from 0.3% for deep sternal wound infection to 11.8% for prolonged ventilation. The number of predictors in each model ranged from 10 covariates in the sternal infection model to 24 covariates in the composite mortality plus morbidity model. Discrimination as measured by the c-index ranged from 0.639 for reoperation to 0.799 for mortality. When patients in the validation sample were grouped into 10 categories based on deciles of predicted risk, the average absolute difference between observed versus predicted events within these groups ranged from 0.06% for deep sternal wound infection to 1.06% for prolonged postoperative stay. The new STS risk models for valve surgery include mitral valve repair as well as multiple endpoints other than mortality. Model coefficients are provided and an online risk calculator is publicly available from The Society of Thoracic Surgeons website.

The Ethics of Transparency: Publication of Cardiothoracic Surgical Outcomes in the Lay Press

he Congenital Heart Institute of Florida, Division of Thoracic and Cardiovascular Surgery, All Children’s Hospital and Children’s ospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates of Florida, Saint Petersburg and ampa, Florida; Section of Thoracic Surgery at University of Alabama at Birmingham, Division of CardioThoracic Surgery, epartment of Surgery, Birmingham, Alabama; Division of Cardiothoracic Surgery, Department of Surgery, Institute of Human alues in Health Care, Medical University of South Carolina, Charleston, South Carolina

Cardiac Injury During Resternotomy Does Not Affect Perioperative Mortality

Cardiac injury at the time of resternotomy is a complication faced by all cardiac surgeons, although little is known about its effects on morbidity and mortality. This study was designed to address these questions. Resternotomies performed at the University of Virginia from 1996 to 2005 were identified. Operative notes were reviewed, and any injury during resternotomy to the heart, great vessels, or bypass grafts was recorded. Perioperative complications and mortality were recorded using the Society of Thoracic Surgeons National Database. In the 11-year period studied, 612 resternotomies were performed out of 7,872 total adult cardiac procedures (7.8%). Fifty-six patients (9.1%) had an injury sustained during resternotomy and initial dissection. Injury to grafts was most common (46.4%), with mammary arteries comprising 21% of the total and vein grafts, 25%. The right ventricle was the second most commonly injured structure (21.4%). There were no significant differences in overall nonadjusted mortality in the injured group compared with that in the noninjured group (8.9% versus 10.2%, p=0.66). Multivariate analysis demonstrated third-time resternotomy to be an independent risk factor for cardiac injury (p=0.04). Cardiac injury at the time of resternotomy is not associated with an increase in perioperative morbidity or mortality. Third-time resternotomy is an independent risk factor for cardiac injury, so vigilance and adequate preparation are paramount in these patients.

Invited commentary

Invited commentary

Quality indicators, performance measures, and accountability: The right thing, at the right time, for the right reason

4 The Journal of Thoracic and Cardiova The article in this issue of the Journal by the Canadian CABG Surgery Quality Indicator Consensus Panel entitled “The identification and development of Canadian coronary artery bypass graft surgery quality indicators” brings to the forefront an increasingly important issue for health care providers. As a financing crisis looms in the US health care system, both public and private purchasers are demanding more transparency and performance data related to services provided. This is grounded in the belief that improving quality will lead to cost savings, a point clearly made in the Society of Thoracic Surgeons (STS) testimony before the House Ways and Means Committee in March 2005. The Center for Medicare and Medicaid Services (CMS) Director McClellan believes, as do others in the private sector, that payments for health care services should be adjusted according to quality. This has driven the need for the development of specialty-specific quality and performance measures to be used for both quality improvement and accountability. Recognizing this need, the STS, under the leadership of Dr Peter Pairolero in 2004 and Dr Sid Levitsky in 2005, have taken a leadership role in bringing the use of the STS National Cardiac Database (STS NCD) and the STS as a professional society to a position of national prominence. Through the National Quality Forum (NQF) Consensus Development Process, a set of 21 performance measures for cardiac surgery suitable for quality improvement and accountability have been established, with 16 of these measures specified and derived from the STS NCD. The complete description can be found in the NQF publication “National Voluntary Consensus Standards for Cardiac Surgery.” The Canadian group has followed suit with an independent project to mirror these efforts in the United States by the STS. A careful comparison of these projects and a discussion of the implications for US cardiac surgeons are imperative. The Canadian CABG Survey Quality Indicator Consensus panel is well described in their article, with the important point being that 75% of its members were specialty specific, a topic touched on later. The inclusion of Dr Frederick Grover, incoming president of the STS, with 2 decades of experience in measure development initially at the Veterans Health Administration and subsequently with the STS database, gave enormous credibility to this project as did the presence of Dr O’Conner from the Northern New England Cardiovascular Disease Study Group (NNE). The group used a Delphi Consensus process, which is, in essence, blinded voting on the attributes of measures after thoughtful open discussion. The final result included 18 measures covering the spectrum of structure, process, and outcomes, as found in the Donabedian model of quality improvement. Specifically, the set included 14 outcome measures (none risk adjusted), 3 process measures, and 1 structural measure (volume). Arguably, 2 of the 3 process variables (waiting time to surgical intervention and completion of surgical intervention within a recommended waiting time) represent measures of efficiency system capacity rather than processes of care. Additionally, one of the outcome measures, intensive care unit (ICU) length of stay, might also fall into the category of system capacity because transfer out of the ICU might be influenced by lack of step-down or telemetry beds or floor nurse shortages, for example, and might not reflect quality of care. To their credit, they paired this measure with ICU readmission, which enables inappropriate early

Gender-Specific Practice Guidelines for Coronary Artery Bypass Surgery: Perioperative Management*

Gender differences in coronary bypass surgery have been the focus of numerous publications in recent years. Unfortunately these publications have contradictions that leave surgeons with conflicting recommendations for care. To help resolve these inconsistencies, The Society of Thoracic Surgeons (STS) Workforce on Evidence-Based Surgery has carried out an objective review of published information in this field. The STS Workforce recognizes that there are important gender issues associated with referral bias, the impact of body size, psychosocial factors, and postoperative support, but the intent of this guideline is to focus specifically on perioperative management. As with all practice guidelines, our goal is to gather the most important information, analyze the information in a logical and unbiased fashion, and make recommendations based solely on the available evidence.

The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)

The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)

The clinical development of percutaneous heart valve technology: A position statement of the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society of Cardiovascular Angiography and Intervention (SCAI)

The clinical development of percutaneous heart valve technology: A position statement of the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society of Cardiovascular Angiography and Intervention (SCAI)

Are unaudited records from an outcomes registry database accurate?

Background Data from outcomes registry databases are being increasingly used for peer review and public reporting. However, administrative and clinical databases are mostly unaudited; thus, their accuracy has not been verified. Methods Outcomes data from all coronary artery bypass operations from a single cardiac surgery practice were entered into The Society of Thoracic Surgeons (STS) National Cardiac Database. From our practice of 18 surgeons, we audited 247 (10%) of the clinical records of patients undergoing surgery in 2001 and correlated them with all 315 elements of the STS National Cardiac Database for verification of accuracy. Inaccuracies were defined as a disagreement with a nominal or categorical variable or, for continuous variables, as the value not being within a predetermined window. When discrepancies existed, the hospital clinical record was assumed to be accurate. Outcomes discrepancies were then analyzed by four major categories: components of the preoperative risk algorithm, operative mortality, major complications, and other outcomes. Results Discrepancies were noted in 5% (16) or fewer of the audited fields for 98.8% of the records. Of the 32 variables in the mortality risk algorithms, discrepancies were present in fewer than 10% of the audits on 30 of the 32 variables. More than 95% of the audited charts had zero or one discrepancy in the seven most important variables in the mortality risk models. Operative mortality was determined to be completely accurate with no discrepancies between the database and the audited clinical record. Among major complications, the error rate was less than 1% for all complications except prolonged ventilation (4.0%). A higher rate of discrepancies did exist in some of the other variables, including discharge medications (14.1%) and ventilator time (36.4%). Conclusions A detailed audit of a clinical outcomes registry database demonstrated that the major fields within this specific database including operative mortality, major complications, and the significant factors in the risk algorithm were highly accurate. Process improvement factors were identified to further increase the accuracy of data collection.

Procedural volume as a marker of quality for cabg surgery

THE ASSOCIATION BETWEEN HOSpitals’ coronary artery bypass graft (CABG) surgery volume and outcome has been the subject of multiple investigations. Based on these studies, the Center for Medicare & Medicaid Services (CMS) and the Leapfrog Group have proposed using hospital volume as an indicator of CABG quality. Prior studies of the association between volume and outcome, however, generally have been based on administrative data sources, have reflected selected patient populations, and often have not adequately accounted for patient case mix, patient clustering, and other methodological concerns. Before hospital surgery volume is accepted as a standard quality metric, further research into issues related to both analysis and policy implication is warranted. We undertook a contemporary examination of the association between hospital CABG procedural volume and outcome using clinical data available from the Society of Thoracic Surgeons (STS) National Cardiac Database. Specifically, we considered whether hospital CABG volume was associated with operative mortality after accounting for patient case mix. Second, we examined the extent to which patient clustering within centers and site variance issues affected this association. Third, we determined how the association varied as a function of patient age and predicted surgical risk. Fourth, we determined whether the association between hospital volume and outcome was influenced by individual surgeon volume. Finally, we investigated the potential health policy implications of using hospital volume as a quality indicator. This included determining the ability of hospital volume to discriminate high-mortality outliers, as well as investigating the potential number of lives saved if low-volume centers were systematically closed. METHODS Data Source The STS National Cardiac Database was established in 1989 to report surgical outcomes following cardiothoracic surgical procedures. The database cur-

Congenital heart surgery nomenclature and database project: update and proposed data harvest

The first report of The Society of Thoracic Surgeons (STS) National Congenital Heart Surgery Database in 1998 reported the clinical features of 18 congenital heart categories. The report provided a significant amount of important information and also highlighted the strengths and weaknesses of the existing database. Following this report the STS Congenital Heart Surgery Committee in cooperation with the European Association of Cardio-Thoracic Surgery and the European Congenital Heart Surgeons Foundation initiated the International Congenital Heart Surgery Nomenclature and Database Project. The goal was to begin the standardization of nomenclature reporting strategies and establish the foundations for an international congenital heart surgery database. The first report of the International Congenital Heart Surgery Nomenclature Project was published in The Annals of Thoracic Surgery in April 2000. The current report outlines modifications to the minimum dataset as well as the diagnoses and procedure short lists. Plans for the next STS National Congenital Heart Surgery Database harvest are also presented.

The STS National Database: current changes and challenges for the new millennium

Background. The Society of Thoracic Surgeons (STS) established the National Database (NDB) for Cardiac Surgery in 1989. Since then it has grown to be the largest database of its kind in medicine. The NDB has been one of the pioneers in the analysis and reporting of risk-adjusted outcomes in cardiothoracic surgery.Methods and Results. This report explains the numerous changes in the NDB and its structure that have occurred over the past 2 years. It highlights the benefits of these changes, both to the individual member participants and to the STS overall. Additionally, the vision changes to the NDB and reporting structure are identified. The individuals who have participated in this effort since 1989 are acknowledged, and the STS owes an enormous debt of gratitude to each of them.Conclusions. Because of their collective efforts, the goal to establish the STS NDB as a “gold standard” worldwide for process and outcomes analysis related to cardiothoracic surgery is becoming a reality.

1995 Coronary Artery Bypass Risk Model: The Society of Thoracic Surgeons Adult Cardiac National Database

Background. The Society of Thoracic Surgeons (STS) Adult Cardiac National Database has recently completed the development of the 1995 risk model to be used to estimate the risk of operative death for isolated coronary artery bypass graft (CABG) procedures. This article describes the detailed methodology used, as well as a new Expert Advisory Panel review mechanism that was initiated by The Society.Methods. Placing emphasis on clinical relevance, data quality, data completeness, and univariate analyses, a logistic regression analysis was used to develop the 1995 CABG-only risk model. The STS National Office invited an Expert Advisory Panel (composed of nationally recognized, independent biostatisticians) to review the modeling process used.Results. The 1995 CABG-only model details are reported. Standard performance measures indicated the model had high predictive power and an acceptable level of calibration. The Expert Advisory Panel reviewed the 1995 CABG model and concluded that the current modeling techniques were adequate. Suggestions for future model development and reporting were proposed by the Panel.Conclusions. The most current STS risk model of CABG operative mortality is a reliable and statistically valid tool. Its development and performance have been critically examined and approved by an independent panel of experts.