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Myocardial revascularization: the evolution of the STS database and quality measurement for improvement

  • Reilly Daniel Hobbs
  • Gaetano Paone
  • Richard Salvatore D’Agostino
  • Jeffrey Phillip Jacobs
  • Donna Eileen McDonald
  • Richard Laurence PragerEmail author
  • David Michael Shahian
Review Article
  • 58 Downloads

Abstract

The Society of Thoracic Surgeons (STS) is a not-for-profit organization dedicated to helping clinicians and researchers provide optimal outcomes for patients undergoing heart, lung, and esophageal surgery. The organization was founded in 1964 and has grown to now include over 7300 members in over 90 countries. The STS created a national database that collects detailed clinical information on patients undergoing adult cardiac, pediatric and congenital cardiac, and general thoracic operations. The data collected are used to produce risk-adjusted, nationally benchmarked performance assessments and feedback; facilitate voluntary public reporting; support quality initiatives; develop evidence-based guidelines; monitor long-term clinical outcomes; track device performance; and promote high-quality research collaboratives.

Keywords

Society of Thoracic Surgeons Surgery Myocardial revascularization 

Introduction

The STS is a not-for-profit organization dedicated to helping clinicians and researchers provide optimal outcomes for patients undergoing heart, lung, and esophageal surgery. The organization was founded in 1964 and has grown to now include over 7400 members in over 90 countries. The STS created a national database that collects detailed clinical information on patients undergoing adult cardiac, pediatric and congenital cardiac, and general thoracic operations [1]. The data collected are used to produce risk-adjusted, nationally benchmarked performance assessments and feedback; facilitate voluntary public reporting; support quality initiatives; develop evidence-based guidelines; monitor long-term clinical outcomes; track device performance; and promote high-quality research collaboratives [2].

Creation of the STS National Database

The STS National Database was created in response to a 1986 report by the Health Care Financing Administration (HCFA) on hospital mortality data, including coronary artery bypass grafting (CABG) results generated from essentially unadjusted administrative data. There was widespread concern that these unadjusted reports could be misleading to the public and would not accurately reflect CABG surgery performance. The STS responded to the HCFA reports with a “statement of concern” followed in 1988 by the appointment of an ad hoc committee dedicated to evaluating the risk factors for CABG surgery. In addition, interest in developing a risk-adjusted data management and collection system led to the creation of an ad hoc committee to develop a national database for thoracic surgery [3]. This then led to the development of the STS database which became operational in 1989 [1, 4]. Today, the STS database is comprised of the Adult Cardiac Surgery Database (ACSD), the General Thoracic Surgery Database (GTSD), the Congenital Heart Surgery Database (CHSD), and most recently, the Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) database. The STS has also partnered with the American College of Cardiology (ACC) to develop the STS/ACC Transcatheter Valve Therapy (TVT) registry. The STS database was able to quickly enroll participants for a variety of reasons. The STS had a longstanding history of being an organization dedicated to serving its members and the database was viewed as a way for members to participate in meaningful data collection, promote their specialty, and improve patient care. There was also a feeling among members that objectively measuring outcomes and quantifying risk was important for educating the public about the real risks and benefits of cardiac surgery.

Current status of the STS database

Over its nearly three decades of existence, the STS National Database has grown significantly in terms of participation and stature. The STS database now houses approximately 6.5 million cumulative surgical records and has more than 3700 participating clinicians. In the USA, more than 90% of programs performing cardiac surgery participate in the ACSD and over 95% of congenital or pediatric cardiac surgery programs participate in the CHSD [5]. The overall percentage of surgeons participating in the GTSD database is not known due to the difficulty of determining the denominator of that metric. The Intermacs database became a part of the STS National Database on January 1, 2018 and transition to full participation of hospitals where mechanical circulatory support procedures are performed is almost complete.

Adult cardiac surgery database enhancements

As the field of cardiothoracic surgery evolves to include more endovascular, robotic, and minimally invasive procedures, there are protocols in place to ensure that the ACSD stays current in its data collection practices. Data elements collected in the ACSD are reviewed every 3 years and participating data sites are encouraged to offer suggestions for new data fields. Equally important is the elimination of obsolete data fields which helps prevent the data collection process from becoming overly burdensome. Version 2.9 of the ACSD became operational on July 1, 2017. Data can now be uploaded on a continuous basis in order to provide real-time performance feedback to data sites. There is also an STS Aortic Surgery Task Force on national databases that is currently working on adding data elements to better reflect the evolving endovascular, hybrid, and open aortic surgery techniques [5].

It is anticipated that with technologic advancements including natural language processing as well as abilities to extract administrative data elements from other sources, data retrieval will be facilitated in the near future.

Data integrity

Since the inception of the ACSD, data integrity has been prioritized by the STS. Each year, 10% of facilities are audited to help insure accuracy. Medical records are compared to captured data and surgical logs are reviewed to confirm that there are no missing cases. These audits have shown that essentially 100% of cases are captured and that collected data exceeds 95% accuracy [1, 2].

NQF cardiac surgery metrics

The National Quality Forum (NQF) is a consensus-based healthcare organization dedicated to endorsing quality initiatives and public reporting that improve patient education and outcomes. The NQF has described the STS National Database as the gold standard in clinical data collection. NQF-endorsed quality measures are recognized as “best in class.” At present, there are a total of 34 NQF-endorsed STS performance measures in the areas of adult cardiac, congenital, and thoracic surgery, more than from any other professional organization (Table 1).
Table 1

NQF-endorsed STS quality measures as of June 1, 2018

NQF-endorsed STS performance measures

Adult cardiac surgery measures

 Measure

Procedure(s)

Endorsement

  CABG Composite Score

Isolated CABG

1/26/11

  Post-operative renal failure

Isolated CABG

12/6/11

  Surgical Re-exploration

Isolated CABG

12/6/11

  Operative mortality for CABG

Isolated CABG

12/6/11

  Post-operative prolonged intubation

Isolated CABG

12/6/11

  Deep sternal wound infection

Isolated CABG

12/6/11

  Stroke/CVA

Isolated CABG

12/6/11

  CABG readmission rate

Isolated CABG

12/8/16

  Operative mortality for aortic valve replacement

Isolated AVR

12/6/11

  Operative mortality for mitral valve replacement

Isolated MVR

12/6/11

  Operative mortality for mitral valve repair

Isolated MVr

12/6/11

  Aortic Valve Replacement Composite Score

Isolated AVR

11/7/14

  Mitral Valve Repair/Replacement Composite Score

Isolated MVrR

12/21/16

  Anti-platelet medication at discharge

Isolated CABG

12/6/01

  Beta blockade at discharge

Isolated CABG

1/31/12

  Anti-lipid treatment at discharge

Isolated CABG

12/6/11

  Pre-operative beta blockade

Isolated CABG

1/31/12

  Use of internal mammary artery

Isolated CABG

1/31/12

  Operative mortality for mitral valve replacement + CABG

MVR + CABG

12/6/11

  Operative mortality for aortic valve replacement + CABG

AVR + CABG

12/6/11

  Operative mortality for mitral valve repair + CABG

MVr + CABG

12/6/11

  Aortic valve replacement + CABG Composite Score

AVR + CABG

11/7/14

  Mitral valve repair/replacement + CABG Composite Score

MVrR + CABG

  Selection of antibiotic prophylaxis for cardiac surgery patients

N/A

1/31/12

  Duration of antibiotic prophylaxis for cardiac surgery patients

N/A

5/2/12

  Participation in a systematic database for cardiac surgery

N/A

12/6/11

Adult cardiac surgery measures-surgeon level

 Individual surgeon composite measure for adult cardiac surgery

Multiple

 

Congenital/pediatric heart surgery measures

 Operative mortality stratified by the 5 STAT mortality categories

11/16/11

 Operative mortality for pediatric and congenital heart surgery

9/3/15

 Surgical volume for pediatric and congenital heart surgery

11/16/11

 Participation in a national database for pediatric congenital heart surgery

12/5/11

 Pediatric cardiac surgery stratified mortality and volume pair

General thoracic surgery measures

 Morbidity and mortality for lung resection for lung cancer

8/9/12

 Participation in a systematic database for general thoracic surgery

8/9/12

The STS risk calculator

Developed utilizing data generated from the STS database, the online STS Risk Calculator was released in 2003 and provided statistically robust probabilities of morbidity and mortality following CABG surgery [6, 7]. The Risk Calculator has since undergone periodic revisions and now additionally provides probabilities of morbidity and mortality for aortic valve replacement, mitral valve repair or replacement [8] as well as concomitant aortic or mitral valve repair/replacement and CABG [9, 10, 11].

The STS risk calculator is readily available to clinicians and provides accurate and individualized risk profiles for surgical candidates [12]. Based on STS risk models, it can rapidly calculate a patient’s risk for mortality or major morbidity based on pre-operative risk factors and has proven to be a powerful tool to support quality initiatives, encourage voluntary public reporting, and promote evidence-based research [1, 5, 13, 14]. Additionally, surgeon and hospital performance can be assessed by calculating observed/expected ratios. The STS Risk Calculator is also useful for patient education and quantifying the impact of potentially modifiable risk factors, lung disease, or decompensated heart failure, on mortality and morbidity. This may inform the pre-operative consultation and help to focus pre-operative medical optimization. The STS Risk Calculator may also assist surgeons in advising patients about setting realistic recovery expectations.

STS quality measures and initiatives in coronary artery bypass surgery

Background

As the most commonly performed cardiac operation in the USA, CABG surgery is reproducible, has well defined indications, and has known risk factors. In 2016, there were 156,931 isolated CABG operations performed in the USA with another 23,545 CABG operations performed with concomitant valve surgery [5]. Since the inception of the STS National Database, CABG surgery has been a central focus of many of its quality initiatives and performance benchmarks. The STS has developed strategies for measuring performance, educating providers, and improving outcomes in the pre-, intra-, and post-operative phases. CABG surgery is also a subject of voluntary public reporting through the STS website (publicreporting.sts.org). Publicly reported scores are based on the Composite CABG Scores.

Overall CABG Composite Score

Composite CABG scores are calculated using a combination of 11 quality measures divided into four domains, including absence of operative mortality, absence of major morbidity, use of the internal mammary artery, and receipt of all 4 NQF-endorsed peri-operative medications (Table 2). The composite score calculates a single number along with a star rating system for ease of interpretation, which is used for voluntary public reporting. A single star indicates performance that is “worse than expected”, two stars indicates “as expected” performance, and three stars indicates “better than expected” performance. Typically, about 10% of participants are one-star, 10% are three-star, and the remainder are two-star programs. These ratings are readily available to the public at the website publicreporting.sts.org [15]. At present, over 60% of ACSD participants publicly report their composite score and star rating for isolated CABG.
Table 2

Measured domains with respective components used for the calculation of the STS Overall CABG Composite Score

Overall CABG Composite Score components

Peri-operative medication domain

 Pre-operative beta blockade

 Beta blockade at discharge

 Anti-lipid treatment at discharge

Operative care process domain

 Use of an internal mammary artery in CABG

Risk-adjusted operative morbidity

 Stroke/CVA

 Surgical re-exploration

 Deep sternal wound infection rate

 Post-operative renal failure

 Prolonged ventilation

Risk-adjusted mortality

Peri-operative medication domain

Pre-operative beta blockade is an STS quality measure initially endorsed by the NQF on January 31, 2012. Post-operative atrial fibrillation (POAF) occurs in 25–40% of patients following cardiac surgery and is associated with increased risk of stroke, infections, renal failure, septicemia, and mortality [16]. POAF is also associated with an increase in both intensive care unit and total length of stay as well as increased hospital costs. [17]. Pre-operative beta blockade has been shown to decrease the incidence of POAF which motivated the STS to instill quality initiatives encouraging pre-operative beta blocker administration [18]. The American Heart Association also recommends that “Beta blockers should be prescribed to prevent POAF, ideally starting before surgery, unless contraindicated (i.e., bradycardia or severe airway disease) (Class I; level of evidence A) [19].”

Despite professional organizations endorsing the use of peri-operative beta blockers for patients undergoing CABG surgery, recent studies have questioned their benefit. A 2014 study by Brinkman et al. utilizing the ACSD performed a retrospective analysis with propensity matching of all patients undergoing CABG surgery from 2008 to 2011. The findings showed no difference in mortality or major morbidity between patients who did, or did not, receive peri-operative beta blockade [20]. An additional study by LaPar et al. utilizing a large multi-institutional study including 43,747 patients found no risk-adjusted mortality difference without beta blocker use [21]. However, both studies have limitations, and their findings conflict with consistent and compelling evidence from many other studies favoring peri-operative beta blockade in CABG surgery [22]. As evidence continues to evolve, the STS will continue to evaluate peri-operative beta blockade as a quality measure in the future.

Beta blockade at discharge

NQF endorsed the STS quality measure that encourages beta blockade prescription upon discharge on January 31, 2012. Multiple high-quality studies have demonstrated improved long-term survival in patients prescribed beta blockade after CABG surgery [20, 23, 24]. It was previously thought that this benefit was solely applicable to patients with a history of myocardial infarction or heart failure. However, a study by Chan et al. found that all patients discharged with beta blockade after CABG surgery experienced substantially decreased long-term mortality [25]. Additionally, post-operative beta blockade is effective at preventing POAF and associated complications, particularly in patients who were on pre-operative beta blockade [16, 26]. The STS measures the percentage of CABG patients who are prescribed beta blockage upon discharge and awards higher scores to centers with high rates of beta blockade prescription after CABG surgery. Patients with contraindications to beta blockers are excluded.

Anti-platelet medication at discharge

On December 6, 2011, NQF endorsed the STS quality measure aimed at incentivizing the post-operative and discharge use of an anti-platelet medication for CABG patients. Anti-platelet medications are crucial to the treatment and prevention of primary and secondary coronary artery disease and have proven benefit in patients who have undergone CABG surgery [27, 28]. The STS quality initiative measures the percentage of patients receiving anti-platelet therapy upon discharge with those having higher percentages receiving higher scores. Patients with contraindications to anti-platelet therapy are excluded.

Anti-lipid treatment at discharge

NQF endorsed the STS quality measure regarding anti-lipid medication following CABG surgery on December 6, 2011. Anti-lipid therapy, typically statin therapy, has been shown to decrease all-cause mortality and major cardiovascular events following CABG surgery [29, 30]. Statin therapy is effective at decreasing serum lipid levels which are the main contributors to recurrent atherosclerotic disease of both native vessels and bypass grafts [31, 32, 33]; these agents also have many other useful pleiotropic effects. The STS measures the percentage of CABG patients who are prescribed anti-lipid agents upon discharge and awards higher scores to centers with high rates of anti-lipid prescription after CAGB surgery. Patients with contraindications to anti-lipid therapy are excluded.

Operative care process domain

Use of internal mammary artery (IMA) in coronary artery bypass graft

NQF endorsed the STS quality measure for IMA use in CABG surgery on January 31, 2012. The goal of this measure is to encourage routine use of the IMA in CABG surgery. The internal mammary artery has been consistently shown to be superior to other grafts in terms of long-term patency, patient survival, and freedom from reinterventions. Given the overwhelming evidence from retrospective reviews as well as prospective randomized controlled trials, the STS seeks to promote high levels of IMA utilization [34, 35, 36]. Patient populations excluded from this quality initiative are those with subclavian artery stenosis, previous cardiac or thoracic surgery, mediastinal radiation, emergent or salvage procedure, and patients without LAD disease. This STS quality initiative awards higher scores to centers with high IMA utilization for CABG surgery.

Risk-adjusted morbidity

Stroke/cerebrovascular accident

NQF endorsed the STS quality measure regarding stroke after CABG surgery on December 6, 2011. The goal of this measure is to reduce the occurrence of this devastating complication, which is associated with increased hospital cost, infection, respiratory failure, renal failure, increased length of stay, and death [37, 38]. The prevalence of post-operative stroke can be reduced with meticulous operative technique, minimizing the manipulation of the aorta, maintaining appropriate perfusion pressures during cardiopulmonary bypass, prevention of atrial fibrillation, and appropriate management of systemic anticoagulation in the pre- and post-operative setting. The STS measures the percentage of all CABG patients who experience stroke and awards higher scores to centers with low incidence of stroke following CABG surgery.

Surgical re-exploration

NQF endorsed the STS quality measure aimed at reducing the incidence of reoperation for bleeding, graft occlusion, valvular dysfunction, or other cardiac reason on December 6, 2011. Reoperation for bleeding after coronary artery bypass grafting adds significant morbidity and mortality to patients having undergone CABG surgery [39, 40, 41]. A recent study by Mehta et al. found that although mortality in patients undergoing reoperation for bleeding has improved over time, there is still a 4.5-fold increase in mortality in patients requiring reoperation for bleeding after CABG surgery [42]. Reoperation following CABG surgery can often be avoided with meticulous attention to hemostasis, anastomotic technique, and careful pre-operative evaluation. The STS quality initiative measures the percentage of patients requiring reoperation after CABG and awards higher scores to centers with low reoperation rates.

Deep sternal wound infection

NQF endorsed the STS quality measure regarding deep sternal wound infection after CABG on December 6, 2011. This measure is aimed at increasing awareness of this very serious complication and thereby reducing its prevalence. Deep sternal wound infection is an exceptional quality measure in cardiac surgery as it measures competency in multiple phases of care and all team members. Prevention depends on appropriate skin decontamination, appropriate peri-operative antibiotic administration, aseptic surgical technique, hand hygiene, glucose control, and post-operative wound care [43, 44, 45]. Deep sternal wound infection is associated with significant increases in hospital costs, renal dysfunction, need for reoperation, chronic pain, and increased mortality [39, 44, 45, 46]. The STS measures the percentage of all CABG patients who develop deep sternal wound infections and awards higher scores to centers with low incidence of deep sternal wound infection following CABG surgery.

Post-operative renal failure

NQF endorsed the STS quality measure regarding post-operative renal failure on December 6, 2011. This measure encourages programs to focus on initiatives to reduce the occurrence of this serious, potentially life-threatening complication. The STS defines post-operative renal failure as a new need for hemodialysis, an increase in serum creatinine level 3.0× greater than baseline, or serum creatinine level ≥ 4 mg/dL. (acute rise must be at least 0.5 mg/dL). Post-operative renal failure after CABG surgery is a known risk factor for prolonged hospitalization, increased costs, infection, long-term morbidity, as well as short- and long-term mortality [39, 47, 48, 49, 50]. Post-operative renal failure can often be avoided with careful attention to pre-operative fluid status, removal of unnecessary nephrotoxic medications, maintaining adequate systemic perfusion during cardiopulmonary bypass, and careful management to post-operative volume status. The STS calculates the percentage of all patients who develop renal failure after CABG surgery and awards higher scores to centers with low incidence of new-onset renal failure. Patients with pre-operative renal failure are excluded.

Prolonged intubation

On December 6, 2011, NQF endorsed the STS quality measure regarding prolonged post-operative ventilation after CABG surgery. The goal of this measure is to encourage providers to use processes of care that reduce the occurrence of this complication. The STS considers post-operative mechanical ventilation > 24 h as prolonged, and this is associated with increased length of stay, increased hospital costs, risk for respiratory failure, renal failure, infection, and death [39, 51, 52, 53]. Attention to pre-operative pulmonary status, smoking cessation, consideration of pre-operative pulmonary rehabilitation, weaning of sedating medications post-operatively, optimal anesthetic management, and aggressive weaning of mechanical ventilation can reduce the incidence of prolonged mechanical ventilation after CABG surgery. The STS measures the percentage of patients requiring prolonged ventilation and awards higher scores to centers with low rates of prolonged ventilation. Patients who are intubated pre-operatively are excluded.

Selection of antibiotic prophylaxis for cardiac surgery patients

Appropriate prophylactic antibiotic use in cardiac surgery patients was endorsed as an STS quality measure by the NQF on January 31, 2012. Post-operative superficial and deep wound infections, including mediastinitis, are associated with increased hospital costs, increased morbidity, and mortality [44, 45, 46]. The incidence of mediastinitis is estimated to occur between 0.25 and 4% [54]. The efficacy of antibiotic prophylaxis in the prevention of post-operative wound infection has been well established for several decades [45, 55]. This STS quality initiative aims to promote appropriate prophylactic antibiotic selection for all patients undergoing cardiac surgery. In 2007, the STS Workforce on Evidence-Based Surgery published a consensus report on recommendations for antibiotic prophylaxis, which advised the following:
  • Class I Recommendation: A beta-lactam antibiotic is indicated as a single antibiotic choice for standard cardiac surgery prophylaxis in populations that do not have a high incidence of methicillin-resistant Staphylococcus aureus [Level of Evidence: A]

  • Class IIA Recommendation: Based on availability and cost, it is reasonable to use first-generation cephalosporins as no randomized trial has shown higher efficacy between cephalosporins [Level of Evidence: B]

  • Class IIB Recommendation: In an institution with high levels of methicillin-resistant Staphylococcus aureus or in cases where prosthetic graft material is implanted, it is reasonable to combine a beta-lactam with vancomycin with the restriction of vancomycin to two doses [Level of Evidence: C]

  • Class IIB Recommendation: Vancomycin is not recommended for exclusive prophylaxis due to its lack of gram-negative coverage [Level of Evidence: C]

  • Class I Recommendation: Routine mupirocin administration is advised for all patients without documentation of negative staphylococcal colonization [Level of Evidence: A]

This STS quality measure records the percentage of antibiotic compliance and awards higher scores to centers with a high utilization of appropriate peri-operative antibiotic therapy. STS is currently updating its recommendations regarding the selection and duration of peri-operative antibiotic therapy.

Future quality measures in CABG surgery

Future STS quality measures and initiatives will address areas of emerging science, clinical evidence, as well as potentially patient-reported outcomes. As an example of emerging science, the evolving literature on multiple arterial grafts in CABG [56, 57, 58, 59] sets the stage for discussion for multiple arterial grafts as a quality metric.

Conclusion

The STS National Database and its many quality measures have been a driving force for evidence-based practice improvement and quality initiatives in CABG surgery. The data are utilized by individual surgeons and hospitals for potential improvement, hospital network reviews, as well as state government mandated reviews and voluntary state quality collaboratives.

The ongoing evolution of the STS National Database with the input and advice of the participating surgeons and teams has helped continue its place as a trusted source of data, information, and quality improvement.

Notes

Compliance with ethical standards

Ethical approval

IRB for Human and Animal rights were not required.

Informed consent

NA

Conflict of interest

The authors declare that they have no conflict of interest.

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Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2018

Authors and Affiliations

  • Reilly Daniel Hobbs
    • 1
  • Gaetano Paone
    • 2
  • Richard Salvatore D’Agostino
    • 3
  • Jeffrey Phillip Jacobs
    • 4
    • 5
  • Donna Eileen McDonald
    • 6
  • Richard Laurence Prager
    • 1
    Email author
  • David Michael Shahian
    • 7
  1. 1.Department of Cardiac SurgeryUniversity of MichiganAnn ArborUSA
  2. 2.Division of Cardiac SurgeryHenry Ford HospitalDetroitUSA
  3. 3.Department of Thoracic and Cardiovascular SurgeryLahey Hospital & Medical CenterBurlingtonUSA
  4. 4.The Congenital Heart Institute of Florida (CHIF), All Children’s HospitalUniversity of South Florida College of MedicineSaint PetersburgUSA
  5. 5.The Congenital Heart Institute of Florida (CHIF), All Children’s HospitalUniversity of South Florida College of MedicineTampaUSA
  6. 6.The Society of Thoracic SurgeonsChicagoUSA
  7. 7.Center for Quality and Safety and Department of SurgeryMassachusetts General HospitalBostonUSA

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