Quality Initiatives at STS

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Quality Initiatives at STS

• Cynthia M. Shewan, PhD
• Director, Quality, Research and Patient Safety
• The Society of Thoracic Surgeons
• NSQIP Conference
• June 26, 2007

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Quality Initiatives at STS

• Many quality initiatives stem from STSs National
  Database
• 3 Components
• Adult Cardiac Surgery
• General Thoracic Surgery
• Congenital Heart Surgery

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Adult Cardiac Surgery Database

• Inception 1989
• 826 active participants
• 3 Million surgical procedures
• 2 data harvests/yr.
• 286 harvested data fields
• Focused on CABG and Valve Replacement/Repair

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General Thoracic Surgery Database

• Inception 2002
• 63 active participants
• 49,150 surgical procedures recorded
• 1 data harvest /yr.
• 140 harvested data fields
• Focused on Lung and Esophageal Cancer

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Congenital Heart Surgery Database

• Inception 2002
• 63 active participants
• 71,385 surgical procedures submitted
• 1 data harvest/yr.
• 84 harvested data fields
• Focused on 9 Specific Lesions

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Basis for Measuring Quality

• 21 NQF-endorsed adult cardiac measures
• Structural
• Volume
• Process
• Use of Internal Mammary Artery (IMA)
• Outcomes
• Risk-adjusted Operative Mortality

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Basis for Measuring Quality

• 6 provisional general thoracic measures
• Approved by AQA
• 26 congenital heart surgery measures
• Submitted to NQF for endorsement

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Adult Cardiac Quality Initiatives

• STS Database collects data on 17 of the NQF
  measures
• Focus on process and outcomes measures

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NQF Measures
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Composite Quality Score

• Establishment of Quality Measurement Task Force
• Quality Indicators selected on several
  principles, including IOM criteria, from 21
  NQF-endorsed measures
• CABG only
• Selected 11 measures

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Composite Quality Score

• 4 quality of care domains
• Operative Care
• Perioperative Medical Care
• Risk-adjusted Mortality
• Risk-adjusted Major Morbidity
• All 4 domain scores contribute to overall quality
  score
• Quality score converted to performance tiers

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Composite Quality Score
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Composite Quality Score

• Assigned to middle tier () if score was
  indistinguishable from STS national average,
  based on 99 Bayesian certainty criterion
• Assigned to bottom tier () if score was lower
  than STS national average, based on 99 Bayesian
  certainty criterion

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Composite Quality Score

• Assigned to top tier () if score was higher
  than STS national average, based on 99 Bayesian
  certainty criterion
• Quality Measurement in Adult Cardiac Surgery.
  The Annals of Thoracic Surgery. Vol. 83, No. 4,
  April 2007 Supplement.

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Quality with 3rd Parties

• Collaborating with 3rd Parties
• Quality Measurement Advisory Committee
• Representatives from several organizations
• Provide input on quality measurement
• STS representatives on 3rd party quality groups

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Quality with 3rd Parties

• 3 Tier Approach to Quality
• Aggregate Level Reports
• STS Overall
• State/Regional
• Individual Participant/hospital Level Reports
• 3 Star Rating System

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Reporting Performance

• Type of Reporting Program
• Voluntary
• Mandated
• Level of Reporting
• Surgeon Group/Hospital
• Individual Surgeon
• Recipient of Report
• Private Sector
• Government

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Reporting Performance

• Type of Data
• Clinical
• Administrative
• Use of Reported Data
• Recognition
• Financial Reward/Pay for Performance

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Pay for Performance

• STS advocates a phased in approach
• Pay for participation
• Pay for improvement
• Pay for performance
• STS Education about PQRI
• CMS initiative
• Replacement for PVRP
• Prepare CT surgeons to report measures

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Pay for Performance

• Have adult cardiac measures
• Goal to have CMS directly accept data from STS
  database in 2008
• General thoracic measures under perioperative
  care measures

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New Quality Initiatives

• 1. Addition of Unique Identifiers to Databases
• Level of Identifier
• Patient level
• Physician level
• Hospital level
• Facilitates linking among STS databases and with
  external databases

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New Quality Initiatives

• 2. Link STS Database with Other Databases
• Link STS clinical data with CMS administrative
  (e.g., billing) data
• Link STS clinical data with 3rd party payer
  longitudinal data
• Look at long term outcomes
• Apply knowledge of positive outcomes
  prospectively
• Link STS with National Death Index (NDI) Social
  Security Death Index
• Enables longitudinal follow-up

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New Quality Initiatives

• 3. Addition of Modules to Core AC Database
• Web-based data collection reporting
• Link to core via Record ID number
• Circumscribed clinical area
• E.g., Atrial Fibrillation
• More nimble operationally
• Easily changed

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New Quality Initiatives

• 4. New Version (2.6) Adult Cardiac Database
• Revision of current variables, as necessary
• Addition of new variables
• Harmonization of common variables with American
  College of Cardiology (ACC)

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New Quality Initiatives

• 5. Addition of Participants from Another
  Specialty
• Congenital Cardiac Anesthesia Society (CCAS)
• Pediatric anesthesiologists

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Quality Improvement Activity

• Randomized Clinical Trial
• Secondary Prevention and CABG A Society-Led
  RCT
• T. Bruce Ferguson, Jr., MD, PI
• Determined that feedback improved performance

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Quality Improvement Activity

• Regional Groups
• Michigan Quality Improvement Project funded by
  Blue Cross Blue Shield (BCBS)
• Virginia Cardiac Surgery Quality Initiative
  (VCSQI)
• 12 Regional Groups

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Shaping Future of Quality

• STS taking proactive role
• Surgeons better than anyone else know how to
  measure quality
• STS surgeons have assumed leadership positions in
  major quality organizations
• NQF (National Quality Forum)
• AQA
• SQA (Surgical Quality Alliance)

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Shaping Future of Quality

• PCPI (Physician Consortium for Quality
  Improvement)
• STS surgeons serving on 3rd party quality boards
• United HealthCare
• Blue Cross Blue Shield Association

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Shaping Future of Quality

• Strong Advocacy Presence in Washington, DC
• Need to use clinical data
• Focus on participation, improvement, performance
• Testify before Congress

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Quality Initiatives at STS

• Thank you