Adult Cardiac Surgery Measures
Coronary Artery Bypass Graft (CABG) Composite Score
NQF #0696
NQF Status
Endorsed*
Date of Endorsement
1/26/11
Description
This multidimensional performance measure assesses surgical performance based on a combination of 11 NQF-endorsed CABG process and outcomes measures, grouped into four domains:
1. Perioperative medication domain, scored all-or-none and consisting of:
0127 – Preoperative beta blockade
0117 – Beta blockade at discharge
0116 – Anti-platelet medication at discharge
0118 – Anti-lipid treatment at discharge
2. Operative care process domain
0134 – Use of an internal mammary artery in CABG
3. Risk-adjusted operative mortality
0119 – Risk-adjusted operative mortality for CABG
4. Risk-adjusted morbidity, scored any-or-none and consisting of:
0131 – Stroke/cerebrovascular accident
0115 – Surgical re-exploration
0130 – Deep sternal wound infection rate
0114 – Postoperative renal failure
0129 – Prolonged intubation (ventilation)
Participants receive a score for each of the four domains, plus an overall composite score. The overall composite score was created by “rolling up” the four domain scores into a single number. In addition to receiving a numeric score, participants were assigned to rating categories designated as one (below average performance), two (average performance), and three (above average performance) stars.
*The STS star rating system was not eligible to be considered for NQF endorsement due to the fact that at the time of review, NQF did not have a process in place to endorse "reporting protocols."
Risk-Adjusted Postoperative Renal Failure
NQF #0114
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG (without pre-existing renal failure) who develop postoperative renal failure or require dialysis
Numerator
Number of patients undergoing isolated CABG who develop postoperative renal failure or require dialysis
Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Exclusions
Patients with documented history of renal failure, baseline serum creatinine ≥4.0; prior renal transplants are not considered preoperative renal failure unless since transplantation their Cr has been or is ≥4.0
Risk-Adjusted Surgical Re-exploration
NQF #0115
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG who require a return to the operating room for bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason
Numerator
Number of patients undergoing isolated CABG who require return to the operating room for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason
Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Risk-Adjusted Operative Mortality for CABG
NQF #0119
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Risk-Adjusted Postoperative Prolonged Intubation (Ventilation)
NQF #0129
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG who require intubation for more than 24 hours
Numerator
Number of patients undergoing isolated CABG who require intubation > 24 hours
Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Risk-Adjusted Deep Sternal Wound Infection
NQF #0130
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/for mediastinum requiring operative intervention
Numerator
Number of patients who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention
Must have all of the following conditions:
- Wound opened with excision of tissue (I&D) or re-exploration of mediastinum
- Positive culture unless patient on antibiotics at time of culture or no culture obtained
- Treatment with antibiotics beyond perioperative prophylaxis
Numerator Time Window
Within 30 days postoperatively
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Risk-Adjusted Stroke/Cerebrovascular Accident
NQF #0131
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours
Numerator
Number of patients undergoing isolated CABG who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours
Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission Rate
NQF #2514
NQF Status
Endorsed
Date of Endorsement
12/8/16
Description
Risk-adjusted percentage of Medicare fee-for-service beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting (CABG) and are discharged alive but have a subsequent acute care hospital inpatient admission within 30 days of the date of discharge from the CABG hospitalization.
Numerator
Number of Medicare fee-for-service beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting (CABG) and are discharged alive but have a subsequent acute care hospital inpatient admission within 30 days of the date of discharge from the CABG hospitalization.
Numerator Time Window
Within 30 days of the date of discharge from the index CABG hospitalization
Denominator
Number of Medicare fee-for-service beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting (CABG) during the designated 3-year measurement period and are discharged alive
Denominator Time Window
Designated 3-year measurement period
Risk-Adjusted Operative Mortality for Aortic Valve Replacement
NQF #0120
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients undergoing aortic valve replacement (AVR) who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing AVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing isolated AVR surgery
Denominator Time Window
36 months
Risk-Adjusted Operative Mortality for Mitral Valve Replacement
NQF #0121
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients undergoing mitral valve (MV) replacement who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing MV Replacement who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing isolated MV Replacement surgery
Denominator Time Window
36 months
Risk-Adjusted Operative Mortality for Mitral Valve Repair
NQF #1501
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients undergoing mitral valve (MV) repair who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing MV Repair who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing isolated MV Repair surgery
Denominator Time Window
36 months
Aortic Valve Replacement (AVR) Composite Score
NQF #2561
NQF Status
Endorsed
Date of Endorsement
11/07/14
Description
STS AVR Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1. reoperations for any cardiac reason, 2. renal failure, 3. deep sternal wound infection, 4. prolonged ventilation/intubation, and 5. cerebrovascular accident/permanent stroke. All measures are based on audited clinical data collected in a prospective registry and are risk-adjusted.
Numerator and Denominator Statements and Time Periods
Due to the complex methodology used to construct the composite measure, it is impractical to separately discuss the numerator and denominator. The following discussion describes how each domain score is calculated and how these are combined into an overall composite score.
The STS AVR Composite Score comprises two domains consisting of six individual measures:
- Absence of Operative Mortality
NQF # 0120 Risk-Adjusted Operative Mortality for AVR - Absence of Major Morbidity, scored any-or-none. The measures used are the same morbidity outcomes included in NQF #0696 STS CABG Composite Score.
Risk-Adjusted Postoperative Stroke/Cerebrovascular Accident
Risk-Adjusted Postoperative Surgical Re-exploration
Risk-Adjusted Postoperative Deep Sternal Wound Infection Rate
Risk-Adjusted Postoperative Renal Failure
Risk-Adjusted Postoperative Prolonged Intubation (Ventilation)
Participants receive a score for each of the two domains, plus an overall composite score. The overall composite score is created by “rolling up” the domain scores into a single number. In addition to receiving a numeric score, participants are assigned to rating categories designated by one star (below average performance), two stars (average performance), or three stars (above average performance).
Patient Population: The analysis population consists of adult patients aged 18 years or older who undergo isolated AVR surgery
Time Period: 3 years
Data Completeness Requirement: Participants are excluded from the analysis if they have fewer than 10 isolated AVR procedures in the patient population
Mitral Valve Repair/Replacement Composite Score
NQF #3031
NQF Status
Endorsed
Date of Endorsement
1/25/17
Description
The STS Mitral Valve Repair/Replacement (MVRR) Composite Score measures surgical performance for isolated MVRR with or without concomitant tricuspid valve repair (TVr), surgical ablation for atrial fibrillation (AF), or repair of atrial septal defect (ASD), and comprises two domains consisting of six measures:
Domain 1 – Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death before hospital discharge or within 30 days of the operation.
Domain 2 – Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as the occurrence of any one or more of the following major complications: 1. Prolonged ventilation, 2. Deep sternal wound infection, 3. Permanent stroke, 4. Renal failure, and 5. Reoperations for bleeding, prosthetic or native valve dysfunction, and other cardiac reasons, but not for other non-cardiac reasons.
All measures are based on audited clinical data collected in a prospective registry and are risk-adjusted.
Numerator and Denominator Statements and Time Periods
Due to the complex methodology used to construct the composite measure, it is impractical to separately discuss the numerator and denominator. The following discussion describes how each domain score is calculated and how these are combined into an overall composite score.
The STS Mitral Valve Repair/Replacement (MVRR) Composite Score comprises two domains consisting of six measures:
Domain 1 – Absence of Operative Mortality
Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death before hospital discharge or within 30 days of the operation.
Domain 2 – Absence of Major Morbidity
Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as the occurrence of any one or more of the following major complications:
- Prolonged ventilation
- Deep sternal wound infection
- Permanent stroke
- Renal failure, and
- Reoperations for bleeding, prosthetic or native valve dysfunction, and other cardiac reasons, but not for other non-cardiac reasons.
Participants receive a score for each of the two domains, plus an overall composite score. The overall composite score is created by “rolling up” the domain scores into a single number. In addition to receiving a numeric score, participants are assigned to rating categories designated by the following: 1 star – lower-than-expected performance; 2 stars – as-expected performance; or 3 stars – higher-than-expected performance.
Patient Population: The analysis population consists of adult patients aged 18 years or older who undergo isolated MVRR with or without concomitant tricuspid valve repair (TVr), surgical ablation for atrial fibrillation (AF), or repair of atrial septal defect (ASD).
Time Period: 3 years
Data Completeness Requirement: Participants are excluded from the analysis if they have fewer than 36 isolated MVRR procedures in the patient population.
Anti-Platelet Medication at Discharge
NQF #0116
NQF Status
Endorsed (Reserve Status)
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on anti-platelet medication
Numerator
Number of patients undergoing isolated CABG who were discharged on anti-platelet medication
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Exclusions
Cases are removed from the denominator if there was an in-hospital mortality or if discharge aspirin OR discharge ADP inhibitor OR other discharge anti-platelet was contraindicated
Beta Blockade at Discharge
NQF #0117
NQF Status
Endorsed
Date of Endorsement
1/31/12
Description
Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on beta blockers
Numerator
Number of patients undergoing isolated CABG who were discharged on beta blockers
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Exclusions
Cases are removed from the denominator if there was an in-hospital mortality or if discharge beta blocker was contraindicated
Anti-Lipid Treatment at Discharge
NQF #0118
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on a lipid-lowering statin
Numerator
Number of patients undergoing isolated CABG who were discharged on a lipid-lowering statin
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Exclusions
Cases are removed from the denominator if there was an in-hospital mortality or if discharge anti-lipid treatment was contraindicated
Preoperative Beta Blockade
NQF #0127
NQF Status
Endorsed
Date of Endorsement
1/31/12
Description
Percent of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery
Numerator
Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery
Numerator Time Window
Within 24 hours preceding surgery
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Exclusions
Cases are removed from the denominator if preoperative beta blocker was contraindicated or if the clinical status of the patient was emergent or emergent salvage prior to entering the operating room
Use of Internal Mammary Artery in CABG
NQF #0134
NQF Status
Endorsed
Date of Endorsement
1/31/12
Description
Percentage of patients aged 18 years and older undergoing isolated CABG who received an internal mammary artery (IMA) graft
Numerator
Number of patients undergoing isolated CABG who received an internal mammary artery (IMA) graft
Denominator
All patients undergoing isolated CABG
Denominator Time Window
12 months
Exclusions
Cases are removed from the denominator if the patient had a previous CABG prior to the current admission or if IMA was not used and one of the following reasons was provided:
- Subclavian stenosis
- Previous cardiac or thoracic surgery
- Previous mediastinal radiation
- Emergent or salvage procedure
- No LAD disease
Risk-Adjusted Operative Mortality for Mitral Valve Replacement + CABG Surgery
NQF #0122
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients undergoing combined MV Replacement and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing combined MV Replacement and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing combined MV Replacement + CABG
Denominator Time Window
36 months
Risk-Adjusted Operative Mortality for Aortic Valve Replacement + CABG Surgery
NQF #0123
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing combined AVR + CABG
Denominator Time Window
36 months
Risk-Adjusted Operative Mortality for Mitral Valve Repair + CABG Surgery
NQF #1502
NQF Status
Endorsed
Date of Endorsement
12/6/11
Description
Percent of patients undergoing combined MV Repair and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing combined MV Repair and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing combined MV Repair + CABG
Denominator Time Window
36 months
Aortic Valve Replacement (AVR) + CABG Composite Score
NQF #2563
NQF Status
Endorsed
Date of Endorsement
11/07/14
Description
The STS AVR+CABG Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1. reoperations for any cardiac reason, 2. renal failure, 3. deep sternal wound infection, 4. prolonged ventilation/intubation, and 5. cerebrovascular accident/permanent stroke. All measures are based on audited clinical data collected in a prospective registry and are risk-adjusted.
Numerator and Denominator Statements and Time Periods
Due to the complex methodology used to construct the composite measure, it is impractical to separately discuss the numerator and denominator. The following discussion describes how each domain score is calculated and how these are combined into an overall composite score.
The STS AVR+CABG Composite Score comprises two domains consisting of six individual measures:
- Absence of Operative Mortality
NQF # 0123 Risk-Adjusted Operative Mortality for AVR+CABG Surgery - Absence of Major Morbidity, scored any-or-none. The measures used are the same morbidity outcomes included in NQF #0696 STS CABG Composite Score.
Risk-Adjusted Postoperative Stroke/Cerebrovascular Accident
Risk-Adjusted Postoperative Surgical Re-exploration
Risk-Adjusted Postoperative Deep Sternal Wound Infection Rate
Risk-Adjusted Postoperative Renal Failure
Risk-Adjusted Postoperative Prolonged Intubation (Ventilation)
Participants receive a score for each of the two domains, plus an overall composite score. The overall composite score is created by “rolling up” the domain scores into a single number. In addition to receiving a numeric score, participants are assigned to rating categories designated by one star (below average performance), two stars (average performance), or three stars (above average performance).
Patient Population: The analysis population consists of adult patients aged 18 years or older who undergo AVR+CABG surgery
Time Period: 3 years
Data Completeness Requirement: Participants are excluded from the analysis if they have fewer than 10 AVR+CABG procedures in the patient population.
Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score
NQF #3032
NQF Status
Endorsed
Date of Endorsement
1/25/17
Description
The STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score measures surgical performance for MVRR + CABG with or without concomitant Atrial Septal Defect (ASD) and Patient Foramen Ovale (PFO) closures, tricuspid valve repair (TVr), or surgical ablation for atrial fibrillation (AF). To assess overall quality, the STS MVRR +CABG Composite Score comprises two domains consisting of six measures:
Domain 1 – Absence of Operative Mortality
Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death before hospital discharge or within 30 days of the operation.
Domain 2 – Absence of Major Morbidity
Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as the occurrence of any one or more of the following major complications:
1. Prolonged ventilation, 2. Deep sternal wound infection, 3. Permanent stroke, 4. Renal failure, and 5. Reoperations for bleeding, coronary graft occlusion, prosthetic or native valve dysfunction, and other cardiac reasons, but not for other non-cardiac reasons.
Numerator and Denominator Statements and Time Periods
Due to the complex methodology used to construct the composite measure, it is impractical to separately discuss the numerator and denominator. The following discussion describes how each domain score is calculated and how these are combined into an overall composite score.
The STS Mitral Valve Repair/Replacement (MVRR) Composite Score comprises two domains consisting of six measures:
Domain 1 – Absence of Operative Mortality
Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death before hospital discharge or within 30 days of the operation.
Domain 2 – Absence of Major Morbidity
Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as the occurrence of any one or more of the following major complications:
1. Prolonged ventilation,
2. Deep sternal wound infection,
3. Permanent stroke,
4. Renal failure, and
5. Reoperations for bleeding, coronary graft occlusion, prosthetic or native valve dysfunction, and other cardiac reasons, but not for other non-cardiac reasons.
Participants receive a score for each of the two domains, plus an overall composite score. The overall composite score was created by “rolling up” the domain scores into a single number. In addition to receiving a numeric score, participants are assigned to rating categories designated by the following:
1 star – lower-than-expected performance
2 stars – as-expected performance
3 stars – higher-than-expected performance
Patient Population: The analysis population consists of patients aged 18 years or older who MVRR + CABG with or without concomitant Atrial Septal Defect (ASD) and Patient Foramen Ovale (PFO) closures, tricuspid valve repair (TVr), or surgical ablation for atrial fibrillation (AF).
Time Window: 3 years
Data Completeness Requirement: Participants are excluded from the analysis if they have fewer than 25 MVRR + CABG procedures in the patient population.
Selection of Antibiotic Prophylaxis for Cardiac Surgery Patients
NQF #0126
NQF Status
Endorsed (Reserve Status)
Date of Endorsement
1/31/12
Description
Percent of patients aged 18 years and older undergoing cardiac surgery who received preoperative prophylactic antibiotics recommended for the operation
Numerator
Number of patients undergoing cardiac surgery who received a first generation or second generation cephalosporin prophylactic antibiotic (e.g., cefazolin, cefuroxime, cefamandole) preoperatively or in the event of a documented allergy, an alternate antibiotic choice (e.g., vancomycin, clindamycin) was ordered and administered preoperatively
Denominator
Number of patients undergoing cardiac surgery
Denominator Time Window
12 months
Exclusions
- Patients who had a principal diagnosis suggestive of preoperative infectious diseases
- Patients whose ICD‐9‐CM principal procedure was performed entirely by Laparoscope
- Patients enrolled in clinical trials
- Patients with documented infection prior to surgical procedure of interest
- Patients who expired perioperatively
- Patients who were receiving antibiotics more than 24 hours prior to surgery
- Patients who were receiving antibiotics within 24 hours prior to arrival
- Patients who did not receive any antibiotics before or during surgery, or within 24 hours after anesthesia end time (i.e., patient did not receive prophylactic antibiotics)
- Patients who did not receive any antibiotics during this hospitalization
Duration of Antibiotic Prophylaxis for Cardiac Surgery Patients
NQF #0128
NQF Status
Endorsed (Reserve Status)
Date of Endorsement
5/2/12
Description
Percent of patients aged 18 years and older undergoing cardiac surgery whose prophylactic antibiotics were discontinued within 48 hours after surgery end time
Numerator
Number of patients undergoing cardiac surgery whose prophylactic antibiotics were discontinued within 48 hours after surgery end time
Numerator Time Window
Within 48 hours after surgery end time
Denominator
Number of patients undergoing cardiac surgery
Denominator Time Window
12 months
Exclusions
- Patients who had a principal diagnosis suggestive of preoperative infectious diseases
- Patients whose ICD‐9‐CM principal procedure was performed entirely by Laparoscope
- Patients enrolled in clinical trials
- Patients with documented infection prior to surgical procedure of interest
- Patients who expired perioperatively
- Patients who were receiving antibiotics more than 24 hours prior to surgery
- Patients who were receiving antibiotics within 24 hours prior to arrival
- Patients who did not receive any antibiotics during this hospitalization
- Patients with reasons to extend antibiotics
Participation in a Systematic Database for Cardiac Surgery
NQF #0113
NQF Status
Endorsed (Reserve Status)
Date of Endorsement
12/6/11
Description
Participation in a clinical database with broad state, regional, or national representation that provides regular performance reports based on benchmarked data
Numerator
Does the facility participate in a clinical database with broad state, regional, or national representation that provides regular performance reports based on benchmarked data? (yes/no)
Numerator Time Window
12 months
Congenital/Pediatric Heart Surgery Measures
Operative Mortality Stratified by the 5 STAT Mortality Categories
NQF # 0733
NQF Status
Endorsed
Date of Endorsement
11/16/11
Description
Operative mortality stratified by the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool
Numerator
Number of patients who undergo pediatric and congenital open heart surgery and die during either of the following two time intervals: 1.) Prior to hospital discharge 2.) Within 30 days of the date of surgery
Denominator
Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool
Measure Exclusions
Any operation that is not a pediatric or congenital Cardiac Operation. Cardiac operations are defined as operations that are of operation types of “CPB” or “No CPB Cardiovascular” (CPB is cardiopulmonary bypass.) [1].
Any operation that is a pediatric or congenital open heart surgery (operation types of “CPB” or "No CPB Cardiovascular") that cannot be classified into a level of complexity by the five STS-EACTS Mortality Levels.
Reference
1.Jacobs JP, Mavroudis C, Jacobs ML, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Yeh T, Walters HL 3rd, Kurosawa H, Stellin G, Ebels T, Elliott MJ. What is Operative Mortality? Defining Death in a Surgical Registry Database: A Report from the STS Congenital Database Task Force and the Joint EACTS-STS Congenital Database Committee. The Annals of Thoracic Surgery, 81(5):1937-41, May 2006.
Risk-Adjusted Operative Mortality for Pediatric and Congenital Heart Surgery
NQF #2683
NQF Status
Endorsed
Date of Endorsement
9/3/15
Description
Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator
Number of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure
Numerator Time Window
During the hospitalization regardless of length of stay or within 30 days of surgery if discharged
Denominator
All patients undergoing index pediatric and/or congenital heart surgery
Denominator Time Window
48 months
Surgical Volume for Pediatric and Congenital Heart Surgery
Surgical Volume for Pediatric and Congenital Heart Surgery: Total Programmatic Volume and Programmatic Volume Stratified by the Five STS-EACTS Mortality Categories
NQF # 0732
NQF Status
Endorsed
Date of Endorsement
11/16/11
Description
Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool
Numerator
1) Total number of pediatric and congenital cardiac surgery operations and 2) number of pediatric and congenital cardiac surgery operations in each of the strata of complexity specified by the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool
Measure Exclusions
Any operation that is not a pediatric or congenital cardiac operation. Cardiac operations are defined as operations that are of operation types of “CPB” or “No CPB Cardiovascular” (CPB is cardiopulmonary bypass.) [1].
Any operation that is a pediatric or congenital open heart surgery (operation types of “CPB” or "No CPB Cardiovascular") that cannot be classified into a level of complexity by the five STS-EACTS Mortality Levels.
Reference
1. Jacobs JP, Mavroudis C, Jacobs ML, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Yeh T, Walters HL 3rd, Kurosawa H, Stellin G, Ebels T, Elliott MJ. What is Operative Mortality? Defining Death in a Surgical Registry Database: A Report from the STS Congenital Database Task Force and the Joint EACTS-STS Congenital Database Committee. The Annals of Thoracic Surgery, 81(5):1937-41, May 2006.
Participation in a National Database for Pediatric and Congenital Heart Surgery
NQF # 0734
NQF Status
Endorsed
Date of Endorsement
12/5/11
Description
Participation in at least one multi-center, standardized data collection and feedback program that provides benchmarking of the physician’s data relative to national and regional programs and uses process and outcome measures.
Numerator
Whether or not there is participation in at least one multi-center data collection and feedback program for pediatric and congenital heart surgery.
Measure Exclusions
Any operation that is not a pediatric or congenital Cardiac Operation. Cardiac operations are defined as operations that are of operation types of “CPB” or “No CPB Cardiovascular” (CPB is cardiopulmonary bypass.)
General Thoracic Surgery Measures
Risk-Adjusted Morbidity and Mortality for Lung Resection for Lung Cancer
NQF # 1790
NQF Status
Endorsed
Date of Endorsement
8/9/12
Description
Percentage of patients ≥ 18 years of age undergoing elective lung resection (Open or VATS wedge resection, segmentectomy, lobectomy, bilobectomy, sleeve lobectomy, pneumonectomy) for lung cancer who developed any of the following postoperative complications: reintubation, need for tracheostomy, initial ventilator support > 48 hours, ARDS, pneumonia, pulmonary embolus, bronchopleural fistula, bleeding requiring reoperation, myocardial infarction or operative mortality.
Numerator
Number of patients ≥ 18 years of age undergoing elective lung resection for lung cancer who developed any of the following postoperative complications: reintubation, need for tracheostomy, initial ventilator support > 48 hours, ARDS, pneumonia, pulmonary embolus, bronchopleural fistula, bleeding requiring reoperation, myocardial infarction or operative mortality.
Denominator
Number of patients ≥ 18 years of age undergoing elective lung resection for lung cancer.
Exclusions
Emergency Procedures
Participation in a Systematic National Database for General Thoracic Surgery
NQF # 0456
NQF Status
Undergoing endorsement maintenance
Description
Participation in a multi-center data collection and feedback program that provides benchmarking of the physician’s data relative to national programs and uses structural, process, and outcome measures.
Numerator
Whether or not the physician participates for a 12-month period in at least one multi-center data collection and feedback program that provides benchmarking of the physician’s data relative to national programs and uses structural, process, and outcome measures.
Lobectomy for Lung Cancer Composite Score
NQF #3294
NQF Status
Endorsed
Date of Endorsement
6/06/18
Description
The STS Lobectomy Composite Score comprises two domains:
1. Operative Mortality (death during the same hospitalization as surgery or within 30 days of the procedure)
2. Presence of at least one of these major complications: pneumonia, acute respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation/respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room.
The composite score is created by a weighted combination of the above two domains resulting in a single composite score. In addition to receiving a numeric score, participants are assigned to rating categories designated by the following:
1 star: lower-than-expected performance
2 stars: as-expected performance
3 stars: higher-than-expected performance
Numerator Statement
The STS Lobectomy Composite Score comprises two domains:
1. Operative Mortality (death during the same hospitalization as surgery or within 30 days of the procedure)
2. Presence of at least one of these major complications: pneumonia, acute respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation/respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room.
The composite score is created by a weighted combination of the above two domains resulting in a single composite score. Operative mortality and major complications are weighted inversely by their respective standard deviations across participants. This procedure is equivalent to first rescaling mortality and complications by their respective standard deviations and then assigning equal weighting to the rescaled mortality rate and rescaled complication rate. This is the same methodology used for other STS composite measures.
In addition to receiving a numeric score, participants are assigned to rating categories designated by the following:
1 star: lower-than-expected performance
2 stars: as-expected performance
3 stars: higher-than-expected performance
Patient Population: The STS General Thoracic Surgery Database is queried for all patients treated with lobectomy for lung cancer within a 3-year (36 month) time period. We exclude patients with non-elective status, occult or stage 0 tumors, American Society of Anesthesiologists class VI, and with missing data for age, sex, or discharge mortality status.
Model variables: Variables in the model: age, sex, year of operation, body mass index, hypertension, steroid therapy, congestive heart failure, coronary artery disease, peripheral vascular disease, reoperation, preoperative chemotherapy within 6 months, cerebrovascular disease, diabetes mellitus, renal failure, dialysis, past smoker, current smoker, forced expiratory volume in 1 second percent of predicted, Zubrod score (linear plus quadratic), American Society of Anesthesiologists class (linear plus quadratic), and pathologic stage.
Denominator Statement
Number of patients greater than or equal to 18 years of age undergoing elective lobectomy for lung cancer
Denominator Time Window
3 years
Exclusions
Patients are excluded with non-elective status, occult or stage 0 tumors, American Society of Anesthesiologists class VI, and with missing data for age, sex, or discharge mortality status.