The measurement of adult cardiac surgery quality; Part I: conceptual framework and measurement selection.

The Society of Thoracic Surgeons established a Quality Measurement Task Force to develop a methodology for the comprehensive assessment of adult cardiac surgery quality of care, including both individual measures and an overall composite quality score. In Part 1 of a two-part series, the Task Force describes the conceptual framework, principles, and guidelines used to select and categorize the individual measures that comprise the composite score. Quality indicators were selected using the following principles: (1) Quality assessment should be at the level of the program or hospital rather than the individual surgeon. (2) Initial quality reports should focus on coronary artery bypass grafting surgery. (3) Quality measures should be chosen from among those endorsed by the National Quality Forum. (4) Quality measure selection should be consistent with the principles and criteria recommended in the 2006 Institute of Medicine report Performance Measurement: Accelerating Improvement. (5) Quality measures should be available as data elements within The Society of Thoracic Surgeons National Adult Cardiac Surgery Database. (6) Quality scores should consider structure, process, and outcomes. (7) Quality scores should assess three temporal domains—preoperative, operative, and postoperative. (8) Quality scores should satisfy multiple criteria for validity. (9) Quality scores should be interpretable and actionable by providers. Eleven individual measures of coronary artery bypass grafting quality within four domains were selected: (1) Perioperative Medical Care, a process bundle of four medications including preoperative ß-blockade and discharge aspirin, ß-blockade, and lipid-lowering agents. (2) Operative Care, a single process measure—use of at least one internal mammary artery. (3) Risk-Adjusted Operative Mortality. (4) Postoperative Risk-Adjusted Major Morbidity, defined as the risk-adjusted occurrence of any of the following: renal failure, deep sternal wound infection, reexploration, stroke, or prolonged ventilation/intubation. In summary, The Society of Thoracic Surgeons Quality Measurement Task Force has selected a group of measures to serve as the basis for comprehensive assessment of adult cardiac surgery quality. Part 2 of this report describes the statistical considerations relevant to combining these measures into composite scores, then using such scores as the basis for a provider rating system. (April 2007)