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Ann Thorac Surg 2007;83:S1-S2
© 2007 The Society of Thoracic Surgeons
a Chair, The Society of Thoracic Surgeons Quality Measurement Task Force, Chicago, Illinois
b President (2006–2007), The Society of Thoracic Surgeons, Chicago, Illinois
c Chair, The Society of Thoracic Surgeons Council on Quality, Research and Patient Safety, Chicago, Illinois
d Chair, The Society of Thoracic Surgeons Workforce on National Databases, Chicago, Illinois
Accepted for publication January 12, 2007.
* Address correspondence to Dr Shahian, The Society of Thoracic Surgeons, 633 N Saint Clair St, Suite 2320, Chicago, IL 60611 (Email: shahian{at}comcast.net).
Cardiothoracic surgery has a long and distinguished history of critical self-examination to improve the quality of patient care. Twenty years ago our profession was challenged by an unprecedented call for accountability. Recognizing our responsibility to our patients and our profession, The Society of Thoracic Surgeons (STS) embarked on one of the most extensive clinical data collection initiatives in the entire field of medicine, the development of the STS National Adult Cardiac Surgery Database. This database is now among the largest and most respected clinical data registries in the world, and studies based on it have substantially advanced patient care, research, and quality initiatives. Because of the early development and continuing evolution of this outstanding database, it has become the national gold standard for cardiothoracic surgery and has established clearly defined benchmarks for clinical comparisons. Such information has become the cornerstone of quality assessment in cardiothoracic surgery.
Our profession is now at a similar critical juncture as it was 20 years ago. Once again we are faced with a call for greater accountability, but now this attention is directed to the entire medical profession, not just one specialty or particular high-profile procedure. Furthermore, there is now widespread consensus that the keystone of accountability is the objective assessment of quality, and that this is best accomplished through performance measurement.
The objective measurement of provider quality has thus become a dominant theme in the reengineering of American health care. For example, the Institute of Medicine’s 2006 quality report, Performance Measurement: Accelerating Improvement, and Porter and Teisberg’s highly regarded book, Redefining Health Care, advocate strongly for performance measurement as a central tenet of health care reform. By enthusiastically embracing this performance measurement paradigm, which is completely consistent with the principles that have always guided the cardiothoracic surgery profession, the STS will continue to strengthen its leadership position at the forefront of American health care reform. Our proactive development of a comprehensive, scientifically rigorous approach to quality measurement establishes a high standard that will effectively preclude less acceptable alternatives.
Given the current health policy environment, the Society’s historical commitment to quality, and its extensive experience with clinical data collection, the STS Executive Committee voted in May 2005 to initiate a comprehensive quality measurement program for cardiothoracic surgery. A Quality Measurement Task Force (QMTF) was subsequently created to (1) select a set of individual quality indicators within multiple domains of care; (2) develop methodologies for combining such measures within and across domains (commonly referred to as "composite scores"); and (3) examine various approaches for evaluating provider performance based upon overall composite quality scores.
After extensive research, deliberations, and pilot studies, the QMTF presents the results of its work in this two-part supplement to The Annals of Thoracic Surgery. Part 1 (Conceptual Framework and Measure Selection) explains the principles underlying the selection of individual measures and provides a detailed description of the 11 specific measures chosen [1]. It also describes the way in which these measures were grouped into four discrete quality domains (Perioperative Medical Care, Operative Care, Risk-Adjusted Mortality, and Risk-Adjusted Major Morbidity). Notably, the QMTF restricted its consideration of individual measures to those already endorsed by the National Quality Forum, thus assuring their broad acceptance. All these measures are also available within the STS National Adult Cardiac Surgery Database, making it unnecessary for providers to collect extensive additional data.
Part 2 of this report (Statistical Considerations in Composite Measure Scoring and Provider Rating) describes statistical methodologies for combining measures within and across domains into composite scores [2]. This approach relies on objective, rigorous statistical theory and represents the first composite quality score based on NQF-endorsed performance measures. Using actual STS data, the QMTF then illustrates one potential method for using these composite scores to evaluate provider performance.
The voluntary development of this sophisticated performance assessment tool reaffirms the Society’s longstanding commitment to quality. The QMTF recognizes, however, that even an effort with such noble intentions has potential unintended negative consequences. For example, the fear of unfavorable quality scores could make some providers more risk averse, thus limiting access for the highest-risk patients. However, unlike rating systems that rely solely on operative mortality, these more comprehensive and broad-based quality scores encompass multiple measures of performance, thus mitigating to some extent the impact of any single measure. It is also possible that payers may overly rely on such scores and seek to inappropriately redirect patients based solely on perceived quality differences that are, in reality, small or transient. Conversely, there is substantial historical evidence that many consumers and payers may ignore such scores, which would negate some of their intended value. Both these concerns will be addressed with an aggressive education initiative. Finally, it would be unfortunate if such scores were used exclusively for profiling, as they have tremendous potential to direct the focus of provider-initiated quality improvement activities.
Notwithstanding these and other caveats, the STS is confident that this bold step charts the proper course for our specialty. As a professional organization whose members are entrusted with their patients’ lives, the STS holds a very special position of public trust. With this privilege comes the responsibility to always put the public’s interest first, to provide our patients with the highest quality care, and to objectively document our performance. With the quality measurement methodology described in this report, the STS continues its long and proud tradition in pursuit of these goals.
| For related articles, see Ann Thorac Surg 2007;83:1237 and 1240
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