Ann Thorac Surg 2007;83:1918-1919
© 2007 The Society of Thoracic Surgeons
Correspondence
Reply
Frederick L. Grover, MD, Immediate Past President, The Society of Thoracic Surgeons
University of Colorado Health Sciences Center, Department of Surgery, C-305, 4200 East Ninth Ave, Denver, CO 80262
(Email: frederick.grover{at}uchsc.edu).
To the Editor:
I am writing in response to Dr Kratz’s thoughtful letter appearing in this issue of The Annals [1]. His letter discusses The Society of Thoracic Surgeons’ (STS) creation of third party payor access to the STS database. With member permission, a payor may access the STS Database to assess the quality of the cardiac care delivered to that payor’s group of patients. We are appreciative of Dr Kratz’s complimenting the success of the STS Database as a "superb tool allowing for steady improvement in the quality of cardiac surgery..." His major concern, however, is that allowing the use of the Database by payors to assess the quality of cardiac surgery may lead to "corruption of the submitted data." He speculated that, since the quality of demonstrated care may be related to the level of reimbursement from the payor, this will tempt our members to potentially falsify their data submission. He also expresses concern that the audit program (both internal and external) in place for the database is not extensive enough.
Dr Kratz brings up some potential shortcomings of this STS policy if cardiothoracic surgeons consistently engage in dishonest or "gamed" reporting. However, my firm belief is that 95+% of cardiothoracic surgeons are very honest and will report accurate data and that our specialty in particular has been a leader in transparency Our training has taught us to look very critically at our performance in an honest way to improve care. I therefore doubt very much that his fears will be realized. Having said that, let me reassure our membership that the leadership of the STS has thoughtfully considered the pros and cons of the policy of allowing the Database on a voluntary basis to be utilized by third party payors to evaluate the quality of cardiac surgical care that their constituents are receiving.
There are many reasons that factored into our decision to go forward with this program:
- 1 The payors value the STS Database and want to use its high quality information as the basis for their respective recognition of programs and other quality initiatives.
- 2 The STS has used a uniform approach to quality grounded in our National Quality Forum (NQF)-endorsed performance measures and approved by the STS Executive Committee in our dealings with these third parties.
- 3 If STS data are not used, there is a real danger that the third parties will develop their own, probably less desirable, alternatives. Our groups and hospitals would then be subjected to several different systems using different sets of criteria and definitions, causing great duplication for our members and imposing a costly overhead, with some of the payors possibly using inappropriate criteria such as flawed administrative data.
- 4 The STS leadership strongly believes that the Society needs to have a proactive stance on behalf of its members and the patients that we care for. This position allows the surgeons who operate on and care for patients to determine the kind of data that will be utilized in the assessment of their performance as opposed to having that designed by an outside group.
- 5 The STS is taking great care to protect the national database participants against any undue adverse actions in our negotiations with third parties. We have insisted that if a participant is having difficulty with performance, the Society will be informed before any adverse action is taken by the payor unless there is "imminent risk of harm to patients" in which case the payor still must use its best efforts to provide the STS with notice and an opportunity to consult prior to taking an adverse action.
- 6 The goal of the STS is to prevent any misuse of data by licensed payors and to provide a role for the Society in assisting any participating cardiac surgical program with potential performance issues.
- 7 STS’s report will be based on a subset of 15 STS NQF-endorsed measures for adult cardiac surgery. These measures are:
- 1 Pre-operative Beta Blockade
- 2 Use of Internal Mammary Artery (IMA)
- 3 Prolonged Intubation (Ventilation)
- 4 Deep Sternal Wound Infection Rate
- 5 Stroke/Cerebrovascular Accident
- 6 Post-operative Renal Failure/Insufficiency
- 7 Surgical Re-exploration
- 8 Anti-platelet Medication at Discharge
- 9 Beta Blockade Therapy at Discharge
- 10 Anti-lipid Treatment at Discharge
- 11 Risk-adjusted Operative Mortality for Coronary Artery Bypass Grafting (CABG)
- 12 Risk-adjusted Operative Mortality for Aortic Valve Replacement (AVR)
- 13 Risk-adjusted Operative Mortality for Mitral Valve Replacement/Repair (MVR)
- 14 Risk-adjusted Operative Mortality for MVR + CABG Surgery
- 15 Risk-adjusted Operative Mortality for AVR + CABG Surgery
As one can see by the above list, these measures are a combination of process measures and risk-adjusted outcomes measures. Currently, the STS Quality Measurement Taskforce under the Workforce on National Databases is developing a sophisticated statistical model which will appropriately weight the importance of these variables into a composite quality measure.
- 8 Be assured that the data will be analyzed by the STS/Duke Clinical Research Institute, using data that your group or hospital submits for STS Database purposes and will be subject to sophisticated statistical analysis.
- 9 The STS National Database external audit program uses a random selection method to identify sites to be audited, a method that does not require a high percentage of programs to be audited, since the very fact that any program could be audited at any given time has resulted over the years in increased accuracy from these types of efforts. This approach has been proven in states that have created audit systems and has further enhanced the validity of the data submitted both by audited and non audited programs.
In summary, we believe that the potential benefits of a scientific performance report prepared by the STS for third party payors’ use in measuring quality, based on the Society’s NQF-endorsed performance measures in conjunction with STS generated data, far outweigh the risks of not collaborating.
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References
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- Kratz J. Use of the STS database by insurance companies(letter) Ann Thorac Surg 2007;83:1918.[Free Full Text]
Related Article
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Use of The STS Database By Insurance Companies
- John Kratz
Ann. Thorac. Surg. 2007 83: 1918.
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