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Division of Cardiac Research, Eastern Colorado Health Care System, Denver Veterans Affairs Medical Center, 820 Clermont St, No. 112R, Denver, CO 80220
(Email: laurie.shroyer{at}va.gov).
In this timely and policy-relevant article, Welke and colleagues [1] compare the surgical volumes and mortality rates between the voluntary Society of Thoracic Surgeons (STS) National Cardiac Database (NCD) and the Medicare administrative claims database (MEDPAR). Although the authors find that the STS NCD volumes were generally reported to be higher as compared with the MEDPAR data, this difference was partially attributed to Medicare managed care in which administrative claims data are not available for 8% to 15% of the services provided in any given year. In addition, the STS NCD mortality rates were reported to be somewhat lower for the hospitals that participate in the STS NCD as compared with non-STS NCD participating hospitals providing Medicare cardiac surgery procedures. The authors conclude that under-reporting to the STS NCD does not seem to be a significant barrier in that the STS NCD may be the most representative viewpoint of the "current practice of cardiac surgery" within the United States [1].
For this hospital-based (rather than clinician-based or patient-based) comparison, the co-authors point out several key limitations of their study. For their identification of hospitals in which the patients aged 65 years or older in the STS NCD received cardiac surgery, this comparative analysis between the STS NCD and Medicare billing records had several challenges. Of the 1,026 Medicare hospitals performing cardiac surgery procedures, only 626 of these facilities could be matched to the STS NCD. It is not clear whether there were any important differences in the hospital matching process (primarily using facility name and location) for cardiac surgery that might potentially have impacted this analysis. Although a surrogate approach was used to evaluate the participating versus the nonparticipating hospital characteristics of the STS NCD with volumes and mortality rates reported, a more rigorously matched hospital-specific comparison would be required to definitively identify if the hospital characteristics of the nonmatched hospitals or the cardiac surgery patient characteristics of the nonmatched hospitals posed a potential bias to the findings of this study. Therefore, in the next stage of database integrity assessments planned, the STS NCD may wish to collect an encoded data field tracking the unique Medicare hospital facility code in which the cardiac surgery procedure was performed. Ideally, more rigorous matching analyses may be facilitated using this encoded data field to enhance future STS NCD and MEDPAR comparisons.
In addition, it is unclear if a future clinician-based comparison may be coordinated to augment this initial analysis. Given that cardiac surgeons may perform surgery at multiple hospitals, it may be useful in future analyses to identify if a surgeon-specific effect may be an important contributor to hospital-based volume or mortality reporting concordance.
As a model to other professional societies, the STS NCD was originated in 1990 to facilitate local participant self-assessment and self-improvement endeavors, as well as build a quality improvement program to support the development of critical clinical pathways, managed care group applications, and regional and national quality improvement endeavors [2, 3]. Increasingly, national healthcare policies seem to be relying on clinical database information to establish a measurement framework for assessing the value of care provided. The Medicare "Pay for Performance" (P4P) initiatives identify quality measures of the selected performance metrics of completeness, accuracy, reliability, and timeliness of clinical databases, which may very likely have important consequences related to future provider-based reimbursements.
In the Department of Veterans Affairs’ (VA) Continuous Improvement in Cardiac Surgery Program (related to Public Law 99-166), reconciliations are routinely performed between the clinical data forms received, the electronic health records surgical log, the death registry for veterans, and the electronic hospital records for each cardiac surgery case. For this VA-based national quality improvement endeavor, patient-specific and facility-specific assessments are performed to assure 100% completeness of data forms captured, as well as the accuracy, reliability, and completeness of all patient risk-related procedural details and outcome-based data obtained [4].
Given that the STS has not captured either patient-specific or hospital-specific unique identifiers, the authors of this article are to be commended on this first preliminary step forward to evaluate the integrity of the NCD. However, for long-term performance assessment it may be worthy to consider the coordination of ongoing reconciliations with Medicare hospital-specific, provider-specific, and patient-specific data to assure that no potential for bias between or within provider subgroups is related to the determination and occurrence of the metrics of performance.
In summary, this article confirms the general perception that the NCD of the STS is an important resource to consider in support of a national performance dialogue. As the authors themselves noted, "... combinations of clinical, financial, and administrative data, including longitudinal data, will give the most accurate representation of the quality, cost, and medical and financial efficacy of cardiac surgical care" [1]. Thus, enhanced data captured in the NCD of the STS, with ongoing more detailed comparisons with MEDPAR data, seem to be warranted to achieve this laudable long-term goal.
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