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Ann Thorac Surg 1999;68:367-373
© 1999 The Society of Thoracic Surgeons

Data Base Panel

The Society of Thoracic Surgeons National Database: current status and future directions

Frederick L. Grover, MDa

a Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, Denver VA Medical Center, Denver, Colorado, USA

Address reprint requests to Dr Grover, 4200 East 9th Ave, Box C310, Denver, CO 80262
e-mail: frederick.grover{at}uchsc.edu

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

Abstract

The Society of Thoracic Surgeons National Database, established seven years ago by thoracic surgeons for self improvement and quality assurance, now has 1,181,464 patients registered, including 897,914 coronary artery bypass operations. Risk-adjusted 30 day mortality for coronary bypass procedures, unadjusted mortality for other cardiothoracic procedures, unadjusted morbidity and length of stay as well as several processes of care are measured.

There has been a progressive decrease in operative mortality and length of stay over the past seven years. Deaths, complications, and lengths of stay are stratified according to estimated risk of death.

Definitions have been refined in conjunction with the American College of Cardiology. The database is being increasingly utilized for state analyses and is in demand by other organizations and third party carriers. Logistic regression analysis is now utilized for development of the risk models. The database has been useful for health care policy decisions and can be useful for our Professional Affairs Committee in their dealings with government. Other uses include measuring access to care and cost.

Data quality improvement measures have been put in place, as well as data manager education. The General Thoracic and Congenital data acquisition packages are being modified and improved, and a goal is to begin collecting longitudinal data to demonstrate the long term efficacy of thoracic procedures. The data elements have been decreased from 500 to 200+ core variables for simplification.

With the changing healthcare environment and emphasis on cost cutting, collecting valid data by a national specialty group enhances the monitoring of quality of care, thus protecting our patients from overzealous cutbacks. Data is essential to document the efficacy, quality and cost-effectiveness of the procedures we perform and is a necessary tool for each of us to have to assure the quality and continued success of our practices.

I would like to briefly review The Society of Thoracic Surgeons (STS) Database, present and future issues, and then stress at the end, the importance of multi-institutional databases to our specialty in this changing health care environment. The STS database is a voluntary database established 7 years ago under the leadership of Richard Clark [1]. The main objective has been local self-improvement and quality assurance. We think the database is representative of the spectrum of care across this country’s practicing cardiothoracic surgeons. There are currently 1,181,464 patients registered [2]. It allows those of us who practice cardiac surgery to compare our work to the national average.

Currently, risk-adjusted 30-day mortality for coronary bypass patients and non–risk-adjusted 30-day mortality for other cardiothoracic surgical procedures are determined. Non–risk-adjusted morbidity for selected important complications is collected, as well as lengths of stay and certain processes of care. This data is reported back in the form of an annual report to all of our members, plus each member can access the database using their own software, on a daily basis, for calculation of risk in their coronary patients.

Figure 1 demonstrates the number of various cardiac procedures performed. You will note that by far the most frequent procedures are coronary bypass, approaching 900,000, with valve and valve/coronary operations being performed less frequently. The observed-to-expected mortality ratio, calculated annually as shown in Figure 2 , demonstrates a progressive decrease in operative mortality over the past 7 years.



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  		Fig 1. The relative number of coronary bypass procedures, valve procedures and other procedures performed which have been collected in the Summit-STS database since 1970. The patients from 1991 to the present are official STS patients; the others were already entered into the database prior to the development of the official STS database. The vast majority of the procedures entered are coronary bypass grafting operations.

 


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  		Fig 2. The annual observed to expected operative mortality is listed by year for coronary artery bypass grafting procedures. Note a progressive decline in the observed and expected operative mortality over that 7-year period.

 
The effects of operative status and reoperation on coronary bypass mortality are reported annually for the national aggregate as shown in Figure 3 , with the greatest mortality occurring in the reoperative emergent salvage patients. By comparing your own results in these categories you can see where your group stands in relationship to the national cohort. Complications are also stratified according to the predicted risk of operative mortality. The incidence of developing one major complication of coronary surgery is closely related to the patient’s estimated operative mortality based on preoperative risk factors (Fig 4).



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  		Fig 3. Both expected and observed operative mortality increase relative to the urgency or emergency of the procedure and to reoperation, with a very high risk of death in the salvage population, both first time and reoperation.

 


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  		Fig 4. Estimated operative mortality is listed on the horizontal axis and the percent of patients with at least one major complication on the vertical axis. Note that there is a progressive increase in the likelihood of a major complication in the higher risk patients.

 
Hospital length of stays are also collected and are reported back to the membership, allowing the comparison of one’s own group or personal practice to the national average. Length of stays have decreased over time, probably reflecting a change in the process of care to more "fast-track" protocols over the past several years (Fig 5). This can also be risk-stratified according to the estimated operative mortality, with postoperative length of stay increasing in higher risk patients (Fig 6). Length of stay is a surrogate of cost, which we hope to eventually be able to monitor and estimate, based on preoperative risk factors.



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  		Fig 5. Total length of stay has progressively decreased over the past 7 years, decreasing from 10 days to 7 days for coronary artery bypass grafting procedures. The star with the line indicates the median and the dot the mean value.

 


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  		Fig 6. There is a relationship between a greater postoperative length of stay and the higher risk patient population with the lowest risk groups having an average postoperative length of stay of 5 days and the higher risk groups 8–9 days.

 
Thanks to the leadership of Dr Bruce Ferguson, common definitions have been developed with the American College of Cardiology in conjunction with the Healthcare Financing Administration. Our database committee has also been working with the State of California and the California STS members and the Minnesota thoracic surgeons, who have demonstrated, like the Northern New England Cardiovascular Group, the ability of surgeons in a state or region to cooperate in an effort to improve quality of care [3]. They are using the STS database as a method of quality collection for third-party carriers, which has simplified their data collection. We have been approached by numerous other states, as well as the American Medical Association and the American College of Surgeons for use of our data. Our general viewpoint is that it is preferable to use data collected by our membership, where we have some degree of control over the quality, accuracy, and appropriate statistical analysis for use by these outside groups, rather than to have them collect data on their own which may not be of as high a quality or undergo as sophisticated an analysis.

During this past year, the logistic regression risk model for coronary artery bypass surgery was established under the leadership of Drs Fred Edwards and Laurie Shroyer. This allows us to have odds ratios for outcomes for numerous preoperative risk factors [4]. As an example, a first reoperation carries a threefold greater risk of death, and a second or a greater number of reoperations, a three-and-a half-fold greater risk (Table 1).


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  		Table 1. 1995 CABG-Only Risk Model Resultsa,b

 
Some processes of care are collected, such as the use of the internal mammary artery conduit, and there has been a steady increase in its use over the past 7 years (Fig 7). This is probably because of findings in the STS database of better long-term survival and of better risk-adjusted short-term survival [5]. This again offers the opportunity for our membership to compare their own use of the internal mammary artery to its use by their national peer group.



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  		Fig 7. Since the inception of the Society of Thoracic Surgeons National Database, there has been a progressive increase in the utilization of at least one internal mammary artery in coronary artery bypass grafting operations. The 1996 level was approximately 77% as compared to 47% in 1990.

 
This database and other databases can be very useful for health care policy decision-making and allows our specialty to have data to take to the government or other agencies when they need it [6]. For example, the question of the minimum surgical volume required for satisfactory outcomes was raised when some of our members were losing their hospital privileges and/or payments through third-party carriers because of so-called low volume of surgical procedures inspite of satisfactory results. By analyzing our database and several other databases, we identified the minimal number of cases necessary for adequate quality [7]. There are other uses, including the monitoring of cost and accessibility to care, that databases can help us with in order to be proactive in our relationship with government and other parties.

It is very important for us to have assurance that there is good data quality and that the data is valid [8]. We are working on front-end data quality improvement—that is, modifying the software so that STS data managers are automatically notified up front if there is a problem with the data they are submitting, rather than finding out about it later. This past year we had an expert advisory panel composed of 3 well-known biostatisticians, who are not thoracic surgeons, examine our methodology objectively. They approved the risk model and the data quality monitoring, with suggestions for future improvement.

Data manager education is extraordinarily important. Thus, an annual educational meeting has been established for our data managers. Mary Eiken, our National Nurse Coordinator, helps to direct this meeting, which is being very well received.

The database annual report is now up on the STS Web Page under the guidance of Stan Dziuban. We plan to use the web page eventually as a vehicle to report our data. Gus Mavroudis and his subcommittee are working on developing congenital software packages, and David Harpole and his subcommittee are progressing nicely with the general thoracic database. We hope to expand the risk-adjusted outcomes to include all common cardiothoracic procedures.

The longitudinal follow-up that Paul Sergeant just presented from Europe is indeed very impressive [9], and we hope to begin to collect long-term data outcomes that include, in addition to mortality and morbidity, functional health status, incidence of reinterventions, freedom from angina, quality of life, patient satisfaction, and cost. To do this can be costly, but we must be creative and accomplish these tasks in a cost-effective way so as to make our database meaningful to the practicing cardiothoracic surgeon.

We are developing a protocol for the Healthcare Financing Administration (HCFA) to compare outcomes for coronary bypass and angioplasty. We hope that this will serve as an example of a major specialty group and professional society cooperating with government with the common goal of improving patient care.Our goal is for the database to assume a stature and quality that other agencies will respect, and therefore use, rather than trying to collect data on their own. This will be to the advantage of cardiothoracic surgeons because we can take measures to assure the quality of our data and the appropriateness of the data analysis and interpretation.

Our goal is to make the STS database relevant to our members’ clinical decision-making and also to be used as an instrument to further our knowledge. We would like to see this database utilized more for research, and invite you to submit a letter of intent or a small proposal to our database committee with specific requests for data to answer important questions.

We also want to this database to be utilized to help establish the value of cardiothoracic surgery with the government, third-party carriers, other health care organizations, and the public. I think this is where we can really help our Professional Affairs Committee as they take the message forward. You have seen the importance of frequent data feedback and of bringing data to the point of care in order to affect the processes that you use to care for your patients and improve care at your local institution, and the public needs to be aware of these efforts.

Drs Stan Dziuban and Bruce Ferguson have been working hard with our committee to reduce the complexity of the data set by decreasing the approximately 500 variables to 200+ core variables. That should decrease the cost of collection and hopefully improve the quality. We are simplifying the general thoracic surgery data set and we are upgrading the congenital analysis to make it a relational database.

Dr Richard Prager and his colleagues have recently demonstrated the ability to link the STS database to some of the more sophisticated cost databases and to develop risk-adjusted cost models. This obviously will be very helpful in projecting costs and determining contractual arrangements [10].

We plan to separate software vendors from the data warehousing and analysis, allowing for several approved software vendors and for one data warehousing and analysis group. This should give you more variety and ability to select the product that you would like to meet your own needs.

Patient identifiers, as Dr Kaiser mentioned in his Presidential Address [11], are difficult to capture now for legal reasons because of potential confidentiality issues, but would be helpful in the long-term follow-up of patients, and also would be very helpful to our committee in monitoring the data quality. Dr Robert Jones’ work at Duke, comparing PTCA and coronary bypass reintervention rates and long-term outcomes, is an example of the value of long-term data [12]. This type of data can be very advantageous to us in documenting the relative efficacy of coronary bypass as compared to interventional cardiology procedures for given patient populations (Fig 8). The implications of this in terms of functional health status and cost are obvious.



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  		Fig 8. This figure denotes the percentage of patients who underwent either a CABG or a PTCA as their first procedure who have required a secondary procedure during the 10 year-follow up in the Duke University Database. Note that there is a far greater incidence of angioplasty patients requiring a secondary procedure than the coronary artery bypass grafting group. (Reprinted with permission from Jones et al. [12].)

 
Health care costs increased to almost a trillion dollars from 1981 to 1994 (Fig 9 )[13]. This stimulated considerable discussion and changes in the healthcare system, resulting in an influx of health maintenance organizations in an attempt to decrease costs. This has resulted in a decrease in the rate of healthcare cost inflation. These savings come from physicians, including cardiothoracic surgeons, and from our hospitals and not infrequently result in decreased service and patient satisfaction. In turn, this has resulted in decreased physician satisfaction, with some specialists retiring from practice early, and may well decrease the attractiveness of a career in cardiothoracic surgery to the best and brightest of the next generation.



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  		Fig 9. Healthcare spending as a percentage of the United States Gross National Product consistently increased from 1981–1984 from 9.6% to 15%, reaching the $1.06 trillion mark. Physician Services, however, accounted for only a relatively small 18% of this (Reprinted from the New York Times, December 29, 1993:A12. Copyright © 1993 by The New York Times. Reprinted by permission.

 
This is therefore a major issue for our specialty. It is only by carefully collecting data to document any decreasing quality of care caused by funding cutbacks, that we can potentially counterbalance some of these actions.

In summary, if we ask ourselves why does the collection of valid risk-stratified outcomes matter, the answers are:

  1. High-quality data is essential to document, for a wary public, the efficacy, quality, and cost-effectiveness of procedures that we perform.
  2. It is necessary for the very important role of continued improvement in quality of care.
  3. It should yield important scientific data, and
  4. Without it, your group, my group, and our specialty may not survive.

Acknowledgments

I express my appreciation to Ms Melissa Swanson for her assistance in the preparation of this manuscript.

References

  1. Edwards F.H., Clark R.E., Schwartz M. Coronary artery bypass grafting. Ann Thorac Surg 1994;57:12-19.[Abstract]
  2. Data Analysis of The Society of Thoracic Surgeons National Cardiac Surgery Database, the Seventh Year; January, 1998.
  3. Carey J.S., Dziuban S.W., Arom K.V., et al. Quality improvement in thoracic surgery. Bull Am Coll Surg. May 1998;83:24-29.
  4. Shroyer A.L.W., Grover F.L., Edwards F.H. 1995 Coronary artery bypass risk model. Ann Thorac Surg 1998;65:879-884.[Abstract/Free Full Text]
  5. Edwards F.H., Clark R.E., Schwartz M. Impact of internal mammary artery conduits on operative mortality in coronary revascularization. Ann Thorac Surg 1994;57:27-32.[Abstract]
  6. Grover F.L. The bright future of cardiothoracic surgery in the era of changing healthcare delivery. Ann Thorac Surg 1996;61:499-510.[Abstract/Free Full Text]
  7. Crawford F.A., Jr, Anderson R.P., Clark R.E., et al. Volume requirements for cardiac surgery credentialing a critical examination. Ann Thorac Surg 1996;61:12-16.[Abstract/Free Full Text]
  8. Shroyer A.L., Edwards F.H., Grover F.L. Updates to the data quality review program. Ann Thorac Surg 1998;65:1494-1497.[Abstract/Free Full Text]
  9. Sergeant P., Blackstone E. Closing the loop. Ann Thorac Surg 1999;68:362-366.[Abstract/Free Full Text]
  10. Longo K.M., Cowen M.E., Flaum M.A., Schork M.A., Wagner L.A., Prager R.L. Preoperative predictors of cost in median-age patients undergoing coronary artery bypass grafting. Ann Thorac Surg 1998;66:740-745.[Abstract/Free Full Text]
  11. Kaiser G.C. Paranoia or reality?. Ann Thorac Surg 1998;65:1201-1206.[Free Full Text]
  12. Jones R.H., Kesler K., Phillips H.R., et al. Long-term survival benefits of coronary artery bypass grafting and percutaneous transluminal angioplasty in patients with coronary artery disease. J Thorac Cardiovasc Surg 1996;111:1013-1025.[Abstract/Free Full Text]
  13. Pear R. $1 million in health care costs is predicted. New York Times 1993;December 29:A2.



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