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Ann Thorac Surg 2001;72:1-2
© 2001 The Society of Thoracic Surgeons
Address reprint requests to Dr Orringer, General Thoracic Surgery, University of Michigan Medical Center, 1500 E Medical Center Dr, 2120 Taubman Center, Box 0344, Ann Arbor, MI 48109
e-mail: morrin{at}umich.edu
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Selling the concept of a National Cardiac Surgery Database to STS members in these "early years" was viewed by the majority as akin to selling the proverbial coals in Newcastle. Cardiothoracic surgeons, perhaps the most compulsive of all medical practitioners, were accustomed to collecting data about their personal series and saw little reason to adopt a new system with its added administrative burden and costs. And then the extraordinary impact of the HMOs and governmental regulation of Medicine began, and the database began to take on a different meaning. As HMOs attempted to limit the number of specialty practitioners within their spheres, it was suggested that aggregate data in the National Database might be used to provide comparative information on the clinical outcomes of cardiac surgeons. And then Blue Cross/Blue Shield made a decision to use STS Database participation as a criterion of inclusion of cardiac surgeons on its lists of preferred providers. The economic incentive to be part of the National Database was born. The ability of cardiac surgeons to demonstrate that their operative results meet the norms established by the database has become an increasingly powerful tool in discussions with patients, insurers, and hospital administrators. The STS Cardiac Surgery National Database has had its growing pains as Summit, our initial software provider, "folded" and the data warehouse functions were transferred to the Duke Clinical Research Institute (DCRI) in 1998. This has been a positive move, however, as DCRI, an organization which is at "arms length" from the STS, has provided more credible and widely accepted risk-adjusted analyses of our data. And with approximately 1.5 million patients now entered, the STS Cardiac Database, the largest in the world, has gained recognition, particularly in Washington, as the gold standard of the medical profession’s efforts to use data collection to improve patient care. The Health Care Financing Agency (HCFA) now listens to the STS largely because of its database and the manner in which the STS has utilized data responsibly to support its recommendations.
Until the past few years, the STS National Database has essentially been an "adult coronary artery surgery database." The scope of the database has now grown to include cardiac valve and aortic surgery. And predictably, not to be outdone, the subspecialty areas within Thoracic Surgery are getting on-board the Database Express. After five years of intensive discussion and eventual agreement upon definitions in a highly complex field, under the energetic leadership of Dr Gus Mavroudis, the STS Pediatric Cardiac Surgery database has now been established and will clearly be the most comprehensive repository for the storage and retrieval of risk- adjusted outcomes data for these operations.
And now comes the general thoracic surgeons . ... . Is there a need for a general thoracic surgery database? Nearly 50% of pulmonary resections in this country are performed by non-ABTS certified surgeons. Does it matter? Recent reports [1], basically derived from Medicare discharge data, suggest that outcomes after major pulmonary resections performed by board certified thoracic surgeons, particularly in high risk patients, are substantially better. In this era of increasing concern for patient safety, can there be a better surrogate for "quality" care of general thoracic surgery patients than risk-adjusted norms of morbidity and mortality derived from a national STS General Thoracic Surgery database? With the help of Dr Stan Dziuban and other members of the leadership of the STS general thoracic surgery community, this database has been developed and should be up and running within the next two months. And it cannot come soon enough. The majority of STS members lament declining professional reimbursement for Medicare patients as determined by HCFA. Few of us, however, are aware of the process whereby this reimbursement is determined. It is the Relative Value Unit Committee (RUC), consisting of physician representation from all the medical and surgical specialties, which meets and evaluates presentations from each other on the rationale for proposed fee increases for various professional services and makes its recommendations to HCFA which in the past have generally been accepted. Increasingly so, in this budget neutral system in which a gain for one specialty means decreased funds available for another, data drive decisions and win or lose arguments for the presenting group.
I had the opportunity to personally participate in the last round of STS presentations to the RUC (2000–2001) in which our Society made its case for substantial increased reimbursement for pulmonary and esophageal resections of all types and other general thoracic operations. In the absence of a national STS general thoracic surgery database, our case was presented and ultimately won under duress on the basis of data derived from approximately 10 academic general thoracic surgery programs, all from my colleagues who responded to my request for information and help. The personal expenditure of time and energy of the individuals involved in collecting and analyzing these data on more than 8,000 patients going back to 1985 was enormous. But in the end, the STS was able to show convincingly that the basis for its request for increased reimbursement was the increased acuity of our patients (they are older and sicker, e.g. many come to surgery now after chemotherapy and radiation therapy compared with the 1985 population that was the basis for the original RVU reimbursement). The RUC, however, wants data representing "the typical patient", and those undergoing surgery at academic centers are not necessarily typical of national norms. In the future, it is clear that data from a few academic centers will no longer carry the day. Our ability to present ourselves in Washington will be directly related to the strength of data from our National Database, including risk-adjusted morbidity and mortality and actual skin-to-skin operating times from which the "work" we do is calculated.
Finally, there is the crucial role of the STS Database activities in fulfilling an obligation to society and our commitment to excellence in patient care. The 1999 Institute of Medicine report stating that between 45,000 and 95,000 lives a year are lost in the United States as a result of medical errors, has created a firestorm of public and governmental outcry for the profession to insure greater quality in patient care. The assessment of quality begins with data. As usual, the STS is ahead of the curve with its database activities. We have the respect of our peers, HCFA, and insurers because of the credibility and depth of the adult cardiac surgery database. The establishment of the pediatric cardiac and general thoracic surgery databases will reinforce the commitment of the STS to improve patient care delivery. The database offers a scientific basis for quality assurance activities in which outcomes can be compared, a surgeon or center with poorer outcomes identified, and appropriate adjustments instituted to improve results. The database provides a mechanism for national clinical trials to identify optimal methods of care and new technology as is already occurring with our Agency for Health Care Research and Quality (AHRQ)-funded TMR Study. The database addresses many of the recently formulated Institute of Medicine recommendations to redesign and improve care. In the 21st century, participation in the STS National Database activities has become a sign of "good citizenship" for every practicing cardiothoracic surgeon.
I encourage every STS member who has not already done so to contact our headquarters (312-644-6610), 401 N Michigan Ave, Chicago, IL 60611-4267, or e-mail Mary Eikens at (mary_eikens@sba.com) for information on how to participate in the database. The cost is nominal in comparison to the benefit we have derived from our existing database activity. We could not have convinced the RUC and in turn HCFA that reimbursement for many of our cardiothoracic operations should be increased without the availability of data to substantiate our claims of an aging surgical population and one with more comorbid conditions. Despite the fact that our patients are "sicker and older", our data have demonstrated steadily reduced operative morbidity and mortality. All of us – whether in solo or group practices, private or academic practices – need to be a part of the STS database activities. It is fiscally prudent. It addresses responsibly society’s current increased demand for greater patient safety and documentation of efforts to do so and improve care. What better way can we demonstrate that we deserve to be reimbursed because we are doing what the medical profession has been asked to do – and more? Is it not preferable to have our risk-adjusted norms of morbidity and mortality for cardiothoracic surgery become accepted standards and determinants of "quality" rather than an arbitrarily imposed annual number of operations as a surrogate for quality? Every practicing STS member should be participating in the National Database activities. In 2001, we simply cannot afford not to!
References
This article has been cited by other articles:
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  M. E. Porter and E. O. Teisberg How Physicians Can Change the Future of Health Care JAMA, March 14, 2007; 297(10): 1103 - 1111. [Abstract] [Full Text] [PDF]
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 S. Schubert, G. Stoltenburg-Didinger, A. Wehsack, D. Troitzsch, W. Boettcher, M. Huebler, M. Redlin, M. Kanaan, M. Meissler, P. E. Lange, et al. Large-Dose Pretreatment with Methylprednisolone Fails to Attenuate Neuronal Injury After Deep Hypothermic Circulatory Arrest in a Neonatal Piglet Model Anesth. Analg., November 1, 2005; 101(5): 1311 - 1318. [Abstract] [Full Text] [PDF]
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