Public reporting for coronary artery bypass graft surgery: The quest for the optimal scorecard.

OBJECTIVE: A number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices. METHODS: Composite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. News & World Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for Medicare & Medicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated. RESULTS: Correlations between Society of Thoracic Surgeons star rating and U.S. News & World Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for Medicare & Medicaid Services 30-day mortality (r = -0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. News & World Report CABG ratings (r = 0.33) and with Centers for Medicare & Medicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed. CONCLUSIONS: Correlations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center's clinical practice and to better inform patients.

POSSUM, p-POSSUM, and Cr-POSSUM: implementation issues in a United States health care system for prediction of outcome for colon cancer resection.

PURPOSE: The Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM), Portsmouth revision (p)-POSSUM, and colorectal (Cr)-POSSUM scoring systems were developed as audit tools for comparing outcomes in surgical and colorectal patients on the basis of operative risk assessment. The aim of this study was to evaluate the applicability of these systems to a cohort of colon cancer patients undergoing surgery in the United States. METHODS: POSSUM factors from 890 consecutive patients undergoing major surgical procedures for colon cancer in nine United States hospitals over a two-year period from January 2000 through December 2001 were prospectively collected. The observed over the expected hospital mortality was compared by means of the POSSUM, p-POSSUM, and Cr-POSSUM scoring systems. The effect of missing data on the utility of this process for outcome assessment was assessed with three methods for data imputation. RESULTS: The number of resections per institution ranged from 13 to 437. The observed mortality rate ranged from 0.8 percent to 15.4 percent among the institutions, with an overall operative mortality of 2.3 percent. The POSSUM, p-POSSUM, and Cr-POSSUM predicted mortality was 10.7 percent, 11.2 percent, and 4.9 percent, respectively. The POSSUM and p-POSSUM models overpredicted mortality in all institutions ( P < 0.01), whereas the Cr-POSSUM demonstrated an observed over expected hospital mortality ratio of >1 in three institutions. The calculations were unaffected by the various methods of inserting missing data. CONCLUSION: An apparent overprediction of mortality for colon cancer resection was evident with all three POSSUM variants. This implies that a calibration process is required for use of these variants in the United States health care system. Missing data may be treated as normal values without influencing outcome. The Cr-POSSUM appeared to be the most promising audit tool for colorectal cancer surgery; however, it will require further refinement to provide process control graphs for identification of potential outliers and improvement in the quality of care in the United States.

Introducing the quality Institute of the Cleveland Clinic Health System.

Several quality measurement needs surfaced when the Cleveland Clinic Health System (CCHS) was formed, including a need for standardized measurement of clinical processes and outcomes, patient satisfaction, critical care, and patient safety. The Quality Institute (QI) facilitates system teams to address these issues, manages selection of measurement tools, collects and analyzes performance data, coordinates presentations, and presents team findings. The QI manages the CCHS performance improvement plan and coordinates activities designed to accomplish priority goals, in collaboration with multiple CCHS teams and the regional and hospital staffs. The most important outcome of the QI's operations is improved care, as demonstrated through objective measurement. Other outcomes include external recognition and funding; implementation of standardized measurement systems, data management activities, and production of quarterly reports; increased internal recognition; completion of several education programs; acceptance of data by payers and plans; and participation in attainment of Joint Commission on Accreditation of Healthcare Organizations network accreditation.