Publications by authors named "David Shahian"

238 Publications

A Composite Metric for Benchmarking Site Performance in TAVR: Results from the STS/ACC TVT Registry.

Circulation 2021 May 5. Epub 2021 May 5.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, PA.

Transcatheter aortic valve replacement (TAVR) is a transformative therapy for aortic stenosis. Despite rapid improvements in technology and techniques, serious complications remain relatively common and are not well described by single outcome measures. The purpose of this study was to determine if there is site-level variation in TAVR outcomes in the United States using a novel 30-day composite measure. We performed a retrospective cohort study using data from the STS/ACC TVT Registry to develop a novel ranked composite performance measure that incorporates mortality and serious complications. The selection and rank order of the complications for the composite was determined by their adjusted association with 1-year outcomes. Sites whose risk-adjusted outcomes were significantly more or less frequent than the national average based on a 95% probability interval were classified as performing worse or better than expected. The development cohort consisted of 52,561 patients who underwent TAVR between January 1, 2015 and December 31, 2017. Based on the associations with 1-year risk-adjusted mortality and health status, we identified four periprocedural complications to include in the composite risk model in addition to mortality. Ranked empirically according to severity, these included stroke, major, life-threatening or disabling bleeding, stage III acute kidney injury, and moderate or severe peri-valvular regurgitation. Based on these ranked outcomes, we found that there was significant site-level variation in quality of care in TAVR in the United States. Overall, better than expected site performance was observed in 25/301 (8%) of sites; performance as expected was observed in 242/301 sites (80%); and worse than expected performance was observed in 34/301 (11%) of sites. Thirty-day mortality, stroke, major, life-threatening or disabling bleeding, and moderate or severe peri-valvular leak were each substantially more common in sites with worse than expected performance as compared with other sites. There was good aggregate reliability of the model. There are substantial variations in the quality of TAVR care received in the United States, and 11% of sites were identified as providing care below the average level of performance. Further study is necessary to determine structural, process-related, and technical factors associated with high- and low-performing sites.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.051456DOI Listing
May 2021

I-PASS handover system: a decade of evidence demands action.

Authors:
David Shahian

BMJ Qual Saf 2021 Apr 23. Epub 2021 Apr 23.

Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts, USA

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http://dx.doi.org/10.1136/bmjqs-2021-013314DOI Listing
April 2021

Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

Ann Thorac Surg 2021 Apr 9. Epub 2021 Apr 9.

Duke University, Durham, North Carolina.

Background: The STS Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting surgery (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations +/- CABG procedures.

Methods: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database (ACSD) data, risk models for AVR+MVRR (n=31,968) and AVR+MVRR+CABG (n=12,650) were developed with the following endpoints: operative mortality, major morbidity (any one or more of the following: cardiac reoperation; deep sternal wound infection/mediastinitis; stroke; prolonged ventilation; and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 - June 2017, n=35,109) and validation (July 2017 - June 2019, n=9,509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

Results: C-statistics for the overall population of multiple valve +/- CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

Conclusions: New STS-ACSD risk models have been developed for multiple valve +/- CABG operations, and these models will be used in subsequent STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.089DOI Listing
April 2021

Commentary: Failure to rescue: What does it really measure?

J Thorac Cardiovasc Surg 2021 Feb 5. Epub 2021 Feb 5.

Shands Jacksonville, University of Florida College of Medicine Jacksonville, Jacksonville, Fla.

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.129DOI Listing
February 2021

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research.

Ann Thorac Surg 2021 Mar 29. Epub 2021 Mar 29.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.043DOI Listing
March 2021

Updating an Empirically Based Tool for Analyzing Congenital Heart Surgery Mortality.

World J Pediatr Congenit Heart Surg 2021 Mar;12(2):246-281

Duke Clinical Research Institute, 12277Duke University School of Medicine, Durham, NC, USA.

Objectives: STAT Mortality Categories (developed 2009) stratify congenital heart surgery procedures into groups of increasing mortality risk to characterize case mix of congenital heart surgery providers. This update of the STAT Mortality Score and Categories is empirically based for all procedures and reflects contemporary outcomes.

Methods: Cardiovascular surgical operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (January 1, 2010 - June 30, 2017) were analyzed. In this STAT 2020 Update of the STAT Mortality Score and Categories, the risk associated with a specific combination of procedures was estimated under the assumption that risk is determined by the highest risk individual component procedure. Operations composed of multiple component procedures were eligible for unique STAT Scores when the statistically estimated mortality risk differed from that of the highest risk component procedure. Bayesian modeling accounted for small denominators. Risk estimates were rescaled to STAT 2020 Scores between 0.1 and 5.0. STAT 2020 Category assignment was designed to minimize within-category variation and maximize between-category variation.

Results: Among 161,351 operations at 110 centers (19,090 distinct procedure combinations), 235 types of single or multiple component operations received unique STAT 2020 Scores. Assignment to Categories resulted in the following distribution: STAT 2020 Category 1 includes 59 procedure codes with model-based estimated mortality 0.2% to 1.3%; Category 2 includes 73 procedure codes with mortality estimates 1.4% to 2.9%; Category 3 includes 46 procedure codes with mortality estimates 3.0% to 6.8%; Category 4 includes 37 procedure codes with mortality estimates 6.9% to 13.0%; and Category 5 includes 17 procedure codes with mortality estimates 13.5% to 38.7%. The number of procedure codes with empirically derived Scores has grown by 58% (235 in STAT 2020 vs 148 in STAT 2009). Of the 148 procedure codes with empirically derived Scores in 2009, approximately one-half have changed STAT Category relative to 2009 metrics. The New STAT 2020 Scores and Categories demonstrated good discrimination for predicting mortality in an independent validation sample (July 1, 2017-June 30, 2019; sample size 46,933 operations at 108 centers) with C-statistic = 0.791 for STAT 2020 Score and 0.779 for STAT 2020 Category.

Conclusions: The updated STAT metrics reflect contemporary practice and outcomes. New empirically based STAT 2020 Scores and Category designations are assigned to a larger set of procedure codes, while accounting for risk associated with multiple component operations. Updating STAT metrics based on contemporary outcomes facilitates accurate assessment of case mix.
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http://dx.doi.org/10.1177/2150135121991528DOI Listing
March 2021

National Variation in Congenital Heart Surgery Outcomes.

Circulation 2020 Oct 5;142(14):1351-1360. Epub 2020 Oct 5.

Department of Cardiovascular Surgery, Boston Children's Hospital, MA (J.E.M.).

Background: Optimal strategies to improve national congenital heart surgery outcomes and reduce variability across hospitals remain unclear. Many policy and quality improvement efforts have focused primarily on higher-risk patients and mortality alone. Improving our understanding of both morbidity and mortality and current variation across the spectrum of complexity would better inform future efforts.

Methods: Hospitals participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2014-2017) were included. Case mix-adjusted operative mortality, major complications, and postoperative length of stay were evaluated using Bayesian models. Hospital variation was quantified by the interdecile ratio (IDR, upper versus lower 10%) and 95% credible intervals (CrIs). Stratified analyses were performed by risk group (Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT] category) and simulations evaluated the potential impact of reductions in variation.

Results: A total of 102 hospitals (n=84 407) were included, representing ≈85% of US congenital heart programs. STAT category 1 to 3 (lower risk) operations comprised 74% of cases. All outcomes varied significantly across hospitals: adjusted mortality by 3-fold (upper versus lower decile 5.0% versus 1.6%, IDR 3.1 [95% CrI 2.5-3.7]), mean length of stay by 1.8-fold (19.2 versus 10.5 days, IDR 1.8 [95% CrI 1.8-1.9]), and major complications by >3-fold (23.5% versus 7.0%, IDR 3.4 [95% CrI 3.0-3.8]). The degree of variation was similar or greater for low- versus high-risk cases across outcomes, eg, ≈3-fold mortality variation across hospitals for STAT 1 to 3 (IDR 3.0 [95% CrI 2.1-4.2]) and STAT 4 or 5 (IDR 3.1 [95% CrI 2.4-3.9]) cases. High-volume hospitals had less variability across outcomes and risk categories. Simulations suggested potential reductions in deaths (n=282), major complications (n=1539), and length of stay (101 183 days) over the 4-year study period if all hospitals were to perform at the current median or better, with 37% to 60% of the improvement related to the STAT 1 to 3 (lower risk) group across outcomes.

Conclusions: We demonstrate significant hospital variation in morbidity and mortality after congenital heart surgery. Contrary to traditional thinking, a substantial portion of potential improvements that could be realized on a national scale were related to variability among lower-risk cases. These findings suggest modifications to our current approaches to optimize care and outcomes in this population are needed.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.046962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539149PMC
October 2020

Commentary: Machine learning and cardiac surgery risk prediction.

J Thorac Cardiovasc Surg 2020 Aug 24. Epub 2020 Aug 24.

Massachusetts Institute of Technology Lincoln Laboratory, Lexington, Mass.

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http://dx.doi.org/10.1016/j.jtcvs.2020.08.058DOI Listing
August 2020

Commentary: Safety in numbers.

Authors:
David M Shahian

J Thorac Cardiovasc Surg 2021 03 22;161(3):1043-1045. Epub 2020 Jul 22.

Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass; Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.058DOI Listing
March 2021

Expert Consensus on Currently Accepted Measures of Harm.

J Patient Saf 2020 Aug 5. Epub 2020 Aug 5.

From the *Division of Nephrology, Massachusetts General Hospital †Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital ‡Harvard Medical School §Division of Pulmonary and Critical Care, Massachusetts General Hospital ∥Department of Quality and Safety ¶Division of General Internal Medicine, Brigham and Women's Hospital, Boston **Division of General Internal Medicine, Mt Auburn Hospital, Cambridge ††Risk Management Foundation of the Harvard Medical Institutions (CRICO) ‡‡Clinical and Quality Analysis, Mass General Brigham §§Department of Surgery, Massachusetts General Hospital ∥∥Harvard T. H. Chan School of Public Health ¶¶Division of Internal Medicine, Massachusetts General Hospital ***Department of Health Care Policy, Harvard Medical School, Boston, MA.

Background: Twenty-five years after the seminal work of the Harvard Medical Practice Study, the numbers and specific types of health care measures of harm have evolved and expanded. Using the World Café method to derive expert consensus, we sought to generate a contemporary list of triggers and adverse event measures that could be used for chart review to determine the current incidence of inpatient and outpatient adverse events.

Methods: We held a modified World Café event in March 2018, during which content experts were divided into 10 tables by clinical domain. After a focused discussion of a prepopulated list of literature-based triggers and measures relevant to that domain, they were asked to rate each measure on clinical importance and suitability for chart review and electronic extraction (very low, low, medium, high, very high).

Results: Seventy-one experts from 9 diverse institutions attended (primary acceptance rate, 72%). Of 525 total triggers and measures, 67% of 391 measures and 46% of 134 triggers were deemed to have high or very high clinical importance. For those triggers and measures with high or very high clinical importance, 218 overall were deemed to be highly amenable to chart review and 198 overall were deemed to be suitable for electronic surveillance.

Conclusions: The World Café method effectively prioritized measures/triggers of high clinical importance including those that can be used in chart review, which is considered the gold standard. A future goal is to validate these measures using electronic surveillance mechanisms to decrease the need for chart review.
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http://dx.doi.org/10.1097/PTS.0000000000000754DOI Listing
August 2020

Volume-Outcome Association of Mitral Valve Surgery in the United States.

JAMA Cardiol 2020 Oct;5(10):1092-1101

Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston.

Importance: Early surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking.

Objective: To assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation.

Design, Setting, And Participants: This multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services.

Main Outcomes And Measures: The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure.

Results: A total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50).

Conclusions And Relevance: National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.
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http://dx.doi.org/10.1001/jamacardio.2020.2221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330833PMC
October 2020

Interdisciplinary Patient Tracers: Routine, Systematic Safety Surveillance.

Am J Med Qual 2021 Jan-Feb 01;36(1):28-35

Massachusetts General Hospital, Boston, MA Harvard Medical School, Boston, MA.

Patient tracers and leadership WalkRounds proactively identify quality and safety issues. However, these programs have been inconsistent in application, results, and sustainability. The goal was to identify a more consistent and efficient approach to survey health care facilities. The authors developed a Peer-to-Peer Interdisciplinary Patient Tracer program to assess compliance with National Patient Safety Goals and to proactively identify areas of inpatient, ambulatory, and procedural risk. The program has been operational for more than 5 years, with continued expansion annually. In all, 96% of frontline leadership reported satisfaction; 100% reported that they would recommend the program to others (Kirkpatrick level 1 results). Mean absolute change in performance scores from 2014 to 2018 was 15%. All survey findings triggered the development of an improvement project. This novel integrated program advanced institutional improvement by strengthening internal peer-to-peer surveillance, engaging leadership, and creating an accountability structure for internal improvement efforts.
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http://dx.doi.org/10.1177/1062860620929306DOI Listing
June 2020

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2020 Update on Outcomes and Research.

Ann Thorac Surg 2020 06 2;109(6):1646-1655. Epub 2020 Apr 2.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive database in cardiac surgery and one of the most respected clinical data registries in health care. It is widely acknowledged for accurately benchmarking risk-adjusted outcomes and serving as the foundation for quality measurement and improvement activities in cardiac surgery. In addition, the database is a valuable resource for novel research. The advent of the database's fourth decade in operation is being heralded with major revisions to its functionality, ease of use, and value to multiple stakeholders. This report is the fifth in a series of annual reports that provides updated national outcomes, volume trends, and database-related developments, as well as a summary of research performed in the past year using data from this valuable repository on quality and performance improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2020.03.003DOI Listing
June 2020

Surgeons: Buyer beware-does "universal" risk prediction model apply to patients universally?

J Thorac Cardiovasc Surg 2020 Jul 19;160(1):176-179.e2. Epub 2020 Feb 19.

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Department of Health Policy and Management, Yale School of Public Health, New Haven, Conn. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.11.144DOI Listing
July 2020

Estimating Resource Utilization in Congenital Heart Surgery.

Ann Thorac Surg 2020 09 24;110(3):962-968. Epub 2020 Feb 24.

Saint Petersburg, Florida.

Background: Optimal methods to assess resource utilization in congenital heart surgery remain unclear. We compared traditional cost-to-charge ratio methods with newer standardized cost methods that aim to more directly assess resources consumed.

Methods: Clinical data from The Society of Thoracic Surgeons Database were linked with resource use data from the Pediatric Health Information Systems Database (2010 to 2015). Standardized cost methods specific to the congenital heart surgery population were developed and compared with cost-to-charge ratio methods. Resource use in the overall population and variability across hospitals were described using hierarchical mixed effect models adjusting for case-mix.

Results: Overall, 43 hospitals (65,331 patients) were included. There were minimal population-level differences in the distribution of resource use as estimated by the two methods. At the hospital level, there was less apparent variability in resource use across centers with the standardized cost vs cost-to-charge ratio method, overall (coefficient of variation 20% vs 25%) and across complexity (The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT]) categories. When hospitals were categorized into tertiles by resource use, 33% changed classification depending on which resource use method was used (26% by one tertile and 7% by two tertiles).

Conclusions: In this first evaluation of standardized cost methodology in the congenital heart population, we found minimal differences vs traditional methods at the population level. At the hospital level, the magnitude of variation in resource use was less with standardized cost methods, and approximately one third of centers changed resource use categories depending on the methodology used. Because of these differences, care should be taken in future studies and in benchmarking and reporting efforts in selecting optimal methodology.
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http://dx.doi.org/10.1016/j.athoracsur.2020.01.013DOI Listing
September 2020

Concomitant carotid endarterectomy and cardiac surgery does not decrease postoperative stroke rates.

J Vasc Surg 2020 08 14;72(2):589-596.e3. Epub 2020 Feb 14.

Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass.

Objective: The timing of operative revascularization for patients with concomitant carotid artery stenosis and coronary artery disease remains controversial. We examined the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to evaluate the association of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with postoperative outcomes.

Methods: All patients undergoing CABG with known carotid stenosis of >80% were identified from 2011 to 2016. Individuals were stratified by use of cardiopulmonary bypass and whether a concomitant CEA was performed at the time of CABG. Multivariate logistic regression was used to model the probability of combined CABG and CEA. The resulting propensity scores were used to match individuals on the basis of clinical and operative characteristics to evaluate primary (30-day mortality and in-hospital transient ischemic attack and stroke) and secondary (STS morbidity composite events and length of stay) end points, with P < .05 required to declare statistical significance.

Results: After propensity score matching, 994 off-pump CABG patients (497 CABG only and 497 CABG-CEA) and 5952 on-pump CABG patients (2976 CABG only and 2976 CABG-CEA) were identified. For patients who received on-pump operations, those undergoing CABG-CEA had no observed difference in rate of in-hospital stroke (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.72-1.21; P = .6), higher incidence of STS morbidity composite events (OR, 1.15, 95% CI, 1.01-1.31; P = .03), longer length of stay (7.0 [interquartile range, 5.0-9.0] days vs 6.0 [interquartile range, 5.0-9.0] days; P < .005), and no observed difference in 30-day mortality (OR, 1.28; 95% CI, 0.97-1.69; P = .08) compared with those undergoing CABG only. For off-pump procedures, CABG-CEA patients had no observed difference in rate of in-hospital stroke (OR, 0.80; 95% CI, 0.37-1.69; P = .56) compared with those undergoing CABG only.

Conclusions: Whereas the differences are relatively small, these data suggest that a combined CABG-CEA approach is unlikely to provide significant stroke reduction benefit compared with CABG only. However, comparison with staged approaches merits further investigation.
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http://dx.doi.org/10.1016/j.jvs.2019.10.072DOI Listing
August 2020

Improving cardiac surgical quality: lessons from the Japanese experience.

Authors:
David Shahian

BMJ Qual Saf 2020 07 3;29(7):531-535. Epub 2020 Feb 3.

Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

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http://dx.doi.org/10.1136/bmjqs-2019-010125DOI Listing
July 2020

The association of hospital teaching intensity with 30-day postdischarge heart failure readmission and mortality rates.

Health Serv Res 2020 04 9;55(2):259-272. Epub 2020 Jan 9.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Objective: To investigate risk-adjusted, 30-day postdischarge heart failure mortality and readmission rates stratified by hospital teaching intensity.

Data Sources And Study Setting: A total of 709 221 Medicare fee-for-service beneficiaries discharged from 3135 US hospitals between 1/1/2013 and 11/30/2014 with a principal diagnosis of heart failure.

Study Design: Hospitals were classified as Council of Teaching Hospitals and Health Systems (COTH) major teaching hospitals, non-COTH teaching hospitals, and nonteaching hospitals. Hospital teaching status was linked with MedPAR patient data and FY2016 Hospital Readmission Reduction Program penalties. Index hospitalization survival probabilities were estimated with hierarchical logistic regression and used to stratify index hospitalization survivors into severity deciles. Decile-specific models were estimated for 30-day postdischarge readmission and mortality. Thirty-day postdischarge outcomes were estimated by teaching intensity and penalty categories.

Principal Findings: Averaged across deciles, adjusted 30-day COTH hospital readmission rates were, on a relative scale ([COTH minus nonteaching] ÷ nonteaching), 1.63 percent higher (95% CI: 0.89 percent, 2.25 percent) than at nonteaching hospitals, but their average adjusted 30-day postdischarge mortality rates were 11.55 percent lower (95% CI: -13.78 percent, -9.37 percent). Penalized COTH hospitals had the highest readmission rates of all categories (23.99 percent [95% CI: 23.50 percent, 24.49 percent]) but the lowest 30-day postdischarge mortality (8.30 percent [95% CI: 7.99 percent, 8.57 percent] vs 9.84 percent [95% CI: 9.69 percent, 9.99 percent] for nonpenalized, nonteaching hospitals).

Conclusions: Heart failure readmission penalties disproportionately impact major teaching hospitals and inadequately credit their better postdischarge survival.
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http://dx.doi.org/10.1111/1475-6773.13248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080393PMC
April 2020

Making the Case for Teaching Hospitals: Evolving Metrics and Methodologies.

Authors:
David M Shahian

Ann Surg 2020 03;271(3):422-424

Department of Surgery, Division of Cardiac Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1097/SLA.0000000000003758DOI Listing
March 2020

The Society of Thoracic Surgeons Composite Score Rating for Pulmonary Resection for Lung Cancer.

Ann Thorac Surg 2020 03 2;109(3):848-855. Epub 2019 Nov 2.

Department of Surgery, Washington University School of Medicine, St Louis, Missouri.

Background: The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has developed composite quality measures for lobectomy and esophagectomy. This study sought to develop a composite measure including all resections for lung cancer.

Methods: The STS lung cancer composite score is based on 2 outcomes: risk-adjusted mortality and morbidity. GTSD data were included from January 2015 to December 2017. "Star ratings" were created for centers with 30 or more cases by using 95% Bayesian credible intervals. The Bayesian model was performed with and without inclusion of the minimally invasive approach to assess the impact of approach on the composite measure.

Results: The study population included 38,461 patients from 256 centers. Overall operative mortality was 1.3% (495 of 38,461). The major complication rate was 7.9% (3045 of 38,461). The median number of nodes examined was 10 (interquartile range, 5 to 16); the median number of nodal stations sampled was 4 (interquartile range, 3 to 5). Positive resection margins were identified in 3.7% (1420 of 38,461). A total of 214 centers with 30 or more cases were assigned star ratings. There were 7 1-star, 194 2-star, and 13 3-star programs; 70.6% of resections were performed through a minimally invasive approach. Inclusion of minimally invasive approach, which was adjusted for in previous models, altered the star ratings for 3% (6 of 214) of the programs.

Conclusions: Participants in the STS GTSD perform lung cancer resection with low morbidity and mortality. Lymph node data suggest that participants are meeting contemporary staging standards. There is wide variability among participants in application of minimally invasive approaches. The study found that risk adjustment for approach altered ratings in 3% of participants.
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http://dx.doi.org/10.1016/j.athoracsur.2019.08.114DOI Listing
March 2020

The Society of Thoracic Surgeons National Database 2019 Annual Report.

Ann Thorac Surg 2019 12 22;108(6):1625-1632. Epub 2019 Oct 22.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety for cardiothoracic surgery. The STS National Database has 4 components, each focusing on a distinct discipline-Adult Cardiac Surgery, General Thoracic Surgery, Congenital Heart Surgery, and mechanical circulatory support with the STS Interagency Registry for Mechanical Circulatory Support (Intermacs)/Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides the fourth annual summary of the status of the STS National Database.
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http://dx.doi.org/10.1016/j.athoracsur.2019.09.034DOI Listing
December 2019

The Use and Misuse of Indirectly Standardized, Risk-Adjusted Outcomes and Star Ratings.

Ann Thorac Surg 2020 05 8;109(5):1319-1322. Epub 2019 Oct 8.

Duke Clinical Research Institute, Duke University, Durham, North Carolina.

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http://dx.doi.org/10.1016/j.athoracsur.2019.09.010DOI Listing
May 2020

Invited Commentary.

Authors:
David M Shahian

Ann Thorac Surg 2020 05 30;109(5):1407-1408. Epub 2019 Sep 30.

Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Bulfinch 284, 55 Fruit St, Boston, MA 02114. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2019.08.070DOI Listing
May 2020

Discussion.

J Thorac Cardiovasc Surg 2020 Aug 19;160(2):431-432. Epub 2019 Sep 19.

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http://dx.doi.org/10.1016/j.jtcvs.2019.06.107DOI Listing
August 2020

First Database Comparison Between the United States and Japan: Coronary Artery Bypass Grafting.

Ann Thorac Surg 2020 04 17;109(4):1159-1164. Epub 2019 Sep 17.

Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.

Background: International collaboration has an interest in health care quality evaluation. We compared characteristics and surgical outcomes between Asian patients in the United States and Japanese patients who undergo adult cardiac surgery.

Methods: Using the Japan Adult Cardiovascular Surgery Database (JCVSD) and The Society of Thoracic Surgeons (STS) National Database, we compared Asian patients undergoing isolated coronary artery bypass graft surgery between 2013 and 2016 in Japan and the United States. The STS had 16,903 Asian patients among 573,823 patients of all races undergoing isolated coronary artery bypass graft surgery (2.95%); the JCVSD had 55,570 patients, almost all of whom are Japanese. Descriptive statistics were analyzed independently, then the data were aggregated for comparison.

Results: The JCVSD patients were older (69 vs 65 years) with a smaller body surface area (1.65 m vs 1.81 m) and body mass index (24 kg/m vs 26 kg/m). The proportion of males (79% vs 78%), prevalence of chronic lung disease (82% vs 86%), and diabetes mellitus (54% vs 60%) were similar. The JCVSD had higher prevalence of renal disease requiring dialysis (11% vs 6%). The numbers of anastomoses were similar (3.1 vs 3.3); off-pump procedures and the usage of right internal mammary artery were more prevalent (60% vs 15% and 38% vs 7%, respectively) in the JCVSD. The unadjusted operative mortality was 2.7% in the JCVSD and 2.1% in the STS database.

Conclusions: Comparisons of coronary artery bypass graft surgery characteristics and outcomes were conducted between the STS National Database and the JCVSD to illustrate the value of international collaboration on adult cardiac surgery databases.
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http://dx.doi.org/10.1016/j.athoracsur.2019.07.095DOI Listing
April 2020

The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2019 Update on Research.

Ann Thorac Surg 2019 09 20;108(3):671-679. Epub 2019 Jul 20.

Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.

As the largest congenital and pediatric cardiac surgical clinical data registry in the world, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) serves as a platform for reporting of outcomes and for quality improvement. In addition, it is an important source of data for clinical research and for innovations related to quality measurement. Each year, several teams of investigators undertake analyses of data in the STS CHSD pertaining to the surgical management of specific diagnostic and procedural groups, or to specific processes of care, and their associations with patient characteristics and outcomes across centers participating in the STS CHSD. Additional ongoing projects involve the development of new or refined metrics for quality measurement and reporting of outcomes and center-level performance. The STS, through its Workforce for National Databases and the STS Research Center and Workforce on Research Development provides multiple pathways through which investigators may propose and perform outcomes research projects based on STS CHSD data. This report reviews research published within the past year.
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http://dx.doi.org/10.1016/j.athoracsur.2019.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8104073PMC
September 2019

Commentary: Driving improvement.

Authors:
David M Shahian

J Thorac Cardiovasc Surg 2020 05 30;159(5):1794-1795. Epub 2019 May 30.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.05.025DOI Listing
May 2020