The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes

The Society of Cardiovascular Anesthesiologists (SCA) developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database (ACSD) in collaboration with The Society of Thoracic Surgeons (STS) as an essential step toward improving clinical care and demonstrating value of cardiac surgical team effort in the present era of value-based care reimbursement models. 1 SCA leadership recognized that a well-designed, comprehensive, accurate, and accessible global registry would identify critical factors that contribute to safe and high-quality care of cardiac surgical patients. Such a registry would provide data to evaluate anesthetic techniques and their relationship to patient outcomes, thereby informing research efforts and establishing a foundation to define quality of care in cardiac anesthesiology, in connection with thoughtful management and cost containment. The first STS collaboration with anesthesiologists began in 2010 and was focused on patients enrolled in the STS Congenital Heart Surgery Database in conjunction with the Congenital Cardiac Anesthesia Society. 2, 3 More recently, from 2015 until 2018, data from adult patients undergoing cardiac surgical procedures has been contributed to the Adult Cardiac Anesthesiology Section of the STS ACSD, with the goal of providing multiinstitutional contemporary information regarding clinical practices, quality measures, and patient outcomes related to the management of cardiothoracic anesthesiology in these patients. Current and future research opportunities are also emphasized. As of December 2019, 1088 groups comprising 3036 surgeons from all 50 states in the United States (US) participate in the Adult Cardiac Surgery Section of the STS Database, and of these, only 70 groups encompassing 797 anesthesiologists participate in the optional STS/SCA Adult Cardiac Anesthesiology Section. Participant institutions and their locations are presented4 in Supplemental Digital Content, Table 1, https: //links. lww. com/AA/D164. Given the STS ACSD workflow for data harvest and processing, the data presented and reviewed here were collected between 2015 and 2018. Historical Perspective The Institute of Healthcare Improvement summarizes the contemporary goals for health care as a triple aim that includes "improving the experience of care, improving the health of populations, and reducing the per-capita cost of health care. "5 Many stakeholders in the process, including patients, clinicians, multidisciplinary providers, health plans, institutions, and government agencies, share these goals at varying levels and are the ultimate drivers of health care. Indeed, the concept of "value-based health care" was proposed as a comprehensive path that would align the objectives and performance of all parties involved toward improvement of the patients' health outcomes and experience. 6 "Value" in health care is determined by measuring the improvement in a specific patient's outcome relative to the cost incurred during the process. 5–7 Within this framework, to develop solutions that meet the needs of cardiac surgical patients, the aim of the STS and SCA collaboration is to collect data that allows measurement of "value" in specific health outcomes of cardiac surgical patients. However, the purpose of this collaboration is not to capture actual financial or cost data relative to surgical and anesthesia care because this information is subject to frequent changes and regulations. The creation of an optional Adult Cardiac Anesthesiology Section within the STS ACSD intended to capture data elements needed to address the influence of cardiac anesthesiologists' involvement on patient outcomes. 8 Furthermore, a group of data fields in this optional section documents cardiopulmonary bypass (CPB) management techniques looking to determine potential interactions between anesthetic and clinical perfusion management. 9 Participants in the Adult Cardiac Anesthesiology Section could be compared with expected, risk-adjusted benchmarks developed using STS ACDS data to create ratings similar to those provided by STS to surgical programs. Overview of Quality and Outcomes Metrics Many quality-of-care measures have been developed in recent decades. The initial intent of such indicators was to develop quality improvement processes that would address specific institutional or departmental deficiencies identified by external reviewers or regulatory bodies. The first institution that developed standards for health care organizations in the US was the Joint Commission on Accreditation of Hospitals, now known as The Joint Commission. Later, the Social Security Amendment Act allowed participation in Medicare and Medicaid to hospitals accredited by the Joint Commission on Accreditation of Hospitals https: //www. jointcommission. org/-/media/tjc/documents/about-us/tjc-history-timeline-through-2019-pdf. pdf, accessed January 28, 2020. The Centers for Medicare and Medicaid Services (CMS) began releasing unadjusted clinical outcome data to the public in 1986. 10 More recently, the Physician Quality Reporting Initiative program by CMS offered incentives to institutions that reported compliance with specific, standardized, and evidence-based supported quality measures. In 2010, the Affordable Care Act introduced penalties for institutions or providers that did not submit qualifying Physician Quality Reporting Initiative data. Now, all CMS-developed quality measurement indicators are included in the Merit-Based Incentive Payment System (MIPS). These measures are revised and updated annually. 11 Another organization, the not-for-profit National Quality Forum (NQF), defines best measures and practices in health care. The federal government and many public and private organizations rely on NQF-endorsed measures and recommendations for determination of accountability, public reporting, and incentive programs http: //www. qualityforum. org/whatwedo. aspx, accessed January 29, 2020. As a leader in patient safety and a major contributor to improving perioperative safe practices and outcomes, the American Society of Anesthesiologists responded to the need for continued improvement in quality of care and patient safety by establishing the Anesthesia Quality Institute (AQI). In turn, the AQI implemented the National Anesthesia Clinical Outcomes Registry as a source of quality data for specific benchmarking in anesthesiology https: //www. aqihq. org/about-us. aspx, accessed January 29, 2020. Under the conceptual model of perioperative medicine, the performance of surgeons and anesthesiologists, as well as patient-specific and system factors, are all interrelated in determining eventual patient outcome results. 12, 13 The SCA/STS collaboration through the Adult Cardiac Anesthesiology Section of the STS ACSD is a major development in the emerging concept of "shared accountability"14 regarding perioperative outcomes in surgical patients. In this context, increased Adult Cardiac Anesthesiology Section participation along with collaborative and comprehensive analysis of the global STS ACSD "cardiac team"—as opposed to separate professional groups analysis—could yield further evidence regarding the influence of different practice patterns on patient groups' outcomes. Importantly, the Adult Cardiac Anesthesiology Section and STS ACSD data fields are adjusted and upgraded every 3 years. This process guarantees that changes and developments in the field are continuously captured and represented. Quality and Outcome Indicators Relevant to Cardiac Surgery and Anesthesiology Practice The specific measures relevant to cardiothoracic anesthesiology and surgery and the regulatory organizations endorsing them are described in detail in Supplemental Digital Content, Tables 2–4, https: //links. lww. com/AA/D164. Some measures with the same or similar definitions are endorsed or required, or both, for reporting by different regulatory bodies. Thus, there is significant overlap, as summarized in detail in Supplemental Digital Content, Tables 2–4, https: //links. lww. com/AA/D164. Specific measures and overlapping endorsement are demonstrated graphically in Figure 1. Figure 1.: Shared performance and outcome measures relevant to cardiothoracic surgery and anesthesia. The Figure depicts the relationship and overlap between measures and outcomes as required by several regulatory organizations. The measures are shown as specified by each organization. AQI indicates Anesthesia Quality Institute; MIPS, Merit-Based Incentive Payment System; NQF, National Quality Forum; SCA, Society of Cardiovascular Anesthesiologists; STS, The Society of Thoracic Surgeons. The MIPS and NQF measures relevant to cardiothoracic anesthesiologists are focused on specific practice processes and outcomes measures widely supported by the literature (Supplemental Digital Content, Tables 2–3, https: //links. lww. com/AA/D164). In addition to these measures, the AQI/National Anesthesia Clinical Outcomes Registry specifically monitors processes well associated with quality in cardiac surgery and anesthesia, as outlined in Supplemental Digital Content, Table 4, https: //links. lww. com/AA/D164. In combination, the Adult Cardiac Anesthesiology Section and the STS ACSD include an extensive and comprehensive group of data points that cover the requirements set by all previously mentioned regulatory and quality organizations (these variables are detailed in Supplemental Digital Content, Table 5, https: //links. lww. com/AA/D164). This fact greatly facilitates the standardization of reporting for participant institutions. Furthermore, the use of multiple data fields and availability of some continuous variables represents a significant advantage over other indicators, not only to evaluate the differential impact of particular interventions but also to assess the contribution of specific patterns of anesthesiology practice to cardiac surgical patients' outcomes. Finally, the Adult Cardiac Anesthesiology Section of the STS ACSD represents a highly valuable resource for the generation of high-impact research and determination of positive value-based practices in cardiac anesthesiology. Specific data field sections and the reasons for their required reporting and inclusion in this review are described in the following sections. Anesthesia Care Team Model The frequency of different anesthesia care team models reported between 2015 and 2018 is represented in Figure 2. These data are captured in the Adult Cardiac Anesthesiology Section of the STS ACSD. The most common team model is "anesthesiologist working alone" (~46%–56%), followed by "attending anesthesiologist teaching/medically directing fellow" (~18%–27%) and "attending anesthesiologist teaching/medically directing certified registered nurse anesthetists (CRNA) " (12%–18%). The predominant frequencies reported may represent differences in team composition between private and academic institutions. Figure 2.: Anesthesia care team model between 2015 and 2018. The frequencies reported here were based on the number of cases for which the data point was available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons' Adult Cardiac Surgery Database each year. CRNA indicates certified registered nurse anesthetist. Composition of the anesthesia care team varies and depends on national and state regulations as well as institutional policies. Anesthetic care in the US is typically provided by an anesthesiologist working alone or a team consisting of an anesthesiologist supervising other physicians (eg, those in anesthesiology graduate medical programs) or nonphysician providers, such as CRNAs or certified anesthesiology assistants. The American Society of Anesthesiologists' statement on the anesthesia care team established "anesthesia care is personally provided, directed and/or supervised by the physician anesthesiologist" (https: //www. asahq. org/-/media/sites/asahq/files/public/resources/standards-guidelines/statement-on-the-anesthesia-care-team. pdf? la=en SCA, Society of Cardiovascular Anesthesiologists. Ample evidence supports the negative impact of allogenic blood products transfusion on postoperative outcomes in cardiac surgical patients. Despite a notable trend toward decreasing the frequency of blood transfusions, the proportion of patients who receive a transfusion is still significant (~30% in the lowest-risk procedures and ~80% for highest-risk categories). 24 Limiting blood transfusions requires a multifaceted approach that includes reducing blood loss, minimizing hemodilution, and optimizing targeted coagulopathy management. A of such an approach is the use of to blood and transfusion A recent and that tranexamic acid significantly decreased blood loss, blood and proportion of patients a with no significant negative impact on acid postoperative and blood products but studies reporting the of acid and tranexamic acid have shown conflicting studies with tranexamic acid with a safety A recent prospective suggested between tranexamic acid and with a advantage to tranexamic reducing more transfusions specifically in CABG of the are to blood during cardiac operations with is associated not only with and postoperative and transfusion but also the of significant with negative outcomes, including increased risk of cardiac at reducing several clinical perfusion practices during including using and In a recent prospective the use of a set of techniques decreased and was associated with postoperative transfusion A prospective and a that reduces blood transfusions and specific in cardiac surgical patients, but a recent retrospective analysis of a large of such patients from hospitals did not a significant effect on postoperative transfusion to into Despite the effect of and decreasing the of some studies an between increased and increased risk of The effect of on cardiac surgical outcomes requires further results regarding use are more reduces blood products transfusion used during the Finally, the use of blood transfusion that has been the subject of recent A demonstrated the use of such algorithm in frequency of blood and transfusion in addition to major In collaboration with other SCA developed based on including a Clinical Practice Improvement for management of perioperative and in cardiac surgical and practice on management during Use of large-scale data from the STS ACSD and the Adult Cardiac Anesthesiology Section be to define the best perioperative blood management practices to outcomes for specific populations or in patients with different risk Perioperative and outcome measures are represented in the Adult Cardiac Anesthesiology Section of the STS ACSD by data elements provided in Supplemental Digital Content, Table 5, https: //links. lww. com/AA/D164. The frequency and of preoperative and postoperative are shown in Figure patients present no However, only of patients are on postoperative 3 and at In a proportion of patients reported of to at Frequency and of preoperative and postoperative are shown based on the to and the frequency of patients a on postoperative 3 and at from all patients reported between 2015 and 2018. The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons' Adult Cardiac Surgery in management is For the of management in cardiac surgical patients has been However, have been as potential contributors to the development of postoperative and In the incidence of a of and may be and the cardiac surgical is A recent study found that compared with use of during cardiac operations was associated with increased postoperative and requirements until 3 after surgery but did not affect postoperative at techniques may provide with for and postoperative administration of has been shown to postoperative in cardiac surgical research included the of postoperative and the development of after cardiac surgical procedures or based on techniques are to not only evaluate their but also to determine potential benefits for postoperative and A clinical and found consistent in and requirements with More studies are required to the safety and impact of these techniques on patient after cardiac surgery to minimizing requirements and to management and are major of patient a main goal of and Further analysis of frequency and would define the future of and from the STS ACSD and the Adult Cardiac Anesthesiology Section be to define the best perioperative management practices for cardiac surgical patients. management in of for are captured by several fields of the Adult Cardiac Anesthesiology Section of the STS ACSD, as provided in Supplemental Digital Content, Table 5, https: //links. lww. com/AA/D164. Figure and Supplemental Digital Content, Table 6, https: //links. lww. com/AA/D164, represent the of use for different of measurement and compliance with measurement care between 2015 and 2018. These data that over the the frequency of measurement whereas the frequency of measurement The reasons for and possible influence of such practice patterns on patient outcomes are not this as a potential field of future Frequency of source and compliance with measurement care between 2015 and 2018. The use of different for measurement and the of compliance with measurement are The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons' Adult Cardiac Surgery Database. For more details see Supplemental Digital Content, Table 6, and postoperative have a significant influence on several major outcomes after cardiac including increased death is associated with postoperative and is common and also has been associated with increased are particular between and increased postoperative and surgical in different patient A large retrospective suggested that within the first 24 hours may Therefore, of and management of are measures included as of recent for postoperative care of cardiac surgical and of Although studies to the impact of management on different and remains particular management is a shared between clinical perfusion and anesthesiology teams working in conjunction with the surgical from the STS ACSD and the Adult Cardiac Anesthesiology Section be to define perioperative management Anesthetic and Outcomes in Cardiac Surgery The use of specific anesthetic and their possible are represented by multiple data as described in Supplemental Digital Content, Table 5, https: //links. lww. com/AA/D164. The frequencies of anesthetic and used are presented in Figure and Supplemental Digital Content, Table 6, https: //links. lww. com/AA/D164. is an increasing trend for and postoperative and administration compared with A better understanding of how these trends in administration of anesthetic may impact postoperative outcomes future Frequency of anesthetic use between 2015 and 2018. The Figure depicts a of and postoperative use of and and use of anesthetic The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons' Adult Cardiac Surgery Database. For more details see Supplemental Digital Content, Table 6, of different anesthetic on clinical and postoperative outcomes in adult cardiac surgical patients are not well For more a several clinical studies and vs other for of anesthesia have provided The most published review that used in a of cardiac surgical procedures with were associated with mortality and indicators of compared with Nonetheless, a 2019 review and that included only patients undergoing cardiac valvular procedures demonstrated similar and major with use of vs A better understanding of how of anesthetic may impact postoperative outcomes is using data from the Adult Cardiac Anesthesiology Section and the STS ACSD to address this in of patients with specific risk factors (eg, could yield more consistent Use of the Adult Cardiac Anesthesiology Section and STS ACSD data is for large-scale studies to better define which anesthetic and interventions may or and other outcomes. The of postoperative is captured in the Adult Cardiac Anesthesiology Section of the STS ACSD (Supplemental Digital Content, Table 5, https: //links. lww. com/AA/D164). The frequency of postoperative reported from 2015 to 2018 was approximately to and mortality between 2015 and 2018 to of surgical the incidence of postoperative between of The of and mortality The of prolonged ventilation and renal is The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons' Adult Cardiac Surgery Database. For more details see Supplemental Digital Content, Table 7, https: //links. lww. com/AA/D164. indicates coronary artery bypass grafting undergoing cardiac operations are at risk of postoperative and care and of and has been associated with increased long-term morbidity and mortality early postoperative is associated with and long-term A recent prospective study found that compared with patients, those cardiac surgical patients with postoperative a in composite measures at a specifically in was in More evidence is required to the relationship between anesthetic management and postoperative and in cardiac surgical patients. with have conflicting studies found that compared with was associated with a decreased risk for postoperative A recent review of on prevention and of after cardiac operations that administration was most to the of compared with the administration of and results from a multicenter that perioperative administration of could or of postoperative or both, in cardiac surgical In a study in a of cardiac surgical patients that postoperative administration of in with or the incidence of critical postoperative patient outcomes that may be related to anesthetic management in cardiac surgical procedures are captured by the Adult Cardiac Anesthesiology Section and the STS ACSD (Supplemental Digital Content, Tables and 7, https: //links. lww. com/AA/D164). The incidence of mortality and other major postoperative such as prolonged postoperative and renal and their ratios by type of surgical interventions reported between 2015 and 2018, are in Figure and reported in Supplemental Digital Content, Table 7, https: //links. lww. com/AA/D164. were some notable trends by type of surgical interventions the need for further study of and factors that may have a significant in reported outcomes. A study of CABG patients from the STS ACSD found that at significant (eg, atrial prolonged renal or developed in of patients. All were associated with an increased risk of early and to mortality and of significant outcomes that may be by anesthetic management significantly morbidity and mortality and is associated with outcomes. A large analysis that and or are of after cardiac and and use are A recent study that patients with are at risk of postoperative and may from CABG a incidence of postoperative and other of strategies and management to patients at risk could the increased morbidity and death associated with postoperative in cardiac surgical patients. postoperative is an outcome associated with increased risk of incidence of and and care of found postoperative and are associated with the need for prolonged and patients who need prolonged ventilation have a associated in of risk factors would development of after cardiac surgical procedures is a common and widely negative impact on and long-term outcomes. More and involved have of and The use of and other interventions in at the risk of postoperative renal is and of the Adult Cardiac Anesthesiology Section of the STS ACSD and participation cardiac anesthesiologists be to of multiinstitutional data in cardiac surgical patients. only 70 of the 1088 cardiac surgery groups in the US participate in the optional STS/SCA Adult Cardiac Anesthesiology Section of the STS ACSD. Furthermore, the present review not information the contribution of each to the of cardiac surgical procedures Thus, an of the effect of institutional on the measures and outcomes described is not Finally, the and of data required, and institutional incentives for in the STS ACSD include that the data process to and participation and compliance with and data developments to and data by the experience include and as well as availability of to and define research and development of quality improvement programs in institutions. Another be to have the to the value of specific anesthesiology practices for of safe care and outcomes in cardiac surgical patients. Society of Cardiovascular of Thoracic Surgeons Database and The to Database Cardiac Surgery Database, Society of Thoracic and of Society of Thoracic for their in the and providing and would also to of for to the