The Rationale and Development of an Adult Cardiac Anesthesia Module to Supplement the Society of Thoracic Surgeons National Database

BACKGROUND The Society of Cardiovascular Anesthesiologists (SCA) was established in 1978 with a core mission to promote excellence in clinical care, education, and research in cardiovascular anesthesiology. On January 28, 2013, the SCA launched a groundbreaking collaboration with the Society of Thoracic Surgeons (STS) to incorporate an Adult Cardiac Anesthesia Module into the STS national database. This collaboration will allow anesthesiologists, surgeons, and others to better understand the influence of cardiothoracic anesthesia practices, including intraoperative echocardiography, on clinical outcomes among patients undergoing cardiothoracic operations. Despite important advances in anesthesia management and perioperative care for high-risk and critically ill patients, the short- and long-term impact is not yet fully understood. Therefore, the systematic accumulation and integration of perioperative anesthesia and surgical data will be extremely valuable. Anesthesiologists in general, and the SCA specifically, have long been at the forefront of patient safety initiatives in the operating room and the perioperative setting. Their efforts have led to an unprecedented level of safety for even high-risk patients requiring anesthesia for surgical procedures.1–5 Advances in anesthesiology and perioperative care have also allowed surgeons to reliably and safely perform more technically complex operations such as minimally invasive cardiac operations, thoracic endovascular aortic repairs, and transcatheter aortic valve replacement.6–9 The collaboration between the SCA and the STS to create an SCA/STS national database is an important step in the continuing effort to improve patient care and safety, generate knowledge, and foster the clinical application of advances in cardiothoracic anesthesiology. THE STS NATIONAL DATABASE In 1986, the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services [CMS]) released clinical outcomes data (non–risk adjusted) to the public. This heralded an era that established standards for medical providers and foreshadowed a time when medical referrals and reimbursement would be dictated by objective measures of performance.10 In this context, the STS created a committee to develop a physician-operated clinical database to provide government agencies and payers with accurate risk-adjusted performance and clinical outcomes data (Table 1). Data collection began in 1989 for what evolved into the STS National Database.Table 1: Adult Cardiac Surgery MeasuresToday, the STS National Database is perceived by many to be the benchmark database tool for quality improvement and patient safety in cardiac surgery. The STS Adult Cardiac Surgery Database is currently the largest cardiothoracic surgery outcomes and quality improvement registry in the world. It contains >5.1 million cardiothoracic surgical procedure records from 1070 participants and represents nearly 95% of all adult cardiac surgery centers in the United States. In January 2011, the STS created an online public reporting system that allows database participants to voluntarily report surgical outcomes. This was a large step forward as it provides transparency for patients and payers. The STS National Database project has evolved to also provide information on quality performance and clinical investigation. The credibility of the STS database is recognized and endorsed by the National Quality Forum, Ambulatory Care Quality Alliance, CMS, Food and Drug Administration, payers, purchasers, and major hospital systems.11 The Consumers Union, the policy and action division of Consumer Reports, provides public access of individual hospital performance on a voluntary basis with “star” ratings based on STS outcomes data.12 Used primarily by surgeons who specialize in adult cardiac, general thoracic, and congenital heart surgery, the STS database expanded in 2012 to include anesthesiology participation in a Congenital Heart Surgery Database. Now, all adult cardiac anesthesia data can be included in the new SCA Adult Cardiac Anesthesia Module in the STS National Database. THE SCA/STS COLLABORATIVE The SCA recognized that CMS, health insurance companies, and the general public would likely require disclosure of outcomes data related to the practice of cardiothoracic anesthesiology and its impact on patient outcomes. A systematic process for gathering these data would require a national effort, which the SCA was in a position to organize. An SCA task force was formed to examine all possible options for creating and maintaining a comprehensive database. After an exhaustive feasibility study and extensive negotiation, a collaborative decision was made to partner with the STS National Database rather than create an independent database. This partnership with the STS allows the SCA to build on and strengthen its ongoing collaboration and working relationship with cardiothoracic surgeons and creates the potential to connect an anesthesia databank to >5 million cardiothoracic surgical procedure records. The ability to link anesthesia and intraoperative data with surgical outcomes and performance provides a powerful tool to continuously measure and examine the value of anesthesia practices and to refine the quality of perioperative care. SCA/STS DATA FIELD DEVELOPMENT A major objective of the SCA/STS national database is to establish a comprehensive baseline of measurable outcomes. Early experience has shown that many specified outcomes, such as duration of postoperative ventilation support, infection, and reoperation rates, may be contingent on the anesthesia care. However, many of the data fields in the existing STS database did not relate to anesthesia practices. The SCA/STS database is an important first step toward filling that gap. In May 2011, the SCA commissioned a Database Taskforce to develop the anesthesia data fields for the STS database. Over a 15-month period, data fields were proposed for review, analyzed, prioritized, and selected by the taskforce. Data field selection followed a process that balanced competing objectives: (1) demonstrate value, quality, improved outcomes, or safety related to cardiovascular anesthesia services; (2) develop anesthesia-related research questions that are not currently answered by the STS database; (3) maintain practicality by limiting data acquisition burden on anesthesia providers; and (4) manage cost (fees per field added to the database). Other experts in cardiothoracic anesthesiology were also consulted, as needed, to refine data fields of interest. After eliminating data fields that were already included in the STS database, a data collection form was created with the assistance of the STS and the Duke Clinical Research Institute (http://www.sts.org/sites/default/files/documents/STSACAnesthesiaModule.pdf). The initial database fields for the SCA Adult Cardiac Anesthesia Module are comprehensive and capture patient risk factors, operative techniques, anesthesia techniques, processes, and clinical outcomes (Fig. 1). The SCA is also preparing a standardized report of collected data. External audits of data are planned after 1 year of data have been collected and 50 or more participating sites have committed. This initiative is expected to become a global project, spreading beyond North America to Europe and ultimately to Africa, Asia, Australia, and South America. The creation of a worldwide adult cardiac surgery and anesthesia database is aligned with the mission of the SCA and is a step toward the long-term goal of creating a database that spans both geographical and subspecialty boundaries.Figure 1: Data collection form for the Adult Cardiac Anesthesia Module.RELEVANCE TO CARDIOVASCULAR ANESTHESIOLOGY Database information provides a benchmark for risk-adjusted quality improvement and patient safety. Meaningful internal assessment is also possible when collectively recording and sharing outcomes data. Data-driven evidence shapes evolving perceptions of patient risk and ultimately drives policy to incentivize best practices. Clinical practice guidelines, consensus statements, and work value are best derived from comprehensive data. A database also provides a foundation for valuable clinical research.13–24 Combining anesthesia and perioperative data with the STS Adult Cardiac Surgery Database provides a means to link anesthesia techniques and surgical and perioperative care to risk-adjusted patient outcomes. Establishing the impact of anesthetic practices to surgical outcomes is vital to ongoing quality improvement efforts and to understanding how to measure the value of specific interventions such as intraoperative blood and coagulation management, application of transesophageal echocardiography, and pain management techniques. The SCA/STS National Database project is the first comprehensive risk-adjusted clinical outcomes registry to include anesthesia and perioperative data fields and is endorsed by the American Society of Anesthesiologists (ASA) Anesthesia Quality Institute (AQI). As an anesthesiologist, membership and active participation in the SCA/STS database project shows a commitment to improve patient outcomes through teamwork, multispecialty collaboration, and data-driven quality improvement. Participation also demonstrates to the public, government agencies, and health insurance industry that cardiothoracic anesthesiologists are committed to objectively quantify how the practice of cardiothoracic anesthesiology and perioperative medicine impacts surgical outcomes. Finally, a quality database further distinguishes anesthesiologists not only as leaders and innovators in the world of rapidly changing health care delivery, but also as members of a subspecialty with specifically stated criteria necessary for certification, which includes having a distinct and unique body of knowledge in anesthesiology, having clinical applicability sufficient to support a distinct clinical practice that contributes to the scholarly generation of new information, and advancing research in the field. MEMBER BENEFITS Now that an SCA Adult Cardiac Anesthesia Database has been created, it is important that we all participate and contribute. The SCA encourages you to join your colleagues and set a professional example by participating in the SCA/STS National Database because we are in the best position to measure our clinical performance accurately and objectively. Active participation in the SCA/STS National Database project has many benefits: A standardized format for data collection to assess the care of adult patients undergoing cardiothoracic operations. Quarterly performance outcomes reports in a risk-adjusted format that allows comparison of local outcomes with regional benchmarks and national standards. All participating member sites will receive a quarterly report that compares data from their institution with data from the national database and comparable centers. The exact format of the report and the information that it contains will be determined by a task force set up by the SCA. This task force will be receptive to recommendations and comments from participating SCA/STS database sites to design and incrementally refine the contents of the quarterly report to match the needs of individual sites. Report section dedicated to anesthesia. The anesthesia fields will be reported in a separate section of the report. The data manager at each site can create user names and passwords to access the report as defined at the local level. Analysis of major surgical outcomes and process-of-care measures that impact adult cardiac surgery patients. The database has been an important resource for clinical investigation, and >100 publications have been generated from database outcomes.25 The SCA board of directors has established a task force to implement and support the SCA/STS National Database project. The task force is charged with providing information and support to individual member sites, including recommendations for updating the anesthesiology data fields, and it also represents the interests of SCA members on the STS database work group. SCA representation in the STS database workforce is guaranteed by the appointment of 2 SCA designees as STS associate members. One SCA designee serves on the STS Task Force on Access and Publications, and the other serves on the STS Data Warehouse Task Force, which is charged with managing the data in the SCA/STS National Database. Composite quality measure scores for coronary artery bypass graft and valve surgery.26 Risk profiles of your patients benchmarked against national standards. Feedback reports to identify areas for quality improvement. The STS provides a voluntary mechanism whereby hospitals can report risk-adjusted outcomes derived from SCA/STS data for the public to view.27 Feedback reports to document outcomes from quality improvement initiatives. Data from member-specific sites can be compared with deidentified regional and national norms. Thus, through active membership in the SCA/STS National Database project, anesthesiologists and cardiothoracic surgeons can work together to create data-driven initiatives to improve the quality of care for their patients.28 Assessment data on new technology and techniques. Quality-of-care documentation delivered by your practice for interested 3rd parties. SCA/STS data are compiled and analyzed according to site only. The identity and performance of individual practitioners at each site remains anonymous. Similarly, patients and patient-specific outcomes are deidentified. Participation in a national quality improvement effort for adult cardiac surgery. Quarterly reports will be provided to members of the SCA/STS national database so that site-specific practices and outcomes can be compared with national norms. These reports will provide feedback that will help to identify group-specific practices that exceed national standards and also those that can be improved. MEMBERSHIP REQUIREMENTS To be eligible for membership in the SCA/STS database project, your institution must be a participating site for the adult cardiac surgery STS database.29 Currently, >95% of cardiac surgery programs in the United States participate in the STS adult cardiac surgery database. The 2013 fee for SCA/STS Adult Cardiac Surgery Database participation is $2500 per anesthesiology group. (Note: This fee is in addition to the participation fee payable by or on behalf of your surgical colleagues. Their participation is required.) Each hospital should designate an individual physician to be in charge of implementing the mechanism to collect and enter data. Data will be collected and then submitted via a Web-based collection portal. Because the module is Web-based, no special software is required. Each practice should also develop an individualized standard operating procedure to implement the database project and establish its own most efficient method to collect and enter the data. Regardless of the precise procedures developed for data collection and entry at individual centers, membership and participation in the SCA/STS National Database project is expected to foster interdisciplinary collaboration among anesthesiologists, perfusionists, and surgeons. Together, the SCA and the STS have created a standardized collection form that can be used as a data collection tool (Fig. 1). It is important to maintain the accuracy of all data that are entered; so, it is better to leave a data field blank than to enter incorrect data that cannot be verified. Although data entered into the STS database are independent of data in the patient medical record, the STS database workforce began in 2006 to perform periodic audits of the STS database. It is projected that 10% of all data entered into the STS database will be audited beginning 1 year after implementation. For that reason, it is recommended that participating sites implement standard procedures to verify that data entered into the SCA/STS database are also in the patient medical record. DATABASE IMPACT ON ADULT CARDIOTHORACIC ANESTHESIOLOGY FELLOWSHIP TRAINING PROGRAMS Participation in the SCA/STS National Database project promotes many of the Accreditation Council for Graduate Medical Education (ACGME) core competencies including the following30: Patient Care. Promotes an understanding of patient demographics and outcomes within specific practices and provides feedback on practice patterns from a national perspective. Medical Knowledge. Learning to apply knowledge from SCA/STS data toward improved patient care. Practice-Based Learning and Improvement. Documentation of site-specific practices and outcomes reporting through the SCA/STS National Database project promotes evaluation of one’s own patient care practices, appraisal and assimilation of scientific evidence, and improvements in patient care. Interpersonal and Communication Skills. Integrating anesthesia-related data with surgical data promotes effective information exchange among multidisciplinary health professionals. Professionalism. Promotes commitment to performing professional responsibilities. Systems-Based Practice. Promotes a culture of practice that demonstrates an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that has optimal value. Fellows and residents in ACGME-accredited Adult Cardiothoracic Anesthesiology training programs should be taught how to routinely collect and enter quality data for the anesthesiology data fields. After graduation, it is expected that their direct experience with the national SCA/STS database will be an important part of their skill set that will contribute to their group practice. It is important to instill in our trainees, who will constitute the future of the specialty, that participation in the SCA/STS National Database project demonstrates professionalism and is an integral part of a quality practice. Participation in the SCA/STS National Database project provides compelling evidence that the fellowship program satisfies many of the ACGME core requirements. In addition, these fellows have the opportunity to gain experience in developing professional relationships and personal responsibility for monitoring performance and patient outcomes. Participation also provides objective evidence that the fellowship program has a mechanism for demonstrating competence by following standards for patient care and established guidelines for patient safety, error reduction, and improved patient outcomes. Finally, each fellow will have direct experience as an active member of an interdisciplinary team that is committed to clinical quality improvement and patient safety programs. ENDORSEMENT BY AMERICAN SOCIETY OF ANESTHESIOLOGISTS AQI The SCA/STS National Database project is the first comprehensive risk-adjusted clinical outcomes registry to include anesthesia and perioperative data fields. Participation in the SCA/STS National Database project is endorsed by the ASA AQI. The SCA/STS National Database and the ASA AQI are independent projects directed at improving anesthesia patient safety and quality. Individual practices can participate in both the SCA/STS National Database project and the ASA AQI. SUMMARY The practice of medicine, including the practice of anesthesiology, is rapidly becoming judged (as it should be), in large part, according to objective epidemiologic measures of patient outcome.31 The SCA believes that physicians are in the best position to measure clinical performance accurately and objectively and to apply this knowledge to improve the quality of care, safety, patient outcomes, and clinical efficiency. The SCA is committed to continuous improvement in patient safety and quality of cardiothoracic and vascular anesthesia care. We believe it is our responsibility and privilege as a professional organization to lead the way in education and provide an ongoing means to acquire new and clinically relevant knowledge to advance our field. The plan to work together and build an SCA/STS National Database has great potential for the SCA, the subspecialty of cardiothoracic anesthesiology, and the specialty of anesthesiology in general. The option we now face is an important one. We must decide whether we are ready to take the steps necessary to lead this national effort to track our performance and examine the impact of our practices on patient outcomes. If we choose not to take this lead, it is likely that another organization or agency will take the opportunity and be in a position to dictate our future practice. The SCA/STS National Database partnership represents a watershed project for the SCA, its membership, and all cardiothoracic anesthesiologists. Now that an Adult Cardiovascular Anesthesia Module has been created for this database, it is crucial that we all participate as part of our professional and social responsibility. The ultimate success and strength of this project is contingent on the number of participants in both academic and private institutions. The SCA strongly encourages everyone who is eligible to take advantage of this unprecedented opportunity to play a key role in shaping patient care. 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