August 2014
We recognize the importance of providing periodic updates to Database Participants to
ensure that matters pertaining to data collection, analysis and presentation are easily
understood, and to provide participants with timely information that will enable them to
avoid the consequences of missing data for important fields at the time of the next
harvest.
This will address four topics:
I. Review the elements included in the “2014 STS Congenital Heart Surgery
Database Mortality Risk Model,” which appeared for the first time in the Spring
2014 STS Congenital Heart Surgery Database (STS-CHSD) Feedback Report
II. Describe changes to the method of selecting the Primary Procedure of a cardiac
operation in the STS-CHSD
III. Address concerns related to patients in the STS-CHSD who had a cardiac
operation after January 1, 2010 and who had a previous operation at the same
institution coded in STS-CHSD version 2.3 or STS-CHSD version 2.5
IV. Update the timeline for STS Congenital Heart Surgery Database Voluntary
Public Reporting
I. The 2014 STS Congenital Heart Surgery Database Mortality Risk Model
The “2014 STS Congenital Heart Surgery Database Mortality Risk Model” is also
referred to as “Model 1” in the Twentieth Harvest Report (Spring 2014) and as “Case
Mix Adjustment Model 1” in the Report Overview and Interpretation Guide of the
Spring 2014 STS-CHSD Feedback Report, which include a detailed description of the
model.
Briefly, the “2014 STS Congenital Heart Surgery Database Mortality Risk Model”
includes the following covariates:
•
STAT Mortality Category,
•
age at surgery,
•
previous cardiovascular operation(s),
•
any non‐cardiac abnormality,
•
any chromosomal abnormality or syndrome,
•
important preoperative factors (preoperative mechanical circulatory support,
preoperative shock persisting at time of surgery, preoperative mechanical
ventilation, and preoperative renal dysfunction or preoperative renal failure),
•
any other preoperative factor,
•
prematurity (for neonates and infants only),
•
weight (for neonates only), and
•
weight‐for‐age‐and‐sex Z‐score (for infants only).
In order for an Index Cardiac Operation to be included in the outcomes analysis based
upon this new Mortality Risk Model, certain specific model variables must be
complete, and Operative Mortality for the index operation must also be complete (see
Report Interpretation Guide for data completeness requirements for Operative
Mortality). For a participant’s Feedback Report to include the outcome analysis based
on this Mortality Risk Model (which appeared in Table 16 of the Spring 2014 STSCHSD Feedback Report), the rate of missing data for any one or more of the model
variables must not exceed 10% (see below).
Operation-level missing data inclusion criteria:
 Non-missing age
 Non-missing sex (male or female)
Participant-level missing data inclusion criteria:
 Missing data for preoperative factors ≤ 10%
 Missing data for non-cardiac abnormalities ≤ 10%
 Missing data for cardiac abnormalities ≤ 10%
 Missing data for genetic syndromes ≤ 10%
 Missing data for number of prior cardiothoracic operations ≤ 10%
 Missing data for prematurity among neonates and infants ≤ 10%.
During the Fall 2014 harvest your Data Quality Report that you receive each time you
submit a file will contain specific information about missing data levels for variables
involved in the model and will provide a warning about whether your institution is at risk
of being left out of the analysis.
II. A change in the method of selecting the Primary Procedure of a cardiac
operation in the STS-CHSD
In the Spring 2014 STS-CHSD Feedback Report, the Primary Procedure for a given
operation was determined by selecting the procedure with the highest “Difficulty
Ranking” as listed in in the “Difficulty Ranking” column in Appendix F of the 2014 STSCHSD Feedback Report (Lookup Table for Determination of Primary Procedure), with
four exceptions that were described in the Report Overview and Report Interpretation
Guide of the Spring 2014 STS-CHSD Feedback Report.
Beginning with the Fall 2014 STS-CHSD Feedback Report, the Primary Procedure
for a given operation will be determined by selecting the component procedure
with the highest STAT Score, (subject to the same four exceptions mentioned above).
If more than one component procedure of a given operation shares the highest STAT
Score, then:
1. The Primary Procedure is determined to be that component procedure (one of
those with the highest STAT Score) which is designated as Primary Procedure
by the Participant.
2. If the operation doesn't have a Primary Procedure designated by the Participant,
then the first procedure in the data file received by DCRI becomes the Primary
Procedure.
If an operation does not have any component procedure with an assigned STAT
Score, then:
1. The Primary Procedure is determined to be that component procedure
which is designated as Primary Procedure by the Participant.
2. If the operation doesn't have a Primary Procedure designated by the
Participant, then the first procedure in the data file received by the DCRI
becomes the Primary Procedure.
III. Patients in the STS-CHSD who had a cardiac operation after January 1,
2010 and who had a previous operation at the same institution coded in
STS-CHSD version 2.3 or STS-CHSD version 2.5
Concerns have been raised about patients in the STS-CHSD who had a cardiac
operation after January 1, 2010 and who had a previous operation at the same
institution coded during the period of use of STS-CHSD version 2.3 or STS-CHSD
version 2.5. These patients are currently excluded from outcome analyses based on
Model 1 because they do not have information in version 3.0 or version 3.22 from the
following fields:
VARIABLE
Noncardiac Congenital Anatomic Abnormalities
(SeqNo)
NCAA (530)
Syndromes
Syndrome (610)
Chromosomal Abnormalities
ChromAb (570)
Premature Birth (for neonates only)
Premature (350)
This exclusion occurs because versions 2.3 and 2.5 did not include these fields, and
because entry of a new “encounter” or new operation currently does not automatically
afford the opportunity to update these fields in the current version.
A definitive solution to this problem will be implemented at the time of the next
upgrade of the STS-CHSD by revising the software. In the interim, the following
short-term solution is available:
For any patient with index cardiac operation(s) in the analytic window of the Fall
2014 STS-CHSD Harvest (index cardiac operation[s] between July 1, 2010 and
June 30, 2014, inclusive) who had a previous operation coded in STS-CHSD
version 2.3 or STS-CHSD version 2.5, the following steps can be taken to assure
inclusion of this patient’s recent index cardiac operation(s) in outcome analyses
based on Model 1:
1. On August 13 2013, software vendors were provided with instructions from
DCRI as to how to upgrade Demographic records to a newer version. If
sites want to upgrade records to a newer version, they can contact their
vendor to discuss a strategy to obtain a utility that will enable them to
upgrade these records.
2. After your vendor has enabled the capacity to upgrade Demographic
records to a newer version, enter data for this patient in the following
fields:
VARIABLE
Noncardiac Congenital Anatomic Abnormalities
(SeqNo)
NCAA (530)
Syndromes
Syndrome (610)
Chromosomal Abnormalities
ChromAb (570)
Premature Birth (for neonates only)
Premature (350)
The above strategy will allow for inclusion of these patients in analyses based on
Model 1. If a center chooses to implement this strategy, we ask that the center
applies this strategy to ALL of their patients in the STS-CHSD who had a cardiac
operation after January 1, 2010 and who had a previous operation coded in STSCHSD version 2.3 or STS-CHSD version 2.5.
IV. Timeline for STS Congenital Heart Surgery Database Voluntary Public
Reporting
Voluntary Public Reporting from the STS-CHSD will begin in January 2015 based on
data contained in the Fall 2014 STS-CHSD Feedback Report. Center level outcomes
(using a four-year analytic window) will be analyzed and reported using the 2014 STS
Congenital Heart Surgery Database Mortality Risk Model, as described above. The
categories of information that will be included in Public Reporting correspond to those
contained in Table 16 of the Spring 2014 STS-CHSD Feedback Report; however, the
values that will be reported will come from the Fall STS-CHSD Feedback Report.
Please note: NO PUBLIC REPORTING OF DATA FROM THE STS CONGENITAL
HEART SURGERY DATABASE IS TAKING PLACE AT THE PRESENT TIME, AND
PUBLIC REPORTING OF ANY INDIVIDUAL PARTICIPANT-LEVEL DATA IN THE
FUTURE WILL ONLY TAKE PLACE WITH THE PARTICIPANT’S CONSENT TO
PARTICIPATE IN THE PROGRAM OF PUBLIC REPORTING. This Public Reporting
will be voluntary. Voluntary public reporting of data from the STS Congenital
Heart Surgery Database will be at the level of the Cardiac Surgical Program (and
not at the level of the individual surgeon).
Star Ratings: When the system for voluntary public reporting has been operationalized,
centers will be designated as one-star, two-star, or three-star centers with respect to
risk adjusted mortality data. The Overall Star Rating is based on Case-mix Adjustment
Model 1. Centers for which the 95% confidence interval for the observed-to-expected
mortality ratio does not include unity (does not overlap with the number 1) will be
identified as one star (low performing) or three star (high performing) programs with
respect to Operative Mortality. The Star Rating will pertain only to the single category
“all ages and all STAT Categories”.
STS public reporting of center-level data will provide varying levels of granularity. These
varying levels of granularity range from actual risk adjusted outcomes data (observedto-expected mortality ratio and adjusted mortality rate with confidence intervals)
corresponding to individual age groups and STAT Categories ( as shown in Table 16 of
the Spring 2014 STS-CHSD Feedback Report) to star ratings for the single category
“all ages and all STAT Categories”. The great majority of participants will have a twostar rating. Low performing and high-performing “outliers” will have one-star and threestar ratings, respectively. This approach is designed to be maximally informative and
useful for individuals with differing levels of skill in interpretation of such quantitative
data.1
1Hibbard
JH, Peters E, Slovic P, Finucane ML, Tusler M. Making health care quality
reports easier to use. Jt Comm J Qual Improv 2001;27(11):591-604.