Quality Performance Measures

NQF Status
Endorsed*

Date of Endorsement
1/26/11

Description
This multidimensional performance measure assesses surgical performance based on a combination of 11 NQF-endorsed CABG process and outcomes measures, grouped into four domains:
1. Perioperative medication domain, scored all-or-none and consisting of:
 0127 – Preoperative beta blockade
 0117 – Beta blockade at discharge
 0116 – Anti-platelet medication at discharge
 0118 – Anti-lipid treatment at discharge
2. Operative care process domain
 0134 – Use of an internal mammary artery in CABG
3. Risk-adjusted operative mortality
 0119 – Risk-adjusted operative mortality for CABG
4. Risk-adjusted morbidity, scored any-or-none and consisting of:
 0131 – Stroke/cerebrovascular accident
 0115 – Surgical re-exploration
 0130 – Deep sternal wound infection rate
 0114 – Postoperative renal failure
 0129 – Prolonged intubation (ventilation)
Participants receive a score for each of the four domains, plus an overall composite score. The overall composite score was created by “rolling up” the four domain scores into a single number. In addition to receiving a numeric score, participants were assigned to rating categories designated as one (below average performance), two (average performance), and three (above average performance) stars.

*The STS star rating system was not eligible to be considered for NQF endorsement due to the fact that at the time of review, NQF did not have a process in place to endorse "reporting protocols."

NQF Status
Endorsed

Date of Endorsement
12/6/11 

Description
Percent of patients aged 18 years and older undergoing isolated CABG who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/for mediastinum requiring operative intervention

Numerator
Number of patients who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention

Must have all of the following conditions:
-Wound opened with excision of tissue (I&D) or re-exploration of mediastinum
-Positive culture unless patient on antibiotics at time of culture or no culture obtained
-Treatment with antibiotics beyond perioperative prophylaxis

Numerator Time Window
Within 30 days postoperatively

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients undergoing Aortic Valve Replacement (AVR) who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator
Number of patients undergoing AVR who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged

Denominator
All patients undergoing isolated AVR surgery

Denominator Time Window
60 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator
Number of patients undergoing combined AVR and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged

Denominator
All patients undergoing combined AVR + CABG 

Denominator Time Window
60 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure 

Numerator
Number of patients undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure 

Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged 

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients undergoing MV Repair who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator
Number of patients undergoing MV Repair who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged

Denominator
All patients undergoing isolated MV Repair surgery

Denominator Time Window
60 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients undergoing combined MV Repair and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator
Number of patients undergoing combined MV Repair and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged

Denominator
All patients undergoing combined MV Repair + CABG

Denominator Time Window
60 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients undergoing Mitral Valve (MV) Replacement who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator
Number of patients undergoing MV Replacement who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure

Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged

Denominator
All patients undergoing isolated MV Replacement surgery

Denominator Time Window
60 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients undergoing combined MV Replacement and CABG who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure 

Numerator
Number of patients undergoing combined MV Replacement and CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure 

Numerator Time Window
During hospitalization regardless of length of stay or within 30 days of surgery if discharged 

Denominator
All patients undergoing combined MV Replacement + CABG

Denominator Time Window
60 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients aged 18 years and older undergoing isolated CABG (without pre-existing renal failure) who develop postoperative renal failure or require dialysis

Numerator
Number of patients undergoing isolated CABG who develop postoperative renal failure or require dialysis

Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months

Exclusions
Patients with documented history of renal failure, baseline serum creatinine ≥4.0; prior renal transplants are not considered preoperative renal failure unless since transplantation their Cr has been or is ≥4.0

NQF Status
Endorsed

Date of Endorsement
12/6/11 

Description
Percent of patients aged 18 years and older undergoing isolated CABG who require intubation for more than 24 hours

Numerator
Number of patients undergoing isolated CABG who require intubation > 24 hours 

Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days 

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients aged 18 years and older undergoing isolated CABG who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

Numerator
Number of patients undergoing isolated CABG who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients aged 18 years and older undergoing isolated CABG who require a return to the operating room for bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason

Numerator
Number of patients undergoing isolated CABG who require return to the operating room for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason

Numerator Time Window
During the hospitalization for surgery, which includes the entire postoperative period up to discharge, even if over 30 days

Denominator
All patients undergoing isolated CABG 

Denominator Time Window
12 months

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on a statin or other lipid-lowering regimen

Numerator
Number of patients undergoing isolated CABG who were discharged on a statin or other lipid-lowering regimen

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months 

Exclusions
Cases are removed from the denominator if there was an in-hospital mortality or if discharge anti-lipid treatment was contraindicated

NQF Status
Endorsed

Date of Endorsement
12/6/11

Description
Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on anti-platelet medication 

Numerator 
Number of patients undergoing isolated CABG who were discharged on anti-platelet medication

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months

Exclusions
Cases are removed from the denominator if there was an in-hospital mortality or if discharge aspirin was contraindicated

NQF Status
Endorsed

Date of Endorsement
1/31/12 

Description
Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on beta blockers

Numerator
Number of patients undergoing isolated CABG who were discharged on beta blockers

Denominator
All patients undergoing isolated CABG 

Denominator Time Window
12 months

Exclusions
Cases are removed from the denominator if there was an in-hospital mortality or if discharge beta blocker was contraindicated

NQF Status
Endorsed

Date of Endorsement
5/2/12

Description
Percent of patients aged 18 years and older undergoing cardiac surgery whose prophylactic antibiotics were discontinued within 48 hours after surgery end time

Numerator
Number of patients undergoing cardiac surgery whose prophylactic antibiotics were discontinued within 48 hours after surgery end time 

Numerator Time Window
Within 48 hours after surgery end time

Denominator
Number of patients undergoing cardiac surgery

Denominator Time Window
12 months

Exclusions
- Patients who had a principal diagnosis suggestive of preoperative infectious diseases 
- Patients whose ICD‐9‐CM principal procedure was performed entirely by Laparoscope
- Patients enrolled in clinical trials
- Patients with documented infection prior to surgical procedure of interest
- Patients who expired perioperatively
- Patients who were receiving antibiotics more than 24 hours prior to surgery
- Patients who were receiving antibiotics within 24 hours prior to arrival
- Patients who did not receive any antibiotics during this hospitalization
- Patients with reasons to extend antibiotics

NQF Status
Endorsed

Date of Endorsement
1/31/12

Description
Percent of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery 

Numerator
Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery

Numerator Time Window
Within 24 hours preceding surgery

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months

Exclusions
Cases are removed from the denominator if preoperative beta blocker was contraindicated

NQF Status
Endorsed

Date of Endorsement
1/31/12

Description
Percent of patients aged 18 years and older undergoing cardiac surgery who received preoperative prophylactic antibiotics recommended for the operation

Numerator
Number of patients undergoing cardiac surgery who received a first generation or second generation cephalosporin prophylactic antibiotic (e.g., cefazolin, cefuroxime, cefamandole) preoperatively or in the event of a documented allergy, an alternate antibiotic choice (e.g., vancomycin, clindamycin) was ordered and administered preoperatively

Denominator
Number of patients undergoing cardiac surgery 

Denominator Time Window
12 months

Exclusions
- Patients who had a principal diagnosis suggestive of preoperative infectious diseases
- Patients whose ICD‐9‐CM principal procedure was performed entirely by Laparoscope
- Patients enrolled in clinical trials
- Patients with documented infection prior to surgical procedure of interest
- Patients who expired perioperatively
- Patients who were receiving antibiotics more than 24 hours prior to surgery
- Patients who were receiving antibiotics within 24 hours prior to arrival
- Patients who did not receive any antibiotics before or during surgery, or within 24 hours after anesthesia end time (i.e., patient did not receive prophylactic antibiotics)
- Patients who did not receive any antibiotics during this hospitalization

NQF Status
Endorsed

Date of Endorsement
1/31/12 

Description
Percentage of patients aged 18 years and older undergoing isolated CABG who received an internal mammary artery (IMA) graft

Numerator
Number of patients undergoing isolated CABG who received an internal mammary artery (IMA) graft 

Denominator
All patients undergoing isolated CABG

Denominator Time Window
12 months 

Exclusions
Cases are removed from the denominator if the patient had a previous CABG prior to the current admission or if IMA was not used and one of the following reasons was provided:
- Subclavian stenosis
- Previous cardiac or thoracic surgery
- Previous mediastinal radiation
- Emergent or salvage procedure
- No LAD disease

NQF Status
Endorsed (Reserve Status)

Date of Endorsement
12/6/11

Description
Participation in a clinical database with broad state, regional, or national representation that provides regular performance reports based on benchmarked data 

Numerator
Does the facility participate in a clinical database with broad state, regional, or national representation that provides regular performance reports based on benchmarked data? (yes/no) 

Numerator Time Window
12 months

NQF # 0733

NQF Status
Endorsed

Date of Endorsement
11/16/11

 Description
Operative mortality stratified by the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

Numerator
Number of patients who undergo pediatric and congenital open heart surgery and die during either of the following two time intervals:  1.) Prior to hospital discharge 2.) Within 30 days of the date of surgery

Denominator
Number of index cardiac operations in each level of complexity stratification using the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

Measure Exclusions
Any operation that is not a pediatric or congenital Cardiac Operation. Cardiac operations are defined as operations that are of operation types of “CPB” or “No CPB Cardiovascular” (CPB is cardiopulmonary bypass.) [1].
Any operation that is a pediatric or congenital open heart surgery (operation types of “CPB” or "No CPB Cardiovascular") that cannot be classified into a level of complexity by the five STS-EACTS Mortality Levels.

Reference
1.Jacobs JP, Mavroudis C, Jacobs ML, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Yeh T, Walters HL 3rd, Kurosawa H, Stellin G, Ebels T, Elliott MJ. What is Operative Mortality? Defining Death in a Surgical Registry Database: A Report from the STS Congenital Database Task Force and the Joint EACTS-STS Congenital Database Committee. The Annals of Thoracic Surgery, 81(5):1937-41, May 2006.

Surgical Volume for Pediatric and Congenital Heart Surgery: Total Programmatic Volume and Programmatic Volume Stratified by the Five STS-EACTS Mortality Categories

NQF # 0732

NQF Status
Endorsed

Date of Endorsement
11/16/11

Description
Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

Numerator
1) Total number of pediatric and congenital cardiac surgery operations and 2) number of pediatric and congenital cardiac surgery operations in each of the strata of complexity specified by the five STS-EACTS Mortality Levels, a multi-institutional validated complexity stratification tool

Measure Exclusions
Any operation that is not a pediatric or congenital cardiac operation. Cardiac operations are defined as operations that are of operation types of “CPB” or “No CPB Cardiovascular” (CPB is cardiopulmonary bypass.) [1].
Any operation that is a pediatric or congenital open heart surgery (operation types of “CPB” or "No CPB Cardiovascular") that cannot be classified into a level of complexity by the five STS-EACTS Mortality Levels.

Reference
1. Jacobs JP, Mavroudis C, Jacobs ML, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Yeh T, Walters HL 3rd, Kurosawa H, Stellin G, Ebels T, Elliott MJ. What is Operative Mortality? Defining Death in a Surgical Registry Database: A Report from the STS Congenital Database Task Force and the Joint EACTS-STS Congenital Database Committee. The Annals of Thoracic Surgery, 81(5):1937-41, May 2006.

Participation in a National Database for Pediatric and Congenital Heart Surgery

NQF # 0734

NQF Status
Endorsed

Date of Endorsement
12/5/11

Description
Participation in at least one multi-center, standardized data collection and feedback program that provides benchmarking of the physician’s data relative to national and regional programs and uses process and outcome measures.

Numerator
Whether or not there is participation in at least one multi-center data collection and feedback program for pediatric and congenital heart surgery.

Measure Exclusions
Any operation that is not a pediatric or congenital Cardiac Operation. Cardiac operations are defined as operations that are of operation types of “CPB” or “No CPB Cardiovascular” (CPB is cardiopulmonary bypass.)

NQF # 0459

NQF Status
Endorsed

Date of Endorsement
1/24/12

Description
Percentage of patients aged 18 years and older undergoing elective lobectomy for lung cancer who had a prolonged length of stay >14 days

Numerator
Number of patients aged 18 years and older undergoing elective lobectomy for lung cancer who had a prolonged length of stay >14 days

Denominator
Number of patients aged 18 years and older undergoing elective lobectomy for lung cancer

Exclusions
Urgent or emergent lobectomy for lung cancer in a patient with complications of the cancer (bleeding, bronchopleural fistula, empyema)

NQF # 0460

NQF Status
Endorsed 

Date of Endorsement
1/24/12

Description
Percentage of patients aged 18 years and older undergoing elective esophagectomy for esophageal cancer who developed any of the following postoperative conditions: bleeding requiring reoperation, anastomosis leak requiring medical or surgical treatment, reintubation, ventilation >48 hours, pneumonia, or discharge mortality

Numerator
Number of patients aged 18 years and older undergoing elective esophagectomy for esophageal cancer who developed any of the following postoperative conditions: bleeding requiring reoperation, anastomosis leak requiring medical or surgical treatment, reintubation, ventilation >48 hours, pneumonia, or discharge mortality.

Denominator
Number of patients aged 18 years and older undergoing elective esophagectomy for esophageal cancer

Exclusions
Urgent or emergent operation; condition other than esophageal cancer leading to esophagectomy.

NQF # 1790

NQF Status
Endorsed

Date of Endorsement
8/9/12

Description
Percentage of patients ≥ 18 years of age undergoing elective lung resection (Open or VATS wedge resection, segmentectomy, lobectomy, bilobectomy, sleeve lobectomy, pneumonectomy) for lung cancer who developed any of the following postoperative complications: reintubation, need for tracheostomy, initial ventilator support > 48 hours, ARDS, pneumonia, pulmonary embolus, bronchopleural fistula, bleeding requiring reoperation, myocardial infarction or operative mortality.

Numerator
Number of patients ≥ 18 years of age undergoing elective lung resection for lung cancer who developed any of the following postoperative complications: reintubation, need for tracheostomy, initial ventilator support > 48 hours, ARDS, pneumonia, pulmonary embolus, bronchopleural fistula, bleeding requiring reoperation, myocardial infarction or operative mortality.

Denominator
Number of patients ≥ 18 years of age undergoing elective lung resection for lung cancer.

Exclusions
Emergency Procedures

NQF # 0455

NQF Status
Endorsed

Date of Endorsement
1/24/12

Description
Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical staging provided prior to surgery

Numerator
Number of all surgical patients aged 18 years and older undergoing treatment procedures for lung or esophageal cancer who had clinical staging provided prior to surgery

Denominator
Number of all surgical patients aged 18 years and older undergoing treatment procedures for lung or esophageal cancer

NQF # 0457

Endorsed 

Date of Endorsement
1/24/12

Description
Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had their performance status recorded within two weeks prior to the surgery date

Numerator
Number of all surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had their performance status recorded within two weeks prior to the surgery date

Denominator
Number of all surgical patients undergoing resection for lung or esophageal cancer

NQF # 0458

NQF Status
Endorsed

Date of Endorsement
1/24/12

Description
Percentage of thoracic surgical patients aged 18 years and older undergoing at least one pulmonary function test within 12 months prior to a major lung resection (pneumonectomy, lobectomy, or formal segmentectomy)

Numerator
Number of thoracic surgical patients aged 18 years and older undergoing at least one pulmonary function test within 12 months prior to a major anatomic lung resection.

Denominator
Number of thoracic surgical patients undergoing a major anatomic lung resection

Exclusion
Patients who are unable to perform pulmonary function testing (tracheostomy, patient inability to cooperate with pulmonary function test) or those with urgent/emergent need of lung resection (lung abscess, massive hemoptysis, bronchopleural fistula, etc.).

NQF # 0456

NQF Status
Undergoing endorsement maintenance

Description
Participation in a multi-center data collection and feedback program that provides benchmarking of the physician’s data relative to national programs and uses structural, process, and outcome measures.

Numerator
Whether or not the physician participates for a 12-month period in at least one multi-center data collection and feedback program that provides benchmarking of the physician’s data relative to national programs and uses structural, process, and outcome measures.