President's Column: Pressure Makes Diamonds

Robert S.D. Higgins, MD, MSHA

STS News, Summer 2019 — My mother always said that we need to rise to the occasion when things seem challenging in our personal or professional life. Challenges met successfully enhance our ability to tackle the next big obstacle; she would say “pressure makes diamonds.”

I later found out that my mother was not the only prophetic person to use this analogy. General George Patton said the same thing in 1944 during WWII.

For our specialty, recent circumstances surrounding the public reporting of surgical outcomes have and will continue to create a beachhead and challenge our profession to rise to the occasion.

At a recent STS National Database brainstorming session, surgeon leaders emphasized the importance of participation. Since 1989, the STS National Database has been the premier clinical outcomes registry in cardiothoracic surgery, focusing on quality assessment and process improvement, with more than 90%-95% penetration within the adult cardiac and congenital programs in the US.

The four component registries that make up the Database have more than 7.9 million surgical records from more than 6,000 participating surgeons, anesthesiologists, and other physicians in 11 countries, making it the respected leader of clinical registries worldwide.

We take that role seriously, and we continue to assess the foundations of appropriate risk-adjusted performance measurement while enhancing participant satisfaction, reducing data entry burden, and maximizing Database utilization and ease of use.

The beneficiaries of STS National Database participation are widespread and include STS members, hospitals, patients, health care organizations, and federal regulators (CMS and FDA), as well as medical device, pharmaceutical, biotechnology, and insurance companies. It’s no surprise that recent high-profile articles critiquing congenital heart surgery programs reference the value of publicly reporting risk-adjusted outcomes using the Database.

At this moment in time when the pressure to meet or surpass expectations is greatest, our specialty will rise to the occasion.

But it’s not just about measurement; it’s about improvement. In my opinion, participation itself should not be the only goal; quality assessment and process improvement also are extremely valuable tenets. We strongly encourage our members and their programs to use their participant data to internally evaluate team performance and measure observed outcomes versus expected performance. Even though the risk-adjustment models are not perfect (they continually undergo upgrades and improvements), they give our profession the best means to measure and improve the morbidity and mortality associated with adult and congenital heart surgery. This has been the case with open heart surgery, as morbidity and mortality have been reduced significantly over the past 30 years!

It’s not a perfect business. We understand and empathize with patients and families who have imperfect and complicated outcomes after open heart surgery. They deserve the best that our profession can offer. Reporting outcomes in a transparent and understandable format offers them the best chance to make informed decisions for a successful procedure and outcome. We are hopeful that the data reported through the STS Public Reporting system are a value-add to patients and programs.

We recently modified our STS Public Reporting website to provide more accurate and clear delineations of how the star quality metrics are determined and to emphasize their value as internal, program-specific metrics for patients and professionals. The majority of adult and congenital heart programs (more than 90%) are ranked as two- or three-star programs. These reported outcomes allow patients, surgeons, and hospitals alike to determine their performance against industry norms.

Some cardiothoracic surgery programs don’t meet their own expectations. But we are certain that these programs and others around the country will use their data to make improvements. At this moment in time where the pressure to meet or surpass expectations is greatest, our specialty will rise to the occasion, just as it has done over the past 30 years. By reviewing outcomes regularly and instituting better ways to take care of patients, we can continually enhance quality and potentially save lives.

As we respond to today’s extraordinary challenges and pressures, quality assessment and improvement efforts led by The Society of Thoracic Surgeons will remain a “jewel” for modern health care in the years to come.