The National Quality Forum board of directors has given its final stamp of approval on the endorsement of 21 consensus standards for cardiac care, paving the way, standards sponsors say, for widespread adoption of a national yardstick for cardiac surgery and pay-for-performance programs.
"What it means is we are ready to do pay for performance," said J. Michael Hogan, spokesman for the Society of Thoracic Surgeons, which for more than a decade has operated the National Cardiac Database upon which 14 of the new standards are based. In addition, one of the remaining seven standards calls for physician and hospital adoption of a "systematic database for cardiac surgery," which would include the NCD, run by the society in partnership with the Duke Clinical Research Institute at Duke University, Durham, N.C. That database has more than 2.7 million patient records.
Six of the new standards are for risk-adjusted mortality rates for coronary artery bypass graphs, aortic and mitral valve replacements, and combinations of the procedures. Five of those were developed by the society, one by the California CABG Mortality Reporting Program. Five of the NQF-endorsed standards were developed by the CMS.
Jeffrey Rich, M.D., Norfolk, Va., is a cardiac surgeon and a member of the Society of Thoracic Surgeons' workforce on health policy, reform and advocacy. He also served as co-chairman of the NQF steering committee that oversaw the standards approval process.
Rich said the new standards also could be used by surgeons and hospitals across the country in quality improvement programs without a pay-for-performance component and "as a reporting mechanism for patients and consumers."
Rich said cardiac surgeons have developed their database over the course of a decade and "the risk-adjusted model was accepted with open arms." Such broad acceptance of a risk-adjustment methodology eliminates a common physician gripe about quality measurement schemes they say don't adequately account for patient acuity.
Another oft-heard complaint centers on the data itself if it is gleaned from administrative claims, but the cardiac surgeons handled that by using self-reported clinical data taken from a five-page form with about 200 data elements. The participating physician and a data manager complete the form for every patient, Rich said.
Hogan said about 80% of cardiac surgeons and 70% of hospitals with cardiac surgery programs in the U.S. contribute to the database.
"It's an expense that's either borne by the practice, or the hospital, or shared," Rich said. "To belong to the database, for a heart program, it probably costs $100,000 a year." A physician participant contributes about 100 hours a year to data compilation, he said.
"There is a financial burden and a work burden, but the value of it is extraordinary," Rich said. "It's like when you were in school -- you study, take a test and you get feedback. And you try to get better. You get benchmarked to national benchmarks and to regional benchmarks and to your own institution."
Having Duke, an independent entity, involved in developing the risk-adjustment formulas and doing the number-crunching gives the data an added dimension of integrity, he said.
Prior to final endorsement by the NQF board on Dec. 2, the proposed standards were vetted by four committees representing the interests of health plans and professionals, consumers, purchases and research and quality improvement organizations, according to Philip Dunn, NQF vice president for communications and public affairs. All had input in the standards-setting process, Dunn said.
But having the support of the Society of Thoracic Surgeons in the process was critical to adoption of the standards, Dunn said. "The active participation of the surgeons surely helped enable us to get consensus around a robust set of measures," he said. "The goal is to be able to standardize measures of performance so performance can be measured across institutions and over time."
The challenge, now, Dunn said, is implement the standards.