Endorsed

Percentage of patients 13 years of age and older with a diagnosis of HIV who had tests for syphilis, gonorrhea, and chlamydia performed within the measurement period.

This measure captures the proportion of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well for whom IV t-PA was initiated at this hospital within 3 hours of time last known well.

The STS AVR+CABG Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1.

STS AVR Composite Score comprises two domains consisting of six measures: Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure; and Domain 2) Absence of Major Morbidity – Proportion of patients (risk-adjusted) who do not experience any major morbidity. Major morbidity is defined as having at least one of the following adverse outcomes: 1. reoperations for any cardiac reason, 2.

The STS CABG Composite Score comprises four domains consisting of 11 individually NQF-endorsed cardiac surgery measures:
Domain 1) Absence of Operative Mortality – Proportion of patients (risk-adjusted) who do not experience operative mortality. Operative mortality is defined as death during the same hospitalization as surgery or after discharge but within 30 days of the procedure;

The STS Individual Surgeon Composite Measure for Adult Cardiac Surgery includes five major procedures (isolated CABG, isolated AVR, AVR+CABG, MVRR, MVRR+CABG) and comprises the following two domains:

Domain 1 – Risk-Adjusted Operative Mortality
Operative mortality is defined as death before hospital discharge or within 30 days of the operation.

Domain 2 – Risk-Adjusted Major Morbidity
Major morbidity is defined as the occurrence of any one or more of the following major complications:
1. Prolonged ventilation,
2. Deep sternal wound infection,

The STS Lobectomy Composite Score comprises two domains:

1. Operative Mortality (death during the same hospitalization as surgery or within 30 days of the procedure)
2. Presence of at least one of these major complications: pneumonia, acute respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation/respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room.

The STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score measures surgical performance for MVRR + CABG with or without concomitant Atrial Septal Defect (ASD) and Patient Foramen Ovale (PFO) closures, tricuspid valve repair (TVr), or surgical ablation for atrial fibrillation (AF). To assess overall quality, the STS MVRR +CABG Composite Score comprises two domains consisting of six measures:

Domain 1 – Absence of Operative Mortality

The STS Mitral Valve Repair/Replacement (MVRR) Composite Score measures surgical performance for isolated MVRR with or without concomitant tricuspid valve repair (TVr), surgical ablation for atrial fibrillation (AF), or repair of atrial septal defect (ASD). To assess overall quality, the STS MVRR Composite Score comprises two domains consisting of six measures:

Domain 1 – Absence of Operative Mortality

Surgical volume for pediatric and congenital heart surgery: total programmatic volume and programmatic volume stratified by the 5 Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories), a multi-institutional validated complexity stratification tool