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Valid for Initial Endorsement
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STS Lobectomy for Lung Cancer Composite Score

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.

CBE ID
3294

STS Mitral Valve Repair/Replacement (MVRR) + Coronary Artery Bypass Graft (CABG) Composite Score

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

CBE ID
3032

STS Mitral Valve Repair/Replacement (MVRR) Composite Score

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

CBE ID
3031

SUB-1 Alcohol Use Screening

Hospitalized patients 18 years of age and older who are screened within the first day of admission using a validated screening questionnaire for unhealthy alcohol use.

CBE ID
1661

SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB-2a Alcohol Use Brief Intervention

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB-2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the brief intervention during the hospital stay.

CBE ID
1663

SUB-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge.

CBE ID
1664

Suboptimal Asthma Control (SAC) and Absence of Controller Therapy (ACT)

Rate 1 (SAC): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of a short-acting beta2 agonist inhaler during the same 90-day period.

Rate 2 (ACT): The percentage of patients aged 5-50 years as of the last day of the measurement year with persistent asthma who were dispensed more than 3 canisters of short-acting beta2 agonist inhalers over a 90-day period and who did not receive controller therapy during the same 90-day period.

CBE ID
0548

Substance Use Screening and Intervention Composite

Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results

CBE ID
2597

Surgery Patients with Perioperative Temperature Management

Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8° F/36° C recorded within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time.

CBE ID
0452