Skip to main content

The AHRQ National Quality Measures Clearinghouse (NQMC, qualitymeasures.ahrq.gov) Web site will not be available after July 16, 2018 because federal funding
through AHRQ will no longer be available to support the NQMC as of that date. For additional information, read our full announcement.
  • Measure Summary
  • NQMC:010970
  • Dec 2016

Thoracic surgery: percentage of patients aged 18 years and older undergoing elective esophagectomy for esophageal cancer who developed any of the specified postoperative conditions.

Society of Thoracic Surgeons (STS). General thoracic surgery database: NQMC measure submission. Chicago (IL): Society of Thoracic Surgeons (STS); 2016 Dec. 31 p.

This is the current release of the measure.

Primary Measure Domain

Clinical Quality Measures: Outcome

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the 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, anastomotic leak requiring medical or surgical treatment, reintubation/respiratory failure, initial ventilation greater than 48 hours, pneumonia, or discharge mortality.

Rationale

It is important for surgeons to be able to compare their surgical outcomes to those of peer institutions as a means of assessing results and improving quality of care. Measuring risk‐adjusted morbidity and mortality of patients undergoing esophagectomy for cancer provides surgeons and institutions the opportunity to evaluate outcomes and subsequently design quality improvement initiatives to address identified deficits. Utilization of the insight gained should promote improved patient outcome.

Evidence for Rationale

Society of Thoracic Surgeons (STS). General thoracic surgery database: NQMC measure submission. Chicago (IL): Society of Thoracic Surgeons (STS); 2016 Dec. 31 p.

Primary Health Components

Thoracic surgery; elective esophagectomy; esophageal cancer; postoperative conditions; bleeding requiring reoperation; anastomotic leak; reintubation; respiratory failure; initial ventilation greater than 48 hours; pneumonia; discharge mortality

Denominator Description

Number of patients aged 18 years and older undergoing elective esophagectomy for esophageal cancer (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

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, anastomotic leak requiring medical or surgical treatment, reintubation/respiratory failure, initial ventilation greater than 48 hours, pneumonia, or discharge mortality (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Esophageal cancer is an aggressive disease with a generally poor prognosis. The incidence of esophageal adenocarcinoma is increasing faster than any other malignancy in the United States. In 2015, there were an estimated 16,980 people diagnosed with esophageal cancer.

Esophagectomy, a relatively high morbidity and mortality operation, remains a key therapy in treating patients with localized esophageal cancer. The 30-day mortality rate following esophagectomy ranges between 2.7% and 11%. Within the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD), 24% of patients undergoing esophagectomy for cancer experienced major postoperative morbidity or death. Those with a major morbidity had a hospital discharge mortality of 11% while those patients without a major morbidity had a mortality rate of zero. This analysis identified a number of statistically significant predictors of major morbidity or mortality after esophagectomy for cancer. These factors included age, race, cardiac disease, impaired lung function, peripheral vascular disease, hypertension, diabetes, functional status, smoking status, and steroid use. Recognition of these predictors preoperatively, and modifying them when possible may provide improved outcomes, as measured by mortality, length of stay, postoperative quality of life, overall costs and resource utilization. Some of these preoperative predictors are modifiable, such as smoking status, and have been shown to reduce complication rates. Pulmonary complications are the major source of morbidity and mortality after esophageal resection, and numerous studies have identified various factors associated with these complications. Preoperative factors affecting pulmonary complications include advanced age, poor nutritional status, and poor cardiopulmonary reserve. Intraoperative factors associated with increased rates of pulmonary complications include increased blood loss, excessive fluid administration, prolonged operative times, advanced or proximal esophageal tumors, and more extensive operations, including the McKeown resection with three-field lymph node dissection. Postoperative factors associated with pulmonary complications include the development of atrial fibrillation, recurrent laryngeal nerve injury, and aspiration or other abnormality of deglutition. Enhanced recovery pathways and fast-track protocols, have been shown to reduce major morbidity and length of stay without increasing mortality or readmissions. Knowing their rate of risk adjusted morbidity and mortality after esophagectomy gives thoracic programs the opportunity to design quality improvement initiatives around deficiencies.

Evidence for Additional Information Supporting Need for the Measure

Society of Thoracic Surgeons (STS). General thoracic surgery database: NQMC measure submission. Chicago (IL): Society of Thoracic Surgeons (STS); 2016 Dec. 31 p.

Extent of Measure Testing

General Thoracic Surgery Database (GTSD) participating sites are randomly selected for participation in the Society of Thoracic Surgeons (STS) GTSD Audit, which is designed to evaluate the accuracy, consistency, and comprehensiveness of data collection and ultimately validate the integrity of the data contained in the database. Telligen, formerly the Iowa Foundation for Medical Care, has conducted audits on behalf of STS since 2006. In 2015, ten percent of randomly selected STS GTSD participants (N = 25, an increase from 24 in 2014 and 18 in 2013) were audited. The audit process involves re‐abstraction of data for 20 cases records (at least 15 lobectomy and up to 5 esophagectomy) and comparison of 40 STS GTSD V2.2 individual data elements with those submitted to the data warehouse. Agreement rates are calculated for each variable, each variable category and overall. In 2015, the overall aggregate agreement rate was 97.02%, demonstrating that the data contained in the STS GTSD are both comprehensive and highly accurate.

Data Analysis

Aggregate agreement rates were computed for all facilities by calculation of the sum of all facilities' numerators divided by the sum of all facilities' denominators, for each individual variable, each variable category and overall.

Chi-square statistics were calculated to identify any possible relationships between the data collection process variables and agreement rates. Tests where the chi-square statistic had a probability of less than 5% (p less than 0.05) were considered to show statistically significant differences in agreement rate between the levels of the process measure.

Agreement Rate Results

Database validity was evaluated by re-abstraction of defined variables from the medical records and comparison to submitted data. Agreement rates were calculated at the individual variable level, category level and overall. Aggregate agreement rates are presented in the table in the original measure documentation. There were 14,854 total variables abstracted and of those 14,412 variables matched, resulting in an overall agreement rate of 97.02%.

Process Variable Correlation Tables

The relationships between process variables and overall agreement rates were examined and included:

  • Facility data collection performed from electronic medical records or a combination of paper and electronic medical records and overall agreement rate
  • Facility data collection method (concurrent/retrospective/both) and overall agreement rate
  • Data collection performed by a single abstractor or multiple staff and overall agreement rate
  • Attendance at the annual data managers' meeting, STS Advances in Quality and Outcomes (AQO) Conference, and overall agreement rate
  • Agreed upon abstraction location for data elements documented in multiple locations and overall agreement rate

Relationship between Data Collection Source & Agreement Rate

Facilities using an electronic health record (EHR) for data collection had higher agreement rates, 97.36%, than those facilities using both paper medical records and an EHR, 96.31%. There were no facilities that used paper medical records alone (p less than 0.0004).

Relationship between Data Collection Method & Agreement Rate

Facilities collecting data retrospectively have higher agreement rates, 97.55%, than those facilities collecting data concurrently, 96.18%, or both, 96.38% (p equal to or less than 0.0001).

Relationship between Data Collection Performed by a Single Abstractor or Multiple Staff & Agreement Rate

Facilities with a single individual performing data abstraction have higher agreement rates, 98.02%, than those facilities that have multiple individuals performing data abstraction, 96.24% (p less than 0.0001).

Relationship between Attendance at AQO Conference & Agreement Rate

Facilities having staff attend the annual AQO Conference have higher agreement rates, 97.25%, than those that do not have staff attend, 96.11% (p less than 0.0012).

Relationship between Have an Agreed Upon Location & Agreement Rate

Facilities that utilize an agreed upon location for data elements recorded in multiple locations have higher agreement rates, 97.31%, than facilities that do not utilize an agreed upon location, 93.61% (p less than 0.0001).

In addition, validity is regularly assessed by an expert panel of general thoracic surgeons assembled by the STS General Thoracic Surgery Database Task Force, the STS Quality Measurement Task Force, and the STS Task Force on Quality Initiatives, all of which report to the STS Workforce on National Databases.

Evidence for Extent of Measure Testing

Society of Thoracic Surgeons (STS). General thoracic surgery database: NQMC measure submission. Chicago (IL): Society of Thoracic Surgeons (STS); 2016 Dec. 31 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Public reporting

Measurement Setting

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Safety

Case Finding Period

36 months

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Institutionalization

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

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

Denominator Details

  1. Esophageal cancer (EsophCancer – Society of Thoracic Surgeons [STS] General Thoracic Surgery Database [GTSD] sequence number 1140) is marked "yes" and category of disease – primary (CategoryPrim – STS GTSD sequence number 1300) is marked as one of the following (International Classification of Diseases, Ninth Revision [ICD-9], International Classification of Diseases, Tenth Revision [ICD-10]):
    • Esophageal cancer, lower third (150.5, C15.5)
    • Esophageal cancer, middle third (150.4, C15.4)
    • Esophageal cancer, upper third (150.3, C15.3)
    • Esophageal cancer, esophagogastric junction (cardia) (151.0, C16.0)
  2. Primary procedure (Primary – STS GTSD sequence number 1500) is marked as one of the specific Current Procedural Terminology [CPT] codes for esophagectomy (refer to the original measure documentation for specific CPT codes)
  3. Status of operation (Status – STS GTSD sequence number 1420) is marked as "elective"
  4. Gender (Gender – STS GTSD sequence number 190) is marked "male" or "female," and discharge status (MtDCStat – STS GTSD sequence number 2200) is marked as "alive" or "dead"
  5. Only analyze first operation of hospitalization meeting criteria 1 to 4

Exclusions
None

Exclusions/Exceptions

None

Numerator Inclusions/Exclusions

Inclusions
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, anastomotic leak requiring medical or surgical treatment, reintubation/respiratory failure, initial ventilation greater than 48 hours, pneumonia, or discharge mortality

Numerator Details: Number of patients undergoing elective esophagectomy for esophageal cancer for whom:

  1. Postoperative events (POEvents – Society of Thoracic Surgeons [STS] General Thoracic Surgery Database [GTSD] sequence number 1710) is marked "yes" and one of the following items is marked "yes":
    • Anastomotic leak requiring medical treatment only (AnastoMed – STS GTSD sequence number 1950)
    • Reintubation (Reintube – STS GTSD v 2.2, sequence number 1850)/respiratory failure (RespFail – STS GTSD sequence number 1800)
    • Initial ventilator support greater than 48 hours (Vent – STS GTSD sequence number 1840)
    • Pneumonia (Pneumonia – STS GTSD sequence number 1780)

      or

    • Unexpected return to the operating room (OR) (ReturnOR – STS GTSD sequence number 1720) is marked "yes" and primary reason for return to OR (ReturnORRsn – STS GTSD sequence number 1730) is marked "bleeding" or "anastomotic leak following esophageal surgery"

    or

  2. Discharge status (MtDCStat – STS GTSD sequence number 2200) is marked as "dead"

Note: Numerator Time Period:

  • Complications: During hospitalization regardless of length of stay or within 30 days of surgery if discharged
  • Discharge Mortality: During the same hospitalization as surgery regardless of timing

Exclusions
Unspecified

Numerator Search Strategy

Institutionalization

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Registry data

Type of Health State

Adverse Health State

Instruments Used and/or Associated with the Measure

The Society of Thoracic Surgeons General Thoracic Surgery Database (GTSD) Major Procedure Data Collection Form Version 2.3

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Case-mix adjustment

Risk adjustment devised specifically for this measure/condition

Description of Allowance for Patient or Population Factors

The Society of Thoracic Surgeons (STS) General Thoracic Database was queried for all patients treated with esophagectomy for esophageal cancer between January 2002 and December 2007. A multivariable risk model for mortality and major morbidity was constructed.

Multiple risk factors were identified for combined morbidity and mortality after esophagectomy for cancer: age, congestive heart failure (CHF), coronary artery disease (CAD), peripheral vascular disease (PVD), diabetes, hypertension, use of steroids, smoking status, and American Society of Anesthesiology (ASA) score. Using these results, they constructed a risk model for esophagectomy that allows individual STS sites to compare their results with others as a means toward quality improvement.

For more information, refer to Predictors of Major Morbidity and Mortality after Esophagectomy for Esophageal Cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database Risk Adjustment Model (see the "Companion Documents" field).

Standard of Comparison

External comparison at a point in, or interval of, time

Internal time comparison

Original Title

Risk‐adjusted morbidity and mortality for esophagectomy for cancer.

Measure Collection Name

General Thoracic Surgery Measures

Submitter

Society of Thoracic Surgeons - Medical Specialty Society

Developer

Society of Thoracic Surgeons - Medical Specialty Society

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database Task Force. Please contact STS for list of members.

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2016 Dec

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

Society of Thoracic Surgeons (STS). General thoracic surgery database: NQMC measure submission. Chicago (IL): Society of Thoracic Surgeons (STS); 2016 Dec. 31 p.

Measure Availability

Source not available electronically.

For more information, contact the Society of Thoracic Surgeons (STS) at 633 N. Saint Clair Street, Floor 23, Chicago, IL 60611; Phone: 312-202-5800; Fax: 312-202-5801; Web site: http://www.sts.org External Web Site Policy.

Companion Documents

The following is available:

  • Wright CD, Kucharczuk J, O'Brien SM, Grab JD, Allen MS. Predictors Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. J Thorac Cardiovasc Surg. 2009 Mar;137(3):587-95; discussion 596. Available from the Journal of Thoracic and Cardiovascular Surgery Web site External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on January 9, 2017. The information was verified by the measure developer on February 7, 2017.

Copyright Statement

No copyright restrictions apply.

NQMC Disclaimer

The National Quality Measures Clearinghouse™ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.

All measures summarized by NQMC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public and private organizations, other government agencies, health care organizations or plans, individuals, and similar entities.

Measures represented on the NQMC Web site are submitted by measure developers, and are screened solely to determine that they meet the NQMC Inclusion Criteria.

NQMC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or its reliability and/or validity of the quality measures and related materials represented on this site. Moreover, the views and opinions of developers or authors of measures represented on this site do not necessarily state or reflect those of NQMC, AHRQ, or its contractor, ECRI Institute, and inclusion or hosting of measures in NQMC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding measure content are directed to contact the measure developer.

About NQMC Measure Summaries

NQMC provides structured summaries containing information about measures and their development.

Measure Summary FAQs


Measure Summaries

New This Week

View more and sign up for our Newsletter

Get Adobe Reader