This JAMA Guide to Statistics and Methods describes the attributes, potential uses, and limitations of the Society of Thoracic Surgery National Database.
The Society of Thoracic Surgeons (STS) National Database is a voluntary clinical registry created to facilitate a national quality improvement and safety initiative for cardiac surgery. This progressive initiative led to one of the earliest attempts to provide surgeons with nationally benchmarked, risk-adjusted outcomes. The database (Box 13) is now also used to facilitate the public reporting of outcomes and clinical research. It consists of 3 components, each focusing on a separate type of cardiothoracic surgery: adult cardiac surgery (established 1989), congenital heart surgery (1994), and general thoracic surgery (2002). Since 1999, the STS has contracted the Duke Clinical Research Institute to warehouse the data, conduct statistical analyses, and provide participants with performance reports.
BOX 13 Details of the STS National Database
The STS National Database measures demographic variables, specialty-specific covariates, and short-term outcomes such as morbidity, mortality, and length of stay.
Studies using the STS National Database are retrospective cohort designs. Consecutive cases are abstracted with longitudinal follow-up for short-term outcomes.
Like other observational study designs, confounding threatens validity; however, covariate breadth and specificity provide ample opportunity for adjustment through standard methods.
Limitations include the procedure-based (rather than disease-based) nature of the database; absence of clinician-level characteristics, long-term outcomes, and patient-reported outcomes; and possibly limited generalizability.
The STS National Database provides the most granular and specialty-specific data for performance feedback, voluntary public reporting outcomes, and clinical research on patients undergoing cardiothoracic surgery in the United States.
DATA ELEMENT CONSIDERATIONS
Adult Cardiac Surgery Database (ACSD)
As of September 2016, the Adult Cardiac Surgery Database (ACSD) had more than 6.1 million patient records from 1119 participant health care centers (typically defined as an institutional surgical program, rather than a single hospital) encompassing 3100 surgeons from all 50 US states and 29 participants from 8 other countries.1 Linkage analysis between ACSD and Centers for Medicare and Medicaid Services (CMS) data reveals high voluntary participation levels, with data on 94% of Medicare beneficiaries undergoing coronary artery bypass grafting surgery and from 90% of the sites providing care to Medicare beneficiaries.
All STS data are subject to internal validation checks. Each year, a random sample of 10% of sites undergo an external audit, revealing 100% case ascertainment and 95% concordance between abstracted and audited data. Participants receive performance reports with risk-adjusted mortality rates for 7 major procedures; coronary artery bypass grafting surgery accounts for 69% of all cases. Using a 3-star system (in which 3 stars indicate the best performance), the STS calculates a composite score across 11 National Quality Forum indicators to publicly report participant-level performance.1
Congenital Heart Surgery Database