Baptist Health Louisville

Louisville, Kentucky

CABG Results
Year	Overall Composite Score*	Absence of Operative Mortality	Absence of Major Morbidity	Use of Internal Mammary Artery	Receipt of Required Perioperative Medications
July 2017 - June 2018	3 stars 98.1	2 stars 98.3	2 stars 92.6	2 stars 99.7	3 stars 96.2
July 2018 - June 2019	2 stars 97.8	2 stars 98.0	2 stars 91.7	2 stars 99.7	3 stars 97.6

AVR Results
Year	Overall Composite Score**	Absence of Operative Mortality	Absence of Major Morbidity
July 2016 - June 2019	2 stars 96.3	2 stars 98.2	2 stars 90.5

AVR + CABG Results
Year	Overall Composite Score**	Absence of Operative Mortality	Absence of Major Morbidity
July 2016 - June 2019	3 stars 96.0	2 stars 97.4	3 stars 89.2

MVRR Results
Year	Overall Composite Score**	Absence of Operative Mortality	Absence of Major Morbidity
July 2016 - June 2019	3 stars 96.0	2 stars 97.8	2 stars 88.8

MVRR + CABG Results
Participant/hospital is enrolled in public reporting for MVRR + CABG but did not receive composite measure results for July 2016 - June 2019.

* CABG Overall Composite Score is calculated using a combination of 11 quality measures divided into four categories or domains:

Absence of Operative Mortality: Percentage of patients [risk-adjusted] who did 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.
Absence of Major Morbidity: Percentage of patients [risk-adjusted] who did not experience any major morbidity. These are: 1) reoperation for any cardiac reason (NQF definition); 2) renal failure; 3) deep sternal wound infection; 4) prolonged ventilation/intubation; 5) cerebrovascular accident/permanent stroke.
Use of Internal Mammary Artery: Percentage of first-time CABG patients who received at least one IMA graft.
Receipt of Required Perioperative Medications: Percentage of patients who received all required perioperative medications. Performance on perioperative medications is based on a combination of four NQF-endorsed process measures that relate to pre- and postoperative medication usage. The four medication measures are: 1) preoperative beta blockade therapy; 2) discharge anti-platelet medication; 3) discharge beta blockade therapy; and 4) discharge anti-lipid medication.

The Overall Composite Score represents the four domain scores in a single number.

** AVR Overall Composite Score; AVR+CABG Overall Composite Score; MVRR Overall Composite Score; and MVRR+CABG Overall Composite Score represent two domain scores in a single number:

Absence of Operative Mortality: Percentage of patients [risk-adjusted] who did 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.
Absence of Major Morbidity: Percentage of patients [risk-adjusted] who did not experience any major morbidity. These are: 1) reoperation for any cardiac reason (NQF definition); 2) renal failure; 3) deep sternal wound infection; 4) prolonged ventilation/intubation; 5) cerebrovascular accident/permanent stroke.

Baptist Health Louisville

Participating surgery group associated with this Hospital