Memorial Healthcare System Cardiac & Vascular Institute

Hollywood, Florida

CABG Results
Year	Overall Composite Score*	Absence of Operative Mortality	Absence of Major Morbidity	Use of Internal Mammary Artery	Receipt of Required Perioperative Medications
January 2017 - December 2017	3 stars 97.9	2 stars 98.6	2 stars 89.9	2 stars 99.5	3 stars 99.5
January 2018 - December 2018	2 stars 97.8	2 stars 98.3	2 stars 90.9	2 stars 99.5	3 stars 98.9

AVR Results
Year	Overall Composite Score**	Absence of Operative Mortality	Absence of Major Morbidity
January 2016 - December 2018	3 stars 97.2	2 stars 98.6	2 stars 92.0

AVR + CABG Results
Year	Overall Composite Score**	Absence of Operative Mortality	Absence of Major Morbidity
January 2016 - December 2018	2 stars 94.3	2 stars 97.6	2 stars 84.1

MVRR Results
Participant/hospital is not enrolled in public reporting for MVRR but does publicly report for at least one other procedure.

MVRR + CABG Results
Participant/hospital is not enrolled in public reporting for MVRR+CABG but does publicly report for at least one other procedure.

* 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.

Memorial Healthcare System Cardiac & Vascular Institute

Participating hospital associated with this Surgery Group