Memorial Healthcare System Cardiac & Vascular Institute

Memorial Healthcare System Cardiac & Vascular Institute

Associated Hospital

NOTE: Results are based on a participant’s unique group of patients (known as case mix) and the number of surgical procedures in each category. Results and star ratings below are specific to the participant listed and are not intended for direct comparison to other participants.

This Adult Cardiac Surgery Database (ACSD) participant’s score is shown as both a number and a vertical black line in each graph below. Following the participant’s score, the numbers in parentheses – (##, ##) – represent the range (known as a credible interval) within which the participant’s score was likely to fall. Determined using a statistical formula, each participant has a different range. Ranges are based on the participant’s unique mix of patients and number of surgical procedures in each category. The graphs also show the STS average score (the vertical red line) and the lowest-to-highest range across all North American ACSD participants. Hover over each graph for specific descriptions.

Using a statistical formula, participants receive star ratings based on their scores and how they compare to the STS average: 

1 stars
Worse Than Expected
If the participant's score and range is lower than the STS average score, the participant receives 1 star.
2 stars
As Expected
If the STS average score falls within the participant's range, the participant receives 2 stars.
3 stars
Better Than Expected
If the participant's score and range is higher than the STS average score, the participant receives 3 stars.

The majority of ACSD participants receive a 2-star (“as-expected”) rating. In comparison, far fewer participants receive 1-star (“worse than expected”) or 3-star (“better than expected”) ratings. In general, a 2-star or 3-star rating is consistent with good or excellent performance.

  • CABG Composite Quality Rating (January 2018 - December 2018)
    Overall Composite Score 97.8% (96.7, 98.6)
    97.8% (96.7, 98.6)
    100 98 96 94 92 90 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Operative Mortality 98.3% (96.8, 99.2)
    98.3% (96.8, 99.2)
    100 98 96 94 92 90 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Major Morbidity 90.9% (87.3 , 93.8)
    90.9% (87.3, 93.8)
    100 95 90 85 80 75 70 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Use of Internal Mammary Artery 99.5% (98.4 , 99.9)
    99.5% (98.4, 99.9)
    100 90 80 70 60 50 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Receipt of Required Perioperative Medications 98.9% (97.1, 99.8)
    98.9% (97.1, 99.8)
    100 90 80 70 60 50 40 30 20 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    Better Than Expected
    3 stars
  • CABG Composite Quality Rating (January 2019 - December 2019)
    Overall Composite Score 98.2% (97.3, 98.8)
    98.2% (97.3, 98.8)
    100 98 96 94 92 90 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    Better Than Expected
    3 stars
    Absence of Operative Mortality 98.3% (96.9, 99.1)
    98.3% (96.9, 99.1)
    100 98 96 94 92 90 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Major Morbidity 92.7% (89.6 , 95.3)
    92.7% (89.6, 95.3)
    100 95 90 85 80 75 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    Better Than Expected
    3 stars
    Use of Internal Mammary Artery 99.6% (98.5 , 100.0)
    99.6% (98.5, 100)
    100 95 90 85 80 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Receipt of Required Perioperative Medications 99.6% (98.5, 100.0)
    99.6% (98.5, 100)
    100 90 80 70 60 50 40 30 20 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    Better Than Expected
    3 stars
  • AVR Composite Quality Rating (January 2017 - Decmber 2019)
    Overall Composite Score 97.5% (96.2, 98.5)
    97.5% (96.2, 98.5)
    100 98 96 94 92 90 88 86 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    Better Than Expected
    3 stars
    Absence of Operative Mortality 98.6% (97.4, 99.3)
    98.6% (97.4, 99.3)
    100 98 96 94 92 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Major Morbidity 92.4% (88.9 , 95.1)
    92.4% (88.9, 95.1)
    100 95 90 85 80 75 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
  • AVR+CABG Composite Quality Rating (January 2017 - Decmber 2019)
    Overall Composite Score 94.2% (91.4, 96.3)
    94.2% (91.4, 96.3)
    100 95 90 85 80 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Operative Mortality 97.0% (94.6, 98.6)
    97% (94.6, 98.6)
    100 98 96 94 92 90 88 86 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Major Morbidity 85.0% (78.8 , 90.0)
    85% (78.8, 90)
    100 90 80 70 60 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
  • MVRR Composite Quality Rating (January 2017 - Decmber 2019)
    Overall Composite Score 95.7% (93.9, 97.1)
    95.7% (93.9, 97.1)
    100 98 96 94 92 90 88 86 84 82 80 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Operative Mortality 97.9% (96.3, 99.0)
    97.9% (96.3, 99)
    100 98 96 94 92 90 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Major Morbidity 87.7% (82.9 , 91.5)
    87.7% (82.9, 91.5)
    100 90 80 70 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
  • MVRR+CABG Composite Quality Rating (January 2017 - Decmber 2019)
    Overall Composite Score 86.9% (81.7, 91.1)
    86.9% (81.7, 91.1)
    100 95 90 85 80 75 70 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Operative Mortality 94.0% (89.8, 97.0)
    94% (89.8, 97)
    100 95 90 85 80 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars
    Absence of Major Morbidity 70.5% (61.0 , 78.8)
    70.5% (61, 78.8)
    90 80 70 60 50 >
    Participant Score
    Participant Credible Interval
    STS Range
    STS Average Score
    As Expected
    2 stars

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

  1. 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.
  2. 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.
  3. Use of Internal Mammary Artery: Percentage of first-time CABG patients who received at least one IMA graft.
  4. 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:

  1. 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.
  2. 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.