This measure is calculated based on data extracted from the electronic medical record combined with administrative data sources such as professional fee and discharge diagnoses data. This measure is explicitly not based on provider self-attestation.
Percentage of high cardiac risk cases with significantly elevated postoperative troponin levels.
* High-risk surgeries include intraperitoneal, intrathoracic, or suprainguinal vascular procedures, as adapted from the Revised Cardiac Risk Index (RCRI) and identified by Anesthesia CPT codes:
High Risk Surgery Type |
Anesthesia CPT Codes |
Intraperitoneal |
00730, 00754, 00756, 00790, 00792, 00794, 00796, 00797, 00840, 00844, 00846, 00848, 00851, 00866, 01140 |
Intrathoracic |
00500, 00539, 00540, 00541, 00542, 00546, 00548, 00625, 00626, 01636, |
Suprainguinal Vascular |
00216, 00350, 00670, 00770, 00880, 00882, 01650, 01652, 01654, 01656, 01770, 01772, 01925, 01926 |
** Comorbidities posing high cardiac risk are adapted from the Revised Cardiac Risk Index (RCRI) and are identified by Elixhauser Comorbidity Index variables (congestive heart failure, diabetes), preoperative lab values (baseline serum creatinine), or comorbidity-specific ICD-9/10 codes (ischemic heart disease, cerebrovascular disease):
Comorbidity |
Specific Diagnostic Criteria |
Congestive heart failure |
Elixhauser Comorbidity – Congestive Heart Failure: https://collations.mpogresearch.org/Detail.aspx?name=Comorbidity%20-%20Congestive%20Heart%20Failure |
Diabetes |
Elixhauser Comorbidity – Diabetes (uncomplicated): https://collations.mpogresearch.org/Detail.aspx?name=Comorbidity%20-%20Diabetes%20(uncomplicated)
OR
Elixhauser Comorbidity – Diabetes (complicated): https://collations.mpogresearch.org/Detail.aspx?name=Comorbidity%20-%20Diabetes%20(complicated) |
Ischemic Heart Disease |
MPOG Phenotype – Coronary Artery Disease: https://collations.mpogresearch.org/Detail.aspx?name=Coronary%20Artery%20Disease
|
Cerebrovascular Disease |
MPOG Phenotype – Cerebrovascular Disease: https://collations.mpogresearch.org/Detail.aspx?name=Cerebrovascular%20Disease
|
Chronic Kidney Disease |
Most recent serum creatinine within 60 days > 2.0 mg/dL |
*** Rationale for excluding patient with troponin elevation within 42 days prior to date of surgery is based upon ACC/AHA guidelines recommending a delay in elective surgery for 6 weeks following myocardial infarction.
In cases with Troponin I or Troponin T value(s) available within 72 hours after anesthesia end, all values must be less than or equal to the following:
If no Troponin I (or Troponin T) values are available within 72 hours after anesthesia end and there is no documentation of perioperative myocardial injury (MPOG Concepts: 90201, 90202), the case will not be flagged (ie we presume no myocardial injury).
Providers assigned to patient longest duration of case unless there are providers who failed BP 01 (sustained MAP < 55 mmHg) during case. In that case, BP 01 failure takes precedence over longest duration.
Method for determining Responsible Provider:
Troponin MPOG Concept ID |
Myocardial Injury MPOG Concept IDs |
Creatinine MPOG Concept ID |
|||
5011 |
Formal lab – Cardiac Troponin I (cTnl ng/mL) |
90201 |
CPOM measure Cardiac Arrest |
5002 |
Formal lab – Creatinine, Serum/Plasma |
3396 |
Formal lab – Cardiac Troponin I (cTnl ng/L) |
90202 |
CPOM measure Myocardial Ischemia |
|
|
3397 |
Formal lab – High-sensitivity Cardiac Troponin T (hs-cTnT ng/mL) |
|
|||
3392 |
Formal lab – High-sensitivity Cardiac Troponin T (hs-cTnT ng/L) |
|
|||
3401 |
Formal lab – High-sensitivity Cardiac Troponin T (hs-cTnT pg/mL) |
|
Preventing myocardial infarction is an important anesthetic goal. Protecting against this outcome is particularly relevant among patients with comorbid conditions or undergoing surgeries at high risk of major adverse cardiac events.
Troponin I levels are accurate markers of myocardial infarction. Postoperative myocardial injury within 72 hours (as defined by a Troponin I level >2x the 99th percentile upper reference limit) is associated with a significantly increased risk of 30-day mortality. Furthermore, any amount of postoperative myocardial injury (as defined by a Troponin I level > 0.03 ng/mL) is an independent predictor of 30-day mortality. Adjusted relative risk of death was 4.2 for patients with Troponin I ≥ 0.60 ng/mL.
To evaluate provider-level risk adjustment we will calculate the observed to expected outcomes ratio (O/E). The O/E is calculated using a logistic regression model and predicts (given a set list of dependent patient and hospital level variables) the expected probability of having an elevated Troponin I level. We adjust for surgery risk score, emergent procedures, ASA, gender, age, body mass index, laboratory values, and teaching versus private hospital. Patient specific comorbidities are evaluated as well.