SoCal Voice Quarterly Data Managers Webinar. October 26, 2016

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1 SoCal Voice Quarterly Data Managers Webinar October 26, 2016

2 Agenda Update from 1 st Data Managers Meeting at the SVS Annual Meeting Please note- all presentations are posted on the resource tab on the M2S site New Medicine Registry Registry Analytics Enhancements Regional Data Managers Webinar Update

3

4 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Total Procedures Captured (as of 6/1/2016) 298,303 Peripheral Vascular Intervention 93,996 Carotid Endarterectomy 68,466 Infra-Inguinal Bypass 30,947 Endovascular AAA Repair 27,326 Hemodialysis Access 25,450 Carotid Artery Stent 11,183 Supra-Inguinal Bypass 10,508 Open AAA Repair 8, , , , , , , , , ,000 75,000 50,000 25,000 0 VQI Total Procedure Volume Thoracic and Complex EVAR 6,426 IVC Filter 5,541 Lower Extremity Amputations 5,399 Varicose Vein 4,739

5 A Look at Key Issues Across Registries: Inclusion/ Exclusion Inter-rater Reliability

6 Q1: Complications, Multiple Procedures: For which procedure(s) below should the complications be reported? A patient had an SFA stent, developed a hematoma, and required admission. While in the hospital, he had a TIA, underwent carotid endarterectomy and then had an MI. A. Hematoma for PVI, MI for CEA B. Hematoma for PVI, MI for both PVI and CEA C. Hematoma and MI for both PVI and CEA D. None of above

7 Q1: Correct Answer A. Hematoma for PVI, MI for CEA B. Hematoma for PVI, MI for both PVI and CEA C. Hematoma and MI for both PVI and CEA D. None of above

8 Q1: Rationale for Answer Local complications like hematoma from puncture site or surgical site infection can be accurately attributed to a single procedure. However, systemic complications, including death, could be due to either or both prior procedures Any systemic complication should be listed for all procedures that occurred during the same admission

9 Q2: Medication Reporting: How should pre-op Aspirin medication be reported? A patient with a recent TIA is admitted for CEA. Last month he had an upper GI bleed and is not on ASA. A. Yes B. No C. Intolerant D. No for medical reason

10 Q2: Correct Answer A. Yes B. No C. Intolerant D. No for medical reason

11 Q2: Rationale for Answer This response is used to indicate a situation where the patient would normally have been taking a medication, but could not be prescribed this medication due to a co-existing condition which contra-indicated the medication, such as recent bleeding in this case for ASA. Any contra-indication documented in the record provides a basis for this choice This is distinct from a patient who had shown intolerance to ASA previously by bleeding complications due to ASA

12 Q3: Indeterminate Data: How should pre-op stress test be recorded? A patient had a pre-op stress test that is reported as indeterminate for MI and ischemia. A. Normal B. (+) Ischemia C. (+) MI D. (+) Both

13 Q3: Correct Answer A. Normal B. (+) Ischemia C. (+) MI D. (+) Both

14 Q3: Rationale for Answer In order to record that an event occurred or a test was positive, there has to be clear evidence or documentation. If the stress test could not determine that ischemia or MI existed, it must be reported as normal since there is no option for indeterminate This also applies to complications. Only when clear documentation is present should these be recorded as having occurred. Discussing a questionable event or test with the patient s physician can be helpful in unclear situations

15 Registry Overview Open AAA Repair Endovascular AAA Repair Thoracic and Complex EVAR

16 General Overview: oaaa Inclusion Primary repair of infrarenal aortic aneurysms that may include iliac aneurysm repair by abdominal surgery with the proximal anastomosis distal to the renal arteries Suprarenal clamping is recorded, as is renal bypass for occlusive disease

17 General Overview: oaaa Exclusions: Aortic aneurysms that involve the renal artery such that the proximal aortic anastomosis is above a renal artery so that reimplantation or bypass of a renal artery is required Note that AAA repair with renal bypass was done for renal artery occlusive disease is included and the renal bypass is captured as a concomitant procedure Revisions of previous open abdominal aortic aneurysm repairs Isolated iliac aneurysm that do not involve anastomosis to the aorta Repairs done for infected aneurysms Repair done for trauma

18 Definition of a Juxtarenal AAA Juxtarenal infrarenal abdominal aortic aneurysms are defined as those aneurysms that involve the abdominal aorta adjacent to or including the lower margin of the renal origins Open repair is captured as long as the proximal aortic anastomosis is below the renal arteries

19 AAA Types

20 Rationale for Excluding Suprarenal Aneurysms/TAAA In order to obtain uniform data for open AAA, we excluded low volume procedures that can be extremely varied (those involving the visceral segment) Our intention is to capture only those repairs performed below the renal arteries in order to avoid comparing unlike patients/procedures

21 Q1: If a ruptured aneurysm patient dies on the operating table, should this procedure be captured in the registry? A. Only if an EVAR was attempted B. Only if an open repair was attempted C. If any incision was made in an attempt to repair the aneurysm D. Only if a clamp was placed on the aorta

22 Q1: Correct Answer A. Only if an EVAR was attempted B. Only if an open repair was attempted C. If any incision was made in an attempt to repair the aneurysm D. Only if a clamp was placed on the aorta

23 Q1: Rationale for Answer Our intention is to capture not only the outcome of an operation, but also the decision to perform the operation Should the patient die on the operating table during an attempted repair, we want to capture the attempt so that we have the true denominator of attempted aneurysm repairs (both open and EVAR) and their outcome This will help us with forming assessment tools for clinical decision-making in the future

24 General Overview: EVAR Primary endovascular repair of degenerative infrarenal aortic aneurysms that may include iliac aneurysms Uncovered stent grafts extending above the renal arteries are included

25 Exclusions: EVAR Revision of previous VQI endografts (which is captured on the follow-up form for that procedure) Supra-renal covered stents with renal fenestrations or branches (which are entered under TEVAR/Complex EVAR) Isolated iliac aneurysms if the endograft is not placed within the aorta Operations done for infected aneurysms Operations done for anastomotic aneurysm (Pseudoaneurysm) after previous open repair EVAR performed for non-aneurysmal infrarenal pathology, such as isolated dissection or atherosclerotic occlusive disease (the latter is captured under PVI, the former is not captured in the VQI Registry) Repair done for trauma

26 Q2: How do we get the angle measurements for EVAR? A. Obtain formal pre-planning documentation from the vendor B. Use EVAR neck angle cheat sheet from the PATHWAYS resource tab to remind your doctor/qualified assistant to capture C. Axial CT scan and a protractor D. Both A & B E. Both B & C

27 A. Obtain formal pre-planning documentation from the vendor B. Use EVAR neck angle cheat sheet from the PATHWAYS resource tab to remind your doctor/qualified assistant to capture C. Axial CT scan and a protractor D. Both A & B E. Both B & C Q2: Correct Answer

28 Q2: Correct Answer (cont d) Both the formal pre-planning sheet or your doctor s assessment are good resources for obtaining this data point The pre-planning sheet may not be part of the official Medical Record so approval by the site may be needed

29 Q2: Rationale for Answer Angle Assessment

30 Q2: Rationale for Answer Vendor representatives are often trained to use 3D imaging and will provide a formal plan to physicians, usually including neck angulation Physicians and their trainees/assistants are often trained to use 3D imaging software and are capable of obtaining these angles using this software

31 General Overview: TEVAR and Complex EVAR Primary endovascular repair of thoracic aortic pathology, including aneurysm, dissection and trauma Also included are thoracoabdominal and supra-renal AAA (Type IV TAAA), including visceral/renal/great vessels managed with fenestration, branch graft, or debranching bypass

32 Exclusions: TEVAR and Complex EVAR Repairs done for infected aneurysms or trauma Infrarenal AAA (captured in EVAR Registry)

33 Q3: How does a dissection differ from an intramural hematoma (IMH)? A. Dissection has a septum B. IMH has a tear in the septum and dissection does not C. IMH is more often treated with open surgery D. Dissection has a tear in the septum and IMH does not

34 Q3: Correct Answer A. Dissection has a septum B. IMH has a tear in the septum and dissection does not C. IMH is more often treated with open surgery D. Dissection has a tear in the septum and IMH does not

35 Q3: Rationale for Answer

36 General Overview: CAS Inclusion Carotid artery stents Carotid bifurcation/ isolated to the ICA/CCA that may be performed by percutaneous or open (cut down) approach Both primary and redo stenting is included Stenting for trauma If the procedure failed when attempting to place the long sheath in the CCA, this should be recorded as a technical failure

37 General Overview: CAS Exclusions External Carotid Artery or Intracranial Carotid Artery stents (above C1) Stents placed to gain access to cerebral vessels for coiling or active stroke in progress

38 General Overview: CEA Inclusions Conventional or eversion endarterectomy of the carotid bifurcation that extends into the internal carotid artery Both primary and redo operations Concomitant procedures such as CABG or proximal carotid stenting are specified on the data form

39 General Overview: CEA Exclusions Isolated common or external carotid endarterectomy Bypass grafts for carotid disease Operations for infected patches or other infectious etiologies Carotid pseudoaneurysm

40 Q1: For abstraction in VQI, the following procedure is captured as what procedure? The surgeons operative report reads as follows: The carotid artery was opened and endarterectomized with excellent endpoints. An eversion endarterectomy of the external carotid artery was performed. The artery was closed with a bovine pericardial patch. A. Eversion endarterectomy B. Standard endarterectomy C. Both an eversion and standard endarterectomy D. Neither

41 Q1: Correct Answer A. Eversion endarterectomy B. Standard endarterectomy C. Both an eversion and standard endarterectomy D. Neither

42 Q1: Rationale for Answer Conventional and eversion are the two approaches to remove the plaque from the carotid artery Conventional involved opening the carotid longitudinally onto the ICA and removing the plaque and typically patch closure is performed Eversion involves transecting the carotid and removing the plaque by everting the ICA or ICA and ECA. No patch is used These techniques are used to describe treatment of the ICA only, the ECA may be handled differently than the ICA, but this is not tracked

43 Conventional Endarterectomy

44 Eversion Endarterectomy

45 Q2: Based on the following information, how best would you classify this patients preoperative symptoms? A patient undergoes a left carotid artery stenting. The patient had an episode of left eye blindness for 30 minutes one month prior. He then experiences an episode of aphasia >24 hours, resulting in admission to the hospital and stenting. A. Left ocular TIA, left cortical infarction B. Left ocular stroke, left cortical TIA C. Left ocular TIA, right cortical infarction D. Not enough information to determine

46 Q2: Correct Answer A. Left ocular TIA, left cortical infarction B. Left ocular stroke, left cortical TIA C. Left ocular TIA, right cortical infarction D. Not enough information to determine

47 Q2: Rationale for Answer Determining are of the brain involved in a patients symptoms can be very difficult More than one pathology may be present Typically, symptoms lasting less than 24 hours are called transient ischemic attacks (TIAs) Symptoms lasting longer than 24 hours are termed strokes

48 Q2: Rationale for Answer All symptoms should be correlated to brain imaging when available due to variations from patient to patient to properly classify symptoms location Visual changes can be due to events to the eye directly (most commonly), or the occipital lobe (vertebrobasilar symptoms) Speech center may be on the right OR left, based on cerebral dominance When all else fails, discussion with the physician is best to ensure proper classification of symptoms

49 Q2: Rationale for Answer

50 General Overview: Inclusions PVI Lower Extremity Bypass Percutaneous and/or cut-down interventional procedures of leg arteries including balloon angioplasty, stenting, stent-grafting and/or atherectomy for (1) occlusive disease of the infrarenal aorta or distal arteries and (2) true aneurysms of the femoral popliteal arteries Both the initial procedure and any subsequent procedures should be entered into the registry including any repeat interventions on the same artery Interventions on arteries proximal or distal to an existing leg bypass are included as long as the procedure does not include treatment of any part of the bypass including the anastomosis or graft Femoral endarterectomy combined with peripheral vascular intervention on arteries proximal or distal to the femoral artery are included in the registry Isolated thrombolysis or mechanical clot extraction are not captured, unless lysis is done as an adjunct to primary treatment of an atherosclerotic lesion

51 General Overview: Exclusions Treatment of vein or prosthetic grafts that involves the proximal anastomosis, bypass graft or distal anastomosis (this treatment is captured on the follow-up form for the original bypass) Abdominal aortic aneurysms (which are captured under EVAR) Iliac artery aneurysms Mesenteric or renal peripheral vascular interventions (PVI is limited to lower extremity peripheral vascular interventions) Diagnostic procedures not associated with interventions Isolated thrombolysis or mechanical thrombectomy without angioplasty, stenting or atherectomy Treatment of an infected aneurysm Intervention done for trauma. Pseudoaneurysm

52 General Overview

53 General Overview

54 General Overview

55 Q1: If a patient has a PVI procedure that results in a 'technical failure' are we required to record a follow-up in the VQI Registry? A. Yes, if technical failure then record complete followup B. Yes, if technical failure then record long term followup of medications only C. Yes, if technical failure then record long term of patients symptoms only D. No, if technical failure then no long term follow-up should be recorded

56 Q1: Correct Answer A. Yes, if technical failure then record complete follow-up B. Yes, if technical failure then record long term follow-up of medications only C. Yes, if technical failure then record long term of patients symptoms only D. No, if technical failure then no long term follow-up should be recorded If the procedure is recorded as a technical failure for all arteries treated the follow-up tab will not display. A follow-up form will be generated if any arteries were treated without technical failure.

57 Q1: Rationale for Answer Technical failure means no treatment was performed therefore procedure had no impact on patients disease We record technical failures as quality assurance expecting that overall they are rare (in low single digit range)

58 Q2: In the case below, do I enter each of the interventions on two separate PVI forms? In the case of a leg ischemia treated with a pharmacothrombolysis infusion via indwelling catheter, four angiograms were performed (four trips to the EV room) and two of the repeat angiograms included a stent/plasty to the same artery. A. Enter a PVI form for each procedure with angioplasty/stent performed on separate days B. Enter a PVI form for each procedure with angioplasty/stent even if performed on the same day C. Enter each intervention on 4 separate PVI forms D. Do not enter into the PVI registry since it does not record thrombolysis procedures

59 Q2: Correct Answer A. Enter a PVI form for each procedure with angioplasty/stent performed on separate days If the secondary interventions were completed on the same day, use only one PVI form, and indicate the PTA and Stent treatments in the 1st and 2nd Treatment Type fields and the pharmacothrombolysis as an adjunct. If the secondary stents were placed on a different calendar day, they should be captured as separate PVI procedures. A. Enter a PVI form for each procedure with angioplasty/stent even if performed on the same day B. Enter each intervention on 4 separate PVI forms C. Do not enter into the PVI registry since it does not record thrombolysis procedures

60 Q2: Rationale for Answer Thrombolysis alone is not within scope of the Registry. When thrombolysis is used as adjunct to treat an atherosclerotic lesion (stenosis, occlusion or leg aneurysm) then we capture the procedure. PVI that includes thrombolysis as an adjunct should be recorded If procedures were done on the same day then one form is sufficient

61 Vascular Medicine Registry

62 Vascular Medicine Registry Committee Co-Chairs Michael Jaff, DO Massachusetts General Hospital Randall De Martino, MD Mayo Clinic Rochester Members Shipra Arya, Emory University Joshua Beckman MD, Vanderbilt Rumi Faizer MD, University of Minnesota Debabrata Mukherjee, MD Texas Tech University Bob Patterson MD, Brown University Carrie Bosela, SVS PSO Ex-Oficio Jack Cronenwett, MD Jim Froehlich, MD

63 Inclusion Criteria: This registry only includes New Outpatient Consults who are being treated medically for: Peripheral arterial disease due to atherosclerosis Atherosclerotic carotid artery occlusive disease Abdominal aortic aneurysm Exclusion Criteria: Evaluation/diagnosis of pseudo or neurogenic claudication, peripheral arterial disease due to trauma, popliteal entrapment, medial adventious cystic disease, chronic compartment syndrome Carotid disease due to dissection, infection, aneurysm, tumor, isolated common carotid lesion not thought to involve the bifurcation, disease of the carotid bifurcation due solely to vasculitis, and Moyamoya disease, and fibromuscular dysplasia Isolated aortic dissection without aneurysm Thoracic, thoraco-abdominal, and mycotic aneurysms

64 Vascular Medicine Registry Purpose Registry to focus on non-operative medical management of these conditions Medication details and dosages, along with lifestyle modifications and counseling will be the emphasis of this registry Opportunities Identify patterns/variation of treatment and preintervention management Identify QI initiatives Opportunities in comparative effectiveness research

65 Demographics: Disease Evaluated: 1. Lower extremity 2. Carotid 3. Aortic multiple choice; Leg and carotid include atherosclerotic occlusive disease only, AAA includes abdominal aortic/iliac aneurysm of degenerative etiology only

66 New VQI Analytics and Reporting Enhancements

67 Release Order Shared Reporting (released) Drill Down (released) Physician-level Reporting Q3 Longitudinal Charting Q3 Health System Reporting Q3/Q4

68 Drill down Stroke Rate 0.0% 1.3%***

69 Drill down Stroke Rate

70 Drill Down Stroke Rate

71 Drill Down Permissions Physicians can only drill down to their own patient level data Hospital Manager and all other nonphysician users can only drill down if they have permissions to the procedure and follow up download reports privilege (granted by M2S with hospital manager approval)

72 Health System Reporting

73 Health System Reporting

74 Health System Reporting

75 Shared Reports

76 Shared Reports

77 Physician-level Reporting

78 Physician-level Reporting

79 Physician-level Reporting

80 Longitudinal Charting

81 Regional Data Manager Leads Webinar Update Held September 29 th Grant received by the SVS VQI to align with STS and ACC to align definitions Discussion as to whether lead data manager should be at the same facility as the regional medical director Efficacy of this varies by facility Carrie will discuss with each regional group Discussion on attendance at regional webinar SoCal group have gone to quarterly See attached letter regarding launch of QI Webinar Series 1 st one held 10/25

82 Regional Data Manager Leads Webinar Update Discussion of monitoring in CEA module Choices are EEG/ Stump / Other Examples under other were back bleeding / cerebral perfusion Return to OR in CEA module Discussion for category of other if second procedure during admission unrelated such as CABG. Carrie to ask CEA committee to add as option Beta Blockers being removed from all registries

83 Surgeon and Quality Improvement Expert to Launch QI Webinar Series The SVS PSO is developing a series of webinars on the science of quality improvement for physicians, data managers and quality improvement professionals. Dr. Ted James, a surgeon and quality improvement expert from Beth Israel Deaconess Medical Center will present the first webinar on Leading Change to Build and Sustain Quality Improvement Programs. Delivering high quality vascular care is a priority for VQI members and our planned webinar series in will address both broad QI issues and operational interests related to specific QI projects. The SVS PSO held its first annual vascular quality improvement meeting in June 2016 at VAM for almost 200 participants. The meeting participants were especially enthusiastic about the presentation from Dr. Ted James on Making Metrics Meaningful: How to Effectively Use Performance Metrics to Improve Clinical Outcomes and we are happy to announce that Dr. James will present the first QI webinar on Tuesday, October 25 th at 7PM ET/6PM CT/5PM MT/4PMPT. Meeting participants requested change management as a topic for future presentation and noted its importance to initiating and sustaining a successful quality improvement program. Our webinar presenter, Dr. Ted James is Chief, Breast Surgical Oncology at Beth Israel Deaconess Medical Center, a faculty member of Harvard Medical School and Vice Chair for Academic Affairs in the Department of Surgery. Dr. James works with national organizations to improve quality and lectures nationally and internationally on quality improvement and inter-professional training to enhance quality improvement and patient safety. The inaugural QI webinar will be held on Tuesday, October 25 th at 7PM ET/6PM CT/5PM MT/4PMPT (add dial in information from M2S) and is open to all VQI members. The QI webinar series will continue through

84 Questions / Conclusion Next Regional Meeting November 4 th 10a- 4p - USC Next Regional Webinar December 13 th 3pm

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