2/26/2013. NCDR.13 Case Scenario Presentation Cath PCI Registry. Disclosures. Objectives. Dashboard Implications of Some Major Metrics
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1 NCDR.13 Case Scenario Presentation Cath PCI Registry Dashboard Implications of Some Major Metrics Disclosures Tony Hermann has nothing to disclose Mark Hutcheson has nothing to disclose Cornelia Anderson has nothing to disclose Issam Moussa has nothing to disclose Objectives Discuss inclusion & exclusion criteria from five Outcomes Reports metrics Discuss specific data collection and definitions related to medications for the Cath PCI Registry Demonstrate knowledge of data abstraction through participation with the ARS 1
2 Proportion of Patients with Death, Emergency CABG, Stroke or Repeat Target Vessel Revascularization Section G PCI Procedure Seq#7020 (PCI Status) & Seq#7035 (PCI Indication) 47yo male c/o midsternal CP x2hrs Presents ambulatory to Triage/ER PMH: None, +Family History Meds: None ST Elevation leads II & III STEMI diagnosis STEMI protocol initiated ARS Question # 1 What is the PCI Status and PCI Indication? 1. Urgent/Immediate PCI for STEMI 2. Urgent/Rescue PCI 3. Emergency/Immediate PCI for STEMI 2
3 ARS Question #1 47yo male c/o midsternalcp x2hrs ST Elevation leads II & III STEMI diagnosis STEMI protocol initiated What is the PCI Status and PCI Indication? 1. Urgent/Immediate PCI for STEMI 2. Urgent/Rescue PCI 3. Emergency/Immediate PCI for STEMI Section K Discharge Seq#9005 (CABG Status) & Seq#9010 (CABG Indication) Right femoral access Prox RCA 95%, Mid LAD 70%, Mid Cx 70-80% Culprit RCA lesion stented 4.0 BMS Pt decompensates after stent placement Unable to visualize Left System CP 10/10 SBP 70 s, IABP inserted, Dopamine Pt prepared for CABG ARS Question #2 What is the CABG Status and CABG Indication? 1. Urgent/PCI failure without clinical deterioration 2. Emergency/PCI complication 3. Salvage/PCI complication 3
4 ARS Question #2 Pt decompensates after stent placement Unable to visualize Left System CP 10/10 SBP 70 s, IABP inserted, Dopamine Patient prepared for CABG What is the CABG Status and CABG Indication? 1. Urgent/PCI failure without clinical deterioration 2. Emergency/PCI complication 3. Salvage/PCI complication ARS Question #3 Will this patient be included in the Numerator for Metric 17? 1. Yes 2. No ARS Question #3 Culprit RCA lesion stented 4.0 BMS Pt decompensates after stent placement Unable to visualize Left System CP 10/10 SBP 70 s, IABP inserted, Dopamine Emergency CABG due to PCI Complication Will this patient be included in the Numerator for Metric 17? 1. Yes 2. No 4
5 Section H Lesions and Devices Seq# y.o. female s/p elective right hip replacement PMH: Hyperlipidemia, HTN, Arthritis, stent to mid Circumflex C/o chest tightness 3 rd day post op Abnormal ECG Troponin 0.56, NSTEMI dx Cath reveals mid Circlesion 90% -DES placed ARS Question #4 How will Seq#7145 Previously Treated Lesion be coded? 1. No 2. Yes ARS Question #4 PMH: Hyperlipidemia, HTN, Arthritis, stent to mid Circumflex Cath reveals mid Circlesion 90% -DES placed How will Seq#7145 Previously Treated Lesion be coded? 1. No 2. Yes 5
6 ARS Question #5 How will Seq#7155 Treated with Stent be coded? 1. No 2. Yes ARS Question #5 PMH: Hyperlipidemia, HTN, Arthritis, stent to mid Circumflex Cath reveals mid Circlesion 90% -DES placed How will Seq#7155 Treated with Stent be coded? 1. No 2. Yes ARS Question #6 Will this patient appear in the Numerator for Metric 17? 1. Yes 2. No 6
7 ARS Question #6 80 y.o. female s/p elective right hip replacement Troponin 0.56, NSTEMI dx Cath reveals mid Circlesion 90% -DES placed Will this patient appear in the Numerator for Metric 17? 1. Yes 2. No Metric 17-Your hospital s proportion of (unadjusted) death, emergency CABG, stroke or repeat target vessel revascularization Medications 7
8 Section D Cath Lab Visit SEQ # (Procedure Information) Stress test: a large area of reversible ischemia Cardiac cath: 40% RCA lesion 35% second OM lesion 98% mid-lad between first and second diagonal PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis. Fluorotime -7.8 min., contrast 215cc ARS question #1 What is the Fluoro Dose in mgy? 1. Unknown, leave blank mgy mgy 4. Ask your physician ARS question #1 Stress test: a large area of reversible ischemia Cardiac cath: 40% RCA lesion 35% second OM lesion 98% mid-lad between first and second diagonal PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis Fluoro time min., contrast 215cc What is the Fluoro Dose in mgy? 1. Unknown, leave blank mgy mgy 4. Ask your physician 8
9 ARS question #2 What Procedures are coded? 1. Diagnostic cath only 2. PCI only 3. Both Diagnostic cath and PCI 4. Diagnostic cath, PCI and Other Procedure ARS question #2 Stress test: a large area of reversible ischemia Cardiac cath: 40% RCA lesion 35% second OM lesion 98% mid-lad between first and second diagonal PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis. Fluoro time min., contrast 215cc What Procedures are coded? 1. Diagnostic cath only 2. PCI only 3. Both Diagnostic cath and PCI 4. Diagnostic cath, PCI and Other Procedure Section G PCI Procedure SEQ # 9500 (Procedure Medications) Ms. Jansen has 500u unfractionated Heparin added to flush Loading dose of 300mg Clopidogrel A PCI with a 3.0 x 18mm DES Rx with 0% post stenosis Fluorotime was 7.8 min Contrast 215cc 9
10 ARS question #3 What Procedure Medication(s) are coded? 1. Unfractionated Heparin only 2. Unfractionated Heparin and Clopidogrel 3. Unfractionated Heparin and Glycoprotein IIb/IIIa 4. Clopidogrel only ARS question #3 Ms. Jansen has 500u unfractionated Heparin added to flush Loading dose of 300mg Clopidogrel A PCI with a 3.0 x 18mm DES Rx with 0% post stenosis Fluorotime was 7.8 min Contrast 215cc What Medication(s) are coded? 1. Unfractionated Heparin only 2. Unfractionated Heparin and Clopidogrel 3. Unfractionated Heparin and Glycoprotein IIb/IIIa 4. Clopidogrel only Section H Lesions and Devices SEQ # 7225 (Intracoronary Device(s) Used) A PCI with a 3.0 x 18mm Resolute Integrity Rx IVUS post procedure of LAD due to haziness Stent patent with lack of expansion of stent struts Additional inflation with balloon from stent to 8 atm Repeat IVUS shows full expansion of the stent, 0% stenosis 10
11 ARS question #4 What Elements of the Device(s) are coded? 1. IVUS diameter and Resolute Integrity diameter and length 2. Resolute Integrity leave diameter and length blank 3. IVUS diameter and leave length blank 4. Resolute Integrity diameter and length ARS question #4 A PCI with a 3.0 x 18mm Resolute Integrity Rx IVUS post procedure of LAD due to haziness Stent patent with lack of expansion of stent struts Additional inflation with balloon from stent to 8 atm Repeat IVUS shows full expansion of the stent, 0% stenosis What Elements of the Device(s) are coded? 1. IVUS diameter and Resolute Integrity diameter and length 2. Resolute Integrity leave diameter and length blank 3. IVUS diameter and leave length blank 4. Resolute Integrity diameter and length ARS question #5 What Device(s) are coded? 1. Resolute Integrity Rx, Resolute Balloon 2. Resolute Integrity Rx 3. IVUS and Resolute Integrity OTW 4. IVUS, Resolute Integrity Rx, Resolute Balloon 11
12 ARS question #5 A PCI with a 3.0 x 18mm Resolute Integrity Rx IVUS post procedure of LAD due to haziness Stent patent with lack of expansion of stent struts Additional inflation with balloon from stent to 8 atm Repeat IVUS shows full expansion of the stent, 0% stenosis What Device(s) are coded? 1. Resolute Integrity Rx, Resolute Balloon 2. Resolute Integrity Rx 3. IVUS and Resolute Integrity OTW 4. IVUS, Resolute Integrity Rx, Resolute Balloon Section K Discharge SEQ # 9505 (Discharge Medications) A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily ARS question #6 What Medication(s) are coded as Yes for discharge? 1. ACE, ARB, ASA 2. ACE, ARB, Lipid Lowering Non-Statin 3. ARB, ASA, Lipid Lowering Statin, Thienopyridine(P2Y12) 4. ARB, Lipid Lowering Statin, Thienopyridine(P2Y12) 12
13 ARS question #6 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily What Medication(s) are coded as Yes for discharge? 1. ACE, ARB, ASA 2. ACE, ARB, Lipid Lowering Non-Statin 3. ARB, ASA, Lipid Lowering Statin, Thienopyridine(P2Y12) 4. ARB, Lipid Lowering Statin, Thienopyridine(P2Y12) ARS question #7 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily ARS question #7 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily Would this patient be included in the numerator for Metric #9, Proportion of patients with a P2Y12 inhibitor prescribed at discharge? 1. No 2. Yes 13
14 ARS question #8 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily ARS question #8 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily Would this patient be included in the denominator for Metric #9, Proportion of patients with a P2Y12 inhibitor prescribed at discharge? 1. No 2. Yes ARS question #9 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily 14
15 ARS question #9 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily Would this patient be included in the denominator for Metric #38, Composite Medications on Discharge? 1. No 2. Yes ARS question #10 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily ARS question #10 A Mynx M5 is used Patient discharged home the next morning Discharge medications Diovan80mg qd, due to an adverse reaction to ACE I Simvastatin the same as prior to admission New Meds -ASA, Plavix 80 mg, daily Would this patient be included in the numerator for Metric #38, Composite Medications on Discharge? 1. No 2. Yes 15
16 Dashboard Post Procedure MI with/without Biomarkers Objectives: Demonstrate how to capture post procedure MI Seq#8000 Demonstrate the differences in the criteria and timeframe Demonstrate the impact of the element in the Outcomes Report 16
17 Metrics 13 & 14 Inclusion Criteria Metric 13: Metric 14: 17
18 Causes of Procedural/PeriProcedural MI Include: Acute Artery Closure Embolization No reflow Side Branch Occlussion Acute stent Thrombosis Dissection Patient Drilldown view in Dashboard Select 18
19 Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Patient presents to ED w/ angina on 1200 STEMI diagnosed Pthas a PCI to Mid Lcx, baseline CK-MB was 4.5 ng/ml Post PCI CK-MB drawn 8 hrs was 17.3 ng/ml Ptcon tto have STE and taken back to the lab Previously placed stent in the Mid Lcx occluded PCI performed, additional stent deployed ARS Question #1 Would this be captured as a post procedure event in Seq#8000? 1. Yes 2. No Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Patient presents to ED w/ angina on 1200 STEMI diagnosed Pthas a PCI to Mid Lcx, baseline CK-MB was 4.5 ng/ml Post PCI CK-MB drawn 8 hrs was 17.3 ng/ml Ptcon tto have STE and taken back to the lab Previously placed stent in the Mid Lcx occluded PCI performed, additional stent deployed Would this be captured as a post procedure event in Seq#8000? 1. Yes 2. No 19
20 ARS Question #2 If this facility collects pre/post biomarkers on all patients, would this patient be included in the metric 13 denominator? 1. Yes 2. No Post Procedure MI with/without Biomarkers Patient presents to ED w/ angina on 1200 STEMI diagnosed Pthas a PCI to Mid Lcx, baseline CK-MB was 4.5 ng/ml Post PCI CK-MB drawn 8 hrs was 17.3 ng/ml Ptcon tto have STE and taken back to the lab Previously placed stent in the Mid Lcx occluded PCI performed, additional stent deployed If this facility collects pre/post biomarkers on all patients, would this patient be included in the metric 13 denominator? 1. Yes 2. No Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Pt scheduled for elective cath on 0910 Mild disease in LAD and Lcx AnamolousRCA, which had a 20% stenosis in the proxrca Baseline Troponins I normal 0700 the patient was taken back to lab w/ STE Trop I 5.6 ng/ml prior to the procedure Spiral dissection of the RCA, resulted in PCI 20
21 ARS Question #3 How should Seq#8000 be captured for the 1st cathlab visit? 1. Yes 2. No 3. N/A Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Pt scheduled for elective cath on 0910 Mild disease in LAD and Lcx AnamolousRCA, which had a 20% stenosis in the proxrca Baseline Troponins I normal 0700 the patient was taken back to lab w/ STE Trop I 5.6 ng/ml prior to the procedure Spiral dissection of the RCA, resulted in PCI How should Seq#8000 be captured for the 1 st cath lab visit? 1. Yes 2. No 3. N/A Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Patient comes to ED w/ STE Multi-vessel CAD, culprit artery LAD treated on 9/15/12 Trop T not drawn pre PCI, post Trop T 21.5 n/gl Elective Staged PCI on 9/20/12 of the Ramus/OM1 Pre procedure biomarkers were normal Stents deployed, Trop T drawn 2hrs post 7.2 n/gl 21
22 ARS Question #4 How should Seq#8000 be coded for the 2nd cathlab visit? 1.Yes 2.No Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Patient comes to ED w/ STE Multi-vessel CAD, culprit artery LAD treated on 9/15/12 Trop T not drawn pre PCI, post Trop T 21.5 n/gl Elective Staged PCI on 9/20/12 of the Ramus/OM1 Pre procedure biomarkers were normal Stents deployed, Trop T drawn 2hrs post 7.2 n/gl How should Seq#8000 be coded for the 2 nd cath lab visit? 1. Yes 2. No ARS Question #5 Would this patient be included or excluded from the metric? 1. Included 2. Excluded 22
23 Post Procedure MI with/without Biomarkers Patient comes to ED w/ STE Multi-vessel CAD, culprit artery LAD treated on 9/15/12 Trop T not drawn pre PCI, post Trop T 21.5 n/gl Elective Staged PCI on 9/20/12 of the Ramus/OM1 Pre procedure biomarkers were normal Stents deployed, Trop T drawn 2hrs post 7.2 n/gl Would this patient be included or excluded from the metric? 1. Included 2. Excluded ARS Question #6 Is the patient placed in the numerator or denominator for the metric? 1. Numerator 2. Denominator Post Procedure MI with/without Biomarkers Patient comes to ED w/ STE Multi-vessel CAD, culprit artery LAD treated on 9/15/12 Trop T not drawn pre PCI, post Trop T 21.5 n/gl Elective Staged PCI on 9/20/12 of the Ramus/OM1 Pre procedure biomarkers were normal Stents deployed, Trop T drawn 2hrs post 7.2 n/gl Is the patient placed in the numerator or denominator for the metric? 1. Numerator 2. Denominator 23
24 Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Patient has elective cath on 0700 Pre-procedure biomarkers normal Successful PCI is performed on the LAD Post procedure labs drawn on 1301 CK-MB 6.5 n/gl, no chest pain or ECG changes Taken to the cathlab, stent was patent IVUS performed, NC balloon used for malposition ARS Question #7 This Post MI should be captured in Seq#8000 for the 1 st visit? 1. True 2. False Section J Intra/Post Procedure Events Seq# 8000 (Myocardial Infarction) Patient has elective cath on 0700 Pre-procedure biomarkers normal Successful PCI is performed on the LAD Post procedure labs drawn on 1301 CK-MB 6.5 n/gl, no chest pain or ECG changes Taken to the cathlab, stent was patent IVUS performed, NC balloon used for malposition This Post MI should be captured in Seq#8000 for the 1 st visit? 1. True 2. False 24
25 Keys to evaluating Post MI Seq#8000 Determine the initial CAD Presentation (ACS) Lab results pre/post, knowing ULN Troponins vs. CK-MB Knowing the criteria <24hrs, >24hrs, Peri- CABG Intra/Post procedure events Risk Adjusted Mortality Outcomes Report Measure #1 Executive Summary Measure #1 Risk Adjusted Mortality 85 y.o. male s/p cardiac arrest Transported via EMS to tertiary care, trauma/stemi ctr Cardiogenic shock upon arrival to the cathlab CPR ongoing, PCI performed under Salvage status Ptdeceased during salvage PCI 25
26 ARS Question # 1: Considering the associated risk factors for mortality, how does this patient s death influence the hospital s RAM outcome? 1. All deaths worsen the RAM outcome. 2. The severity of his risk factors increase the risk of mortality to a point that it is reflected in the expected mortality. This will then balance ratio between the observed and expected mortality. 3. This is a tertiary care center, so their rate is already likely higher then the mortality rate at a county hospital. This patient will not change that trend. 85 y.o. male s/p cardiac arrest Transported via EMS to tertiary care, trauma/stemi ctr Cardiogenic shock upon arrival to the cathlab CPR ongoing, PCI performed under Salvage status Ptdeceased during salvage PCI How does this death influence the RAM? 1. All deaths worsen the RAM outcome. 2. The severity of his risk factors increase the risk of mortality to a point that it is reflected in the expected mortality. This will then balance ratio between the observed and expected mortality. 3. This is a tertiary care center, their rate is already likely higher then the mortality rate at a county hospital. This patient will not change that trend. Rationale to incorrect responses 1) All deaths worsen the RAM outcome. This is not true. The RAM is a ratio of observed over expected mortalities. 3) This is a tertiary care center, their rate is already likely higher then the mortality rate at a county hospital. This patient will not change that trend. This is not true. The Risk Adjustment allows all hospitals to be compared equally. 26
27 Dashboard RAM 27
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