Data Elements and Definitions with Case Studies. Interpreting Your Outcomes Reports. Kim Hustler, Clinical Quality Consultant, NCDR

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1 Data Elements and Definitions with Case Studies Interpreting Your Outcomes Reports Kim Hustler, Clinical Quality Consultant, NCDR Beth Pruski, Program Manager, NCDR The following relationships exist: Beth Pruski, Kim Hustler, and Kevin Daniel: No Disclosures 1

2 Section I- Lab Results Seq. #10110 Creatinine Peak Patient arrives to ED after developing intense central chest pressure radiating to left arm Cath lab - stent placed Post cath- STEMI-back to cath lab Initial blood draw creatinine value completed- 0.9 mg/dl No follow up value completed Question #1 #7 How would you answer Seq. #10110 Peak Creatinine level collected? Seq. #10110 Creatinine Peak ED after developing intense central CP to left arm Cath lab - stent placed Post cath- STEMI-back to cath lab Initial blood draw creatinine value completed- 0.9 No follow up value completed How would you answer Seq. #10110 Peak Creatinine level collected? 2

3 Section D- History & Risk Factors Seq. #5140 Peripheral Artery Disease Presents and rules in as NSTEMI Documentation in the medical record provided history of: Renal artery disease Deep vein thrombosis (DVT) Question #2#8 Would renal artery disease and/or DVT be captured in history of peripheral artery disease? 1. Renal- yes, DVT- yes 2. Renal- no, DVT- no 3. Renal- yes, DVT- no 4. Renal- no, DVT- yes Seq. #4140 Peripheral Artery Disease NSTEMI-history of: Renal artery disease Deep vein thrombosis (DVT) Would renal artery disease and/or DVT be captured in history of peripheral artery disease? 1. Renal- yes, DVT- yes 2. Renal- no, DVT- no 3. Renal- yes, DVT- no 4. Renal- no, DVT- yes 3

4 Section E- Medications Comfort Measures Only Patient presents with symptoms of ACS and rules in as NSTEMI She is elderly with significant health issues Decision by patient and family- placed on comfort measures only Only ASA is administered within 24 hours of arrival There is no documentation of contraindications to any of the other medications Question #312 How would you answer all the medications within 24 hours, other than ASA? 3. contraindicated Comfort Measures Only Patient presents with ACS and rules in as NSTEMI She is elderly with significant health issues Decision by patient and family- placed on comfort measures only Only ASA is administered within 24 hours of arrival There is no documentation of contraindications to any of the other medications How would you answer all the medications within 24 hours, other than ASA? 3. contraindicated 4

Companion Guide Section F- Procedures and Tests Diagnostic Cath/PCI 2 cath lab visits Patient admitted-nstemi First cath lab visit revealed an innominate thrombotic lesion as the source of his

5 Companion Guide Section F- Procedures and Tests Diagnostic Cath/PCI 2 cath lab visits Patient admitted-nstemi First cath lab visit revealed an innominate thrombotic lesion as the source of his ischemia- he was treated with anticoagulants for 2 days Second cath lab visit- No change in thrombus- treated with thrombectomy device Question #4 How can we enter these two separate cath lab visits? 1. Enter only the first cath lab visit only 2. Enter both- Diag Angiography & PCI- date/time of 1 st cath lab visit, Seq. #7021/ Enter 1st visit into Diag Angiography #7021/7022 & 2nd visit into PCI Seq. #7101/ Enter Diag Angiography & PCI for date/time of 2nd (PCI) cath lab visit, #7101/7102 5

Diagnostic Cath/PCI 2 cath lab visits NSTEMI- First cath lab visit revealed an innominate thrombotic lesion as the source of his ischemia- he was treated with anticoagulants for 2 days Second cath

6 Diagnostic Cath/PCI 2 cath lab visits NSTEMI- First cath lab visit revealed an innominate thrombotic lesion as the source of his ischemia- he was treated with anticoagulants for 2 days Second cath lab visit- No change in thrombus- treated with thrombectomy device How can we enter these two separate cath lab visits? 1. Enter only the first cath lab visit 2. Enter both- Diag Angiography & PCI- date/time of 1 st cath lab visit, Seq. #7021/ Enter 1st visit into Diag Angiography #7021/7022 & 2nd visit into PCI Seq. #7101/ Enter Diag Angiography & PCI for date/time of 2nd (PCI) cath lab visit, #7101/7102 Diagnostic Cath/PCI 2 cath lab visits Section F- Procedures and Tests Seq PCI Presents with N/V, left arm pain 12 lead ECG- STEMI To cath lab for Primary PCI Multiple attempts were made to cross the lesion without success No PCI is performed 6

7 Question #514 If a PCI was attempted but not able to cross the lesion how do you answer Seq #7100? Seq PCI Presents with N/V, left arm pain 12 lead ECG- STEMI To cath lab for Primary PCI Multiple attempts were made to cross the lesion without success No PCI is performed If a PCI was attempted but not able to cross the lesion how do you answer sequence 7100? Section F- Admission Non-system Reason for Delay Seq. #7110 Female, age 50, presented ED with symptoms of ACS Diagnosis AMI ECG shows mm elevation in V2,V3,V4 & V5 Physician dictates "somewhat non dx." Abstractor input- it appears that her stay in the ED was longer than necessary. Per the definition, this pt. is a STEMI. the D2B was 97 min. can I exclude her in any way?( as in a system reason for delay) 7

8 Question #6 How would you answer non-system reason for delay Seq. #7110 for this scenario? 3. Need more information Non-system Reason for Delay Seq. # yo Female ED symptoms of ACS, Dx AMI ECG shows mm elevation in V2,V3,V4 & V5 Physician dictates "somewhat non dx." Abstractor input- it appears that her stay in the ED was longer than necessary. Per the definition, this pt. is a STEMI. the D2B was 97 min. can I exclude her in any way?( as in a system reason for delay) How would you answer non-system reason for delay Seq. #7110 for this scenario? 3. More information needed Section F- Admission Non-system Reason for Delay Seq. #7110 Further details after speaking with the site: Physician writes 50 y/o female with likely ST elevation MI, ECG somewhat non-diagnostic but the patients story is decent and the troponins are mildly elevated. Best served by taking her to the Cath lab. No subsequent ECG History- HTN, DM, chest pain Diagnosis: CAD post anterior wall MI Bifurcation lesion LAD/diag 99% BMS 8

9 Question #7 How would you answer non-system reason for delay Seq. #7110 for this scenario? Non-system Reason for Delay Seq. #7110 Physician writes 50 y/o female with likely ST elevation MI, ECG somewhat non-diagnostic but the patients story is decent and the troponins are mildly elevated. Best served by taking her to the Cath lab. No subsequent ECG History- HTN, DM, chest pain Diagnosis: CAD post anterior wall MI Bifurcation lesion LAD/diag 99% BMS How would you answer non-system reason for delay Seq. #7110 for this scenario? Section J- Discharge Cardiac Rehabilitation Elderly man presented evening symptoms ACS ECG- ST depression, positive Troponin Extensive cardiac history, CVA- L sided impairment Elderly wife is caregiver, does not drive Transferred to PCI hospital next morning diagnostic cath No documentation related to cardiac rehab 9

10 Question #8 12 How would you answer cardiac rehab at discharge? 3. Ineligible Cardiac Rehabilitation Elderly man in evening with symptoms ACS ECG- ST depression, positive Troponin Extensive cardiac history, CVA- L sided impairment Elderly wife is caregiver Transferred to PCI hospital next morning diagnostic cath No documentation related to cardiac rehab How would you answer cardiac rehab at discharge? 3. Ineligible Section B- Admission First Medical Contac vs. Transfer Outside Facility Presents to Satellite ED with chest tightness, diaphoresis ECG ST elevation Ambulance emergently transported to PCI hospital To cath lab for primary PCI 10

11 Question #9 How would you enter the Satellite ED into the registry? 1. Answer yes for Seq. #3110 Transferred from Outside Facility 2. Enter date/time in Seq. #3105/3106 Pre- Arrival 1 st Med. Contact First Medical Contac vs. Transfer Outside Facility Presents to Satellite ED with chest tightness, diaphoresis ECG ST elevation Ambulance emergently transported to PCI hospital To cath lab for primary PCI How would you enter the Satellite ED into the registry? 1. Answer yes for Seq. #3110 Transferred from Outside Facility 2. Enter date/time in Seq. #3105/3106 Pre-Arrival 1st Med. Contact Section E- Medications ACE/ARB at Discharge Metric #12 Presents SOB & GI upset/ vomiting ECG ST elevation History of MI, HF, DM, Renal dysfunction To Cath lab Immediate Primary PCI Echo completed day prior to discharge, EF 38 % Physician documents contraindicated to ARB due to renal dysfunction Review the dashboard for fall out, this patient is included 11

Dashboard Enter timeframe Select discharge

Graphs open in discharge PM Click on the quarter that

#12 The drill down opens metric summary & all

12 Dashboard Enter timeframe Select discharge Performance Measures ACE/ARB at Discharge Metric #12 Graphs open in discharge PM Click on the quarter that you want to drill down on ACE/ARB at Discharge Metric #12 The drill down opens metric summary & all patients information below Not numerator 4 denominator 5 for Q

Question #10 Here is the drill down. Why would this patient be included in the metric as no when ARB is documented as contraindicated? 1. EF did not meet required value 2.

ACE was answered as no ACE/ARB at Discharge Metric #12 Presents SOB & GI upset/ vomiting, ECG ST elevation History of MI, HF, DM, Renal dysfunction To Cath lab Immediate Primary PCI Echo completed

13 Question #10 Here is the drill down. Why would this patient be included in the metric as no when ARB is documented as contraindicated? 1. EF did not meet required value 2. Patient was only documented as contraindicated to ARB 3. ACE was answered as no ACE/ARB at Discharge Metric #12 Presents SOB & GI upset/ vomiting, ECG ST elevation History of MI, HF, DM, Renal dysfunction To Cath lab Immediate Primary PCI Echo completed day prior to discharge, EF 38 % Physician documents contraindicated to ARB due to renal dysfunction Why would this patient be included in the metric when ARB is documented as contraindicated? 1. EF did not meet required value 2. Patient was only documented as contraindicated to ARB 3. ACE was answered as no Outcomes Report QM #22 Door to 1 st ECG D2ECG metric is lower than median You have chest pain center accreditation Need to improve times 13

Selections 2 & 3 Door to 1st ECG D2ECG metric is lower than median You have chest pain center accreditation Need to improve times What ECG s are

14 Question #11 What ECG s are included in this metric? 1. EMS ECG s 2. ECG s completed at your hospital 3. ECG s completed at transferring hospital 4. Subsequent ECG s 5. Selections 2 & 3 Door to 1st ECG D2ECG metric is lower than median You have chest pain center accreditation Need to improve times What ECG s are included in this metric? 1. EMS ECG s 2. ECG s completed at your hospital 3. ECG s completed at transferring hospital 4. Subsequent ECG s 5. Selections 2 & 3 Door to 1st ECG To help assess the data click on the #1- first row- title row To filter- select data - click on filter (funnel shape) 14

Door to 1st ECG The filtering arrows appear- click on arrow Filtered Numerator

place in time order Can then review records for possible reasons Look at- Time

<90 minutes- Physicians Discussion around reducing D2B times to closer to 60

15 Door to 1st ECG The filtering arrows appear- click on arrow Filtered Numerator column no remove all patients met metric Filtered Door to ECG column A to Z place in time order Can then review records for possible reasons Look at- Time & day arrival, Walk in vs Ambulance, staffing Outcomes Report Metric #15 PCI <90 minutes- Physicians Discussion around reducing D2B times to closer to 60 minutes for this site Request to capture Interventionalists related to D2B times 15

16 Question #123 What is the best way to create a report for D2B times for specific physicians? 1. Data Extract 2. Dashboard drill down 3. Outcomes Report 4. Data Extract and Dashboard Metric #15 PCI <90 minutes- Physicians Discussion around reducing D2B times to closer to 60 minutes for this site Request to capture Interventionalists related to D2B times What is the best way to create a report for D2B times for specific physicians? 1. Data Extract 2. Dashboard drill down 3. Outcomes Report 4. Data Extract and Dashboard Outcomes Report US Benchmarking in report Outcomes Report: Executive Summary-R4Q- PCI <90 min My hospital 85.7% US hospital median is 96.7% US Hospital 90th Pctl 100% Detail line My hospital 85.7% US hospital R4Q 94.2% US Comparison R4Q 95.5% 16

Question #13 Why are the values in Executive Summary different from the values in the detail lines? 1. The 2 values are not both median 2. One aggregates by hospital the other by patient 3.

17 Question #13 Why are the values in Executive Summary different from the values in the detail lines? 1. The 2 values are not both median 2. One aggregates by hospital the other by patient 3. The discrepancy falls within acceptable statistical variance US Benchmarking in report Executive Summary-R4Q- PCI <90 min My hospital 85.7% US hospital median is 96.7% US Hospital 90th Pctl 100% Detail line My hospital 85.7% US hospital R4Q 94.2% US Comparison R4Q 95.5% Why are the values in Executive Summary different from the values in the detail lines? 1. The 2 values are not both median 2. One aggregates by hospital the other by patient 3. The variance falls within acceptable statistical variance Outcomes Report Metric #17 Reperfusion Therapy Reperfusion Therapy score is 75% Prior quarter was 86% Need to determine issue- Administrator is asking to see the report 17

18 Start by opening Dashboard drill down Question #14 There are some data entry issues. What fields need corrections? 1. PCI Indication 2. PCI non-system reason for delay 3. Primary PCI 4. Reason PCI not performed 5. Reason Thrombolytic not administered 6. All of the above Start by opening Dashboard drill down 18

Metric #17 Reperfusion Therapy Reperfusion Therapy score is 75% Prior quarter was 86% Need to determine issue- Administrator is asking to see the report There are some data entry issues.

19 Metric #17 Reperfusion Therapy Reperfusion Therapy score is 75% Prior quarter was 86% Need to determine issue- Administrator is asking to see the report There are some data entry issues. What fields need corrections? 1. PCI Indication 2. PCI non-system reason for delay 3. Primary PCI 4. Reason PCI not performed 5. Reason Thrombolytic not administered 6. All of the above Contact NCDR for questions at or call

Dashboard and Outcomes Report with Case Studies

Dashboard and Outcomes Report with Case Studies Kim Hustler Clinical Quality Consultant, American College of Cardiology The following relationships exist: Kim Hustler: No Disclosures Section F- Procedures