VASCULAR QUALITY INITIATIVE Mid-South Vascular Study Group Regional Meeting April 23 rd, 2017 St. Thomas Midtown, Nashville, TN

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1 VASCULAR QUALITY INITIATIVE Mid-South Vascular Study Group Regional Meeting April 23 rd, 2017 St. Thomas Midtown, Nashville, TN I. Dr. Edward Garrett called the meeting to order and welcomed everyone. Introductions were made around the room and those present on the phone. II. Action items from the fall Meeting Dr. Garrett reminded the group of the prior vote to unblind LTFU (long term follow-up) rates and noted that reporting for the Spring meeting now included an identification key, making LTFU rate, by hospital, transparent to all. III. National VQI Update: Jim Wadzinski, SVS PSO There are currently 416 participating VQI centers in 46 states and Ontario. Canada has formed their own regional group 373,209 cases entered in VQI to date Members only Website To help and encourage member to share quality improvement and best practices with other regions Forums for data managers Do not rely on this website for definitions. You will still need to contact Pathways for those types of questions. Currently Regional Data Manager Leads have access to the site. The site will be rolled out to all in conjunction with the Annual Meeting VQI 2 nd Annual Meeting in June 2017 San Diego, will be held May 30 th and 31 st, with a poster session and networking reception. 1 st day will include breakout sessions and the 2nd day will include presentations on VQI National Quality Initiative, case studies from several different institutions about PI projects, Enhanced Recovery After Surgery (ERAS) and VQI Research Projects. VQI Pulse is a newsletter that highlights topics in the VQI and is sent every other month. Please notify the VQI if you are not receiving this communication. The VQI is working with M2S to ensure it has accurate s for all members.

2 QI Guide and QI Project Charter were highlighted to note that the VQI has provided this as a resource to VQI members to help them various QI tool to initiate quality Improvement projects. The VQI is updating these tools with examples of how other institutions have used these resources in their institutions. The QI Project Charter was updated with an example of how one site used it for a QI project on Discharge Meds. MIPS VQI is a specialty registry and a QCDR will help you meet one of your measures VQI will help with CMS submission PSO hosted a webinar in December and will host another in July The group commented that the webinar was helpful, but would like additional information on the measures that can be submitted, the timeframes to report and how the VQI helps individuals and groups report. o To participate using the QCDR-based submission method for 2017 MIPS, physicians must report on at least 50% of their total patient population, of which one patient must be a Medicare Part B patient, that meet individual QCDR measure criteria for six or more measures. The VQI QCDR supports reporting of 12 QPP individual measures and 17 QCDR non-qpp individual measures for the 2017 MIPS reporting period. Refer to Appendix A for detailed list of measures. o To successfully participate, eligible professionals must not be part of an ACO or be associated with a TIN that is registered for the Group Practice Reporting Option (GPRO). o Enrollment in 2017 MIPS, using M2S as your approved QCDR vendor, takes place between June 1 st and October 1, Submission of PQRS data to CMS for 2017 MIPS Quality Component occurs in early March o Eligible professionals who successfully submit on at least one quality measure become eligible to avoid the prospective MIPS payment adjustment equal to 4.0% of their Medicare Part B Physician Fee Schedule (PFS) allowed charges in o Ensure entry of all procedures and MIPS-required data fields whose surgery dates fall within the reporting period by mid-january 2018, for inclusion in the reporting rate calculation. o Groups have the same options for reporting as individuals QCDRs, Qualified Registries, EHR, claims. The main option being used by larger groups is the GPRO option, which is detailed at Some of the EHR companies are offering measure reporting modules with about measures in them, mostly primary care, but for some of the big groups that is what they were reporting in PQRS and is what they still want to report. o The VQI QCDR was not set up to report for groups.

3 Partition awards There has been an increase in 1 star and 3 star which means centers are working to achieve higher ratings There will be some changes to the participation award that will be shared soon A new Quality Domain will be added to the scoring, which will provide credit for those presenting on Quality Initiatives at Regional Meetings or the VQI Annual Meeting. Credit for participation in registries will still be recognized, but at a lower rate than in the past. This will be detailed when the new scoring system is communicated in late Data Managers will be award credit for attending the VQI Annual Meeting Current consequences of being on probation are that data is removed from benchmarking data and that research data will not be made available. MSVSG voted to give credit for phone participation if actively participates in the meeting. Dr. Ryan made the motion, Dr. Broussard 2 nd VQI data discrepancies Due to multiple revisions and coding No significant errors Research Advisory Council will be looking over projects that have been published. If you have based your project on any data that may have discrepancies, they will contact you to look at your project Will continue periodic review Looking at mapping errors IV. Regional Reports: Edward Garrett, MD Dr. Garrett reminded everyone that for the regional report, we must have at least three centers participating in that module with at least 10 procedures/center to get a report for that specific module Missing data This will be the last time this report will be reported until additional information can be provided on the exact data elements that are missing There have also been issues with need for ABIs and the fact that heart rate has not been eliminated from all forms PSO is working on adding required fields, with a focus on LTFU PSO is looking at performing statistical analyses of the registries to eliminate fields not contributing to meaningful outcome results

4 Long Term Follow-up Data has now been unblinded by center There was a significant increase over last year s LTFU rate 62% v 35%, for the region Discharge antiplatelet plus statin rate MSVSG is at 75% which is lower than the national average 3 centers are well above the 80% mark. These centers noted using EPIC hard stops and Cerner Discharge Pathways to help increase Discharge Med rates. Infrainguinal bypass skin prep Compliance rate with using chlorhexidine of 95% was far greater than the VQI rate of 86% Corresponding SSI rate, however, was much higher than the national average Possible application issue Definition of SSI for Infra is the Variable wound, which is defined as Culture positive or requiring antibiotic treatment Percentage of percutaneous femoral procedures using ultrasound guidance The MSVSG has a great compliance rate of 90%, which is well above the National average and the 2 nd highest of any region The rate of any Hematoma was 4.9% as opposed to 3.3% for the nation The moderate or major hematoma rate, however, was only 0.4% compared to 0.8% for the nation. Hematoma is defined as follows: o Minor: visible or symptomatic but requiring no treatment beyond compression; may require admission for observation. o Moderate: requires transfusion or thrombin injection. o Severe: requires a return to OR. PVI: Percentage of Patients with ABI or TBI Poor capture in region Could be a regional project put in place CEA LOS Region shows a higher LOS than National average A lengthy discussion was had on the topic, including possible reasons for increased stays or ways to counter o Foley unable to remove (No need on short cases) o Uncontrolled hypertension o Knoxville gave patients BP cuff, allowed them to go home to monitor BP and instructed to call if above certain number. o Parameters identified when to not bring to surgery if BP elevated o Some sites may not check BP? o Dr. Edwards changed from hydralazine to clonidine to manage hypertension

5 Dr. Jorgensen will present on what his Institution has done, if the MSVSG wants a guest speaker on this topic Open AAA LOS LOS is impacted by culture across all institutions Belmont data presented Troy had good rates o Don t discharge to ICU use PACU o No foley on AAA cases o Some sites did not see a difference between ICU and floor discharge times CAS Stroke or Death Rates were higher than the National benchmarks Possibly due to stenting during acute phase of stroke If TAVR after CAS and poor outcome the TAVR Team gets credit for stroke/poor outcome. V. Research Advisory Council Update: Patrick Ryan, MD Discussed how to submit a project Outlined the process and timelines Highlighted some of the proposals from April 2017 Spoke to the need to submit early or learn how to attach to an existing project VI. Arterial Quality Council Update: Michael McNally, MD Discussed term limits Two national projects: Discharge Meds and EVAR LTFU PSO National QI Project Committee Process COPI Reports Last year was for CEA and CAS Upcoming is on hematoma after PVI Surgeon Level Reports VII. Governing Council Update: Edward Garrett, MD Update on a new policy for the release of Blinded Data Sets with Device Identifiers Venous Stent to be developed in 2018 Medicine to be offered in late-2017 VIII. Pathways Development Update: Deb MacAulay PVI Clone Data for general and demographics Webinar in resources Must clone before you move through case, can t go back and clone Released in quarter 1 PVI Post Procedure tab revision To improve data collection and accuracy

6 TEVAR Dissection 1 year still enrolling Sites have received $854,100 FDA has 4 summary reports Lombard Aorfix Still enrolling Sites have received $79,200 Lombard has 4 summary reports Medtronic IN.PACT DCB ISR Still enrolling Objective is to track long term safety and performance Bard LifeStent Still enrolling Objective is to track long term safety and effectiveness CREST 2 Still enrolling 64 physcians are participating through VQI C2R have received 10 summary reports TCAR Collaboration with CMS to provide reimbursement Submit Medicare claim using NCT Data will be compared to CEA data Objective to Generate real world data for future decisionsabout coverage for TCAR You need to be enrolled in VQI or Roadster

7 Appendix A: Individual measures list Quality ID 021** Title Perioperative Care: Selection of Prophylactic Antibiotic-First OR Second Generation Cephalosporin Process / Outcome* Process Procedure / Procedure VQI CAS, CEA, EVAR, HDA, INFRA, OPEN, PVI, SUPRA Additional fields are required for: Vascular, Cardiothoracic Surgery, and General Thoracic Surgery Applicable CPT Codes Vascular: 27880, 27881, 27882, 27884, 27886, 27888, 33877, 33880, 33881, 33883, 33886, 33889, 33891, 34800, 34802, 34803, 34804, 34805, 34812, 34820, 34825, 34830, 34831, 34832, 34833, 34834, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 34900, 35011, 35013, 35081, 35082, 35091, 35092, 35102, 35103, 35131, 35141, 35142, 35151, 35152, 35206, 35266, 35301, 35363, 35371, 35372, 35512, 35521, 35522, 35523, 35525, 35533, 35537, 35538, 35539, 35540, 35556, 35558, 35565, 35566, 35570, 35571, 35572, 35583, 35585, 35587, 35601, 35606, 35612, 35616, 35621, 35623, 35626, 35631, 35632, 35633, 35634, 35636, 35637, 35638, 35642, 35645, 35646, 35647, 35650, 35654, 35656, 35661, 35663, 35665, 35666, 35671, 36830, 36902, 36905, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37246, 37247, 37248, 37249, Cardiothoracic Surgery: 33120, 33130, 33140, 33141, 33202, 33250, 33251, 33256, 33261,33305, 33315, 33321, 33322, 33335, 33365, 33366, 33390, 33391, 33404, 33405, 33406, 33410, 33411, 33413, 33416, 33422, 33425, 33426, 33427, 33430, 33460, 33463, 33464, 33465, 33475, 33496, 33510, 33511, 33512, 33513, 33514,

8 Quality ID * 259* 260* 344* Title Statin Therapy at Discharge after Lower Extremity Bypass (LEB) Rate of Open Repair of Small or Moderate Non- Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post- Operative Day #7 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate None-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post- Operative Day #2) Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) Rate of Carotid Endarterectomy Stenting (CAS) for Asymptomatic Patients, without Major Complications Process / Outcome* Procedure / VQI Process Procedure INFRA Outcome Procedure EVAR 35081, Applicable CPT Codes 33516, 33530, 33533, 33534, 33535, 33536, 33542, 33545, 33548, 35211, 35241, General Thoracic Surgery: 0236T, 21627, 21632, 21740, 21750, 21825, 31760, 31766, 31770, 31775, 31786, 31805, 32096, 32097, 32098, 32100, 32110, 32120, 32124, 32140, 32141, 32150, 32215, 32220, 32225, 32310, 32320, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32491, 32505, 32506, 32507, 32800, 32810, 32815, 32900, 32905, 32906, 32940, 33020, 33025, 33030, 33031, 33050, 33300, 33310, 33320, 33361, 33362, 33363, 33364, 34051, 35021, 35216, 35246, 35276, 35311, 35526, 37616, 38381, 38746, 39000, 39010, 39200, 39220, 39545, 39561, , 35566, 35571, 35583, 35585, 35587, 35656, 35666, Outcome Procedure EVAR 34800, 34802, 34803, 34804, Outcome Procedure CEA Outcome Procedure CAS 37215

9 Quality ID 345* 346* 347* M2S-1 M2S-2* M2S-3* M2S-4* M2S-5* Title (Discharged to Home by Post-Operative Day #2) Rate of Post-Operative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Rate of Post-Operative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate None-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die in Hospital Varicose Vein Treatment with Saphenous Ablation: Outcome Survey Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal Perioperative Anti- Platelet Therapy for Patients Undergoing Carotid Endarterectomy Procedures with statin and antiplatelet agents prescribed at discharge Amputation-free survival assessed at Infra-Inguinal Bypass for intermittent claudication Infra-Inguinal bypass for claudication patency assessed at least 9 months following surgery Amputation-free survival assessed at Supra-Inguinal Bypass for claudication Amputation-free survival assessed at Process / Outcome* Procedure / VQI Outcome Procedure CAS Outcome Procedure CEA Outcome Procedure EVAR 34800, Outcome VV 36475, Process IVC Process Procedure CAE Process Outcome Process Outcome Procedure CAS, CEA, Endo AAA, Open AAA, TEVAR, Infra, Supra, PVI Infra-Inguinal Bypass Infra-Inguinal Bypass Supra-Inguinal Bypass Outcome PVI Applicable CPT Codes All codes captured in the following VQI Registries: CAS, CEA, Endo AAA, Open AAA, TEVAR, Infra, Supra, PVI All codes captured in the VQI Infra- Inguinal Bypass All codes captured in the VQI Infra- Inguinal Bypass All codes captured in the VQI Supra- Inguinal Bypass All codes captured in the VQI PVI

10 Quality ID M2S-6* M2S-7 M2S-8 M2S-9* M2S-10 M2S-11* M2S-12 M2S-13 M2S-16* M2S-17* Title Peripheral Vascular Intervention for intermittent claudication Peripheral Vascular Intervention patency assessed at least 9 months following infrainguinal PVI for claudication Ipsilateral stroke-free survival assesed at least 9 months following isolated Carotid Artery Stenting for asymptomatic procedures Ipsilateral stroke-free survival assessed at isolated CEA for asymptomatic procedures Imaging-based maximum aortic diameter assessed at Thoracic and Complex EVAR procedures Survival at least 9 months after elective repair of small thoracic aortic aneurysms Imaging-based maximum aortic diameter assessed at Endovascular AAA Repair procedures Survival at least 9 months after elective repair Endovascualt AAA Repair of small abdominal aorta aneurysms Survival at least 9 months after elective Open AAA repair of small abdominal aorta aneurysms Absence of unplanned reoperation after major lower extremity amputation Absence of serious technical complications Process / Outcome* Procedure / VQI Process PVI Outcome CAS Outcome CEA Process TEVAR Outcome TEVAR Process Endo AAA Outcome Endo AAA Outcome Open AAA Outcome Procedure LEA Outcome Procedure PVI Applicable CPT Codes All codes captured in the VQI PVI All codes captured in the VQI CAS All codes captured in the VQI CEA All codes captured in the VQI TEVAR All codes captured in the VQI TEVAR All codes captured in the VQI EVAR All codes captured in the VQI EVAR All codes captured in the VQI Open All codes captured in the VQI LEA All codes captured in the VQI PVI

11 Quality ID Title Process / Outcome* Procedure / VQI Applicable CPT Codes during peripheral arterial intervention Venous clinical severity score (VCSS) assessment All codes captured in the VQI M2S-18 Process Procedure Varicose Vein before varicose vein Varicose Vein Filter treatment Proper patient selection All codes captured in the VQI M2S-19 for perforator vein Process Procedure Varicose Vein Varicose Vein ablation *High Priority measure. Bonus points are available from CMS for Outcome Measures and High Priority Measures **High Priority, Appropriate Use measure. Bonus points are available from CMS for Outcome Measures and High Priority Measures