PIONEERS IN QUALITY: EXPERT TO EXPERT CMS53/AMI 8a: Primary PCI Received Within 90 Minutes of Hospital Arrival Bob Dickerson, RRT, MHSA, Telligen Lynn Perrine, MSN, RN, Lantana Consulting Group Angela Flanagan, MSN, RN, CPHIMS, Lantana Consulting Group
Discussion Topics Logic specifications for AMI 8a Frequently Asked Questions for AMI 8a Changes to measure specifications for 2017 reporting 2
Background Percutaneous Coronary Intervention (PCI) is a procedure that opens blocked blood vessels and prevents further heart muscle damage following a heart attack. Must perform PCI quickly to be effective. Initially part of AMI Measure Set E-specified in 2013 3
Measure Description Acute myocardial infarction (AMI) patients with ST-segment elevation on the electrocardiogram (ECG) closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. 4
Rationale The early use of primary angioplasty in patients with ST-segment myocardial infarction (STEMI) results in a significant reduction in mortality and morbidity. The earlier PCI is provided, the more effective it is (Brodie, 1998 and DeLuca, 2004). National guidelines recommend the prompt initiation of PCI in patients presenting with ST-elevation myocardial infarction (O'Gara, 2013; and Levine, 2011). 5
Variables Logic statements reused throughout a measure: Denoted with a $ Defined in the Data Criteria (QDM Variables) section 6
$EncounterInpatient = AMI 8a Variables "Encounter, Performed: Encounter Inpatient" satisfies all - (length of stay <= 120 day(s)) - ends during "Measurement Period" $AnotherHospitalOrHealthcareFacility = Union of: - "Transfer From: Ambulatory Surgical Center" - "Transfer From: Transfer From Outpatient" - "Transfer From: Transfer From Emergency Department (ED) Locations" - "Transfer From: Transfer From Inpatient" 7
AMI 8a Variables, continued $ReasonForNoFibrinolyticTherapy = Union of: - "Diagnosis, Active: Cardiopulmonary arrest" - "Procedure, Performed: Endotracheal Intubation" - "Procedure, Performed: Aortic balloon pump insertion" - "Procedure, Performed: Ventricular Assist Device placement" Note: $ReasonForNoFibrinolyticTherapy has been updated to $ReasonForNoPCI in version 5. 8
Initial Population Requirements Patients must be at least 18 years old. Encounter must include principal diagnosis of AMI. Diagnosis must be recorded during inpatient encounter or ED visit. ED visit is only considered if it occurs within one hour of inpatient admission. 9
Initial Population AND: Age > = 18 year(s) at: Occurrence A of $EncounterInpatient AND: OR: "Diagnosis, Active: Acute Myocardial Infarction (AMI) (ordinality: Principal)" starts during Occurrence A of $EncounterInpatient OR: "Diagnosis, Active: Acute Myocardial Infarction (AMI) (ordinality: Principal)" starts during ("Encounter, Performed: Emergency Department Visit" <= 1 hour(s) and ends before or concurrent with start of Occurrence A of $EncounterInpatient) 10
Refines cases by assessing AMI patients identified in IP with: ST-elevation on ECG Received primary PCI Fibrinolytic therapy not initiated Denominator Denominator = AND: Initial Population 11
Denominator ECG AND: o OR: o OR: AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient AND: Union of: Most recent: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG)" <= 1 hour(s) starts before start of "Occurrence A of Encounter, Performed: Emergency Department Visit" First: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG)" starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient AND: Union of: Most recent: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG)" <= 1 hour(s) starts before start of Occurrence A of $EncounterInpatient First: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG)" starts after start of Occurrence A of $EncounterInpatient 12
Denominator diagnosis AND: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG) (result: Acute or Evolving MI)" AND NOT: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG) (result: STEMI Exclusions)" 13
AND: o OR: o OR: Denominator - PCI AND: First: "Occurrence A of Procedure, Performed: PCI (ordinality: Primary Procedure)" <= 1440 minute(s) starts after start of Occurrence A of $EncounterInpatient AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient AND NOT: "Occurrence A of Procedure, Performed: PCI" starts after start of "Occurrence A of Medication, Administered: Fibrinolytic Therapy" during Occurrence A of $EncounterInpatient AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient AND: First: "Occurrence A of Procedure, Performed: PCI (ordinality: Primary Procedure)" <= 1440 minute(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit" AND NOT: "Occurrence A of Procedure, Performed: PCI" starts after start of "Occurrence A of Medication, Administered: Fibrinolytic Therapy" starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit 14
Denominator Exclusions Patients received as a transfer from: Inpatient or Outpatient Department Emergency Department Ambulatory Surgical Center Denominator Exclusions = OR: $AnotherHospitalOrHealthcareFacility <= 1 day(s) starts before start of o "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient OR: o AND: $AnotherHospitalOrHealthcareFacility <= 1 day(s) starts before start of Occurrence A of $EncounterInpatient o AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient 15
Numerator Assesses AMI patients whose time from hospital arrival to primary PCI is 90 minutes or less. Numerator = AND: o OR: AND: "Occurrence A of Procedure, Performed: PCI (ordinality: Primary Procedure)" <= 90 minute(s) starts after start of Occurrence A of $EncounterInpatient AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient o OR: "Encounter, Performed: Emergency Department Visit" satisfies all <= 90 minute(s) starts before start of "Procedure, Performed: PCI" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient 16
Denominator Exceptions Patients with a specified medical diagnosis or procedure performed: Cardiopulmonary arrest Endotracheal intubation Aortic balloon pump insertion Ventricular assist device placement 17
Denominator Exceptions Expression Denominator Exceptions = OR: $ReasonForNoFibrinolyticTherapy <= 90 minute(s) starts after start of OR: o"encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient oand: $ReasonForNoFibrinolyticTherapy <= 90 minute(s) starts after start of Occurrence A of $EncounterInpatient oand NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient 18
QDM Data Elements Procedure, Performed: Aortic balloon pump insertion" using "Aortic balloon pump insertion SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.1151) Category: Procedure Data Type: Procedure, Performed Value Set: Aortic balloon pump insertion Code System: SNOMED Codes: 175113001, 399052009, 399175004, 399217008, 432375005, 442807006, 83676006 19
Data Criteria (QDM Data Elements) "Diagnosis, Active: Acute Myocardial Infarction (AMI)" using "Acute Myocardial Infarction (AMI) Grouping Value Set (2.16.840.1.113883.3.666.5.3011)" "Diagnosis, Active: Cardiopulmonary arrest" using "Cardiopulmonary arrest Grouping Value Set (2.16.840.1.113883.3.666.5.748)" "Diagnostic Study, Performed: Electrocardiogram (ECG)" using "Electrocardiogram (ECG) Grouping Value Set (2.16.840.1.113883.3.666.5.735)" "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.292)" "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)" "Medication, Administered: Fibrinolytic Therapy" using "Fibrinolytic Therapy RXNORM Value Set (2.16.840.1.113883.3.666.5.736)" "Procedure, Performed: Aortic balloon pump insertion" using "Aortic balloon pump insertion SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.1151)" "Procedure, Performed: Endotracheal Intubation" using "Endotracheal Intubation Grouping Value Set (2.16.840.1.113762.1.4.1045.69)" "Procedure, Performed: PCI" using "PCI Grouping Value Set (2.16.840.1.113762.1.4.1045.67)" "Procedure, Performed: Ventricular Assist Device placement" using "Ventricular Assist Device placement Grouping Value Set (2.16.840.1.113883.3.666.5.3015 )" 20
Data Criteria (QDM Data Elements) "Transfer From: Ambulatory Surgical Center" using "Ambulatory Surgical Center SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.687)" "Transfer From: Transfer From Emergency Department (ED) Locations" using "Transfer From Emergency Department (ED) Locations SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.3006)" "Transfer From: Transfer From Inpatient" using "Transfer From Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.3013)" "Transfer From: Transfer From Outpatient " using "Transfer From Outpatient SNOMEDCT Value Set (2.16.840.1.113883.3.67.1.101.950)" Attribute: "Result: Acute or Evolving MI" using "Acute or Evolving MI Grouping Value Set (2.16.840.1.113883.3.666.5.3022)" Attribute: "Ordinality: Primary Procedure" using "Primary Procedure SNOMEDCT Value Set (2.16.840.1.113762.1.4.1111.12)" Attribute: "Result: STEMI Exclusions" using "STEMI Exclusions Grouping Value Set (2.16.840.1.113762.1.4.1045.36)" Attribute: "Ordinality: Principal" using "Principal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.14)" 21
22 Frequently asked questions
Question It appears this measure is missing Denominator Exceptions for why a PCI was not done. It looks like a repeat of the Fibrinolytic Reasons Not Done Denominator Exceptions Section from AMI-7a (CMS60/NQF164). 23
Answer The Denominator Exceptions for both CMS53 and CMS60 include: "Diagnosis, Active: Cardiopulmonary arrest" "Procedure, Performed: Endotracheal Intubation" "Procedure, Performed: Aortic Balloon Pump Insertion" "Procedure, Performed: Ventricular Assist Device Placement" The variable name was corrected to $ReasonForNoPCI during the 2016 Annual Update for 2017 reporting to align with the measure content. 24
Question For hospitals with satellite hospital emergency departments with the same CCN number, when does the time begin for 90 minutes of hospital arrival? At the time of origin in the satellite ED, or when the patient arrives at the main facility? 25
Answer If this is truly a satellite ED and not urgent care, the timing would start in the satellite ED. The numerator states: OR: - "Encounter, Performed: Emergency Department Visit" satisfies all <= 90 minute(s) starts before start of "Procedure, Performed: PCI - <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient The arrival time is associated with the encounter. If you want to determine if the patient falls into the Numerator, it would depend on the remaining logic (i.e., <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient). 26
Question The guidance changed between version 4 and version 5. What needs to be captured for reporting Procedure Performed: PCI? 27
Answer The PCI Grouping Value Set (OID 2.16.840.1.113762.1.4.1045.67) identifies a PCI procedure as performed (logic construct Procedure, Performed: PCI). Documentation of ICD-10 or SNOMED codes within this value set will suffice. Timing requirements of a primary PCI procedure within 90 minutes of hospital arrival did not change. 28
Question An ordinality attribute of 'primary' was added to the Procedure, Performed PCI element. We understand that 'primary' is clinical, and does not mean 'principal' as in a billing context. The designation of a PCI as primary is not typically found in the EHR in the way the measure expects. What is the expectation of how the EHR will collect 'primary' for the PCI procedure? 29
Answer Most EHRs do not have the option to capture primary. We believe using 'FIRST' will likely capture the intent in the majority of cases. Added clarifying statement to the current guidance regarding using first to meet the intent of the measure in capturing the primary PCI procedure performed during the inpatient encounter. Added 'FIRST' to replace 'Ordinality: Primary Procedure' to capture the first (primary) PCI procedure performed during an inpatient encounter in the Denominator logic for version 5. 30
Question The ordinality: Primary Procedure clause of the numerator section is not included for ED encounters. Has any consideration been given to ordinality: Primary Procedure in ED also? 31
Answer Removed ordinality in version 5. Revised logic: Moved from numerator to denominator Added FIRST to replace 'Ordinality: Primary Procedure' 32
Question SNOMED code 401314000 (Acute non-st segment elevation myocardial infarction (disorder)) is present in both the Acute Myocardial Infarction (AMI) Grouping Value Set and the "STEMI Exclusions Grouping Value Set. If a user documents a result that's coded with 401314000, it will qualify for both result attributes, yet the measure logic indicates they should be mutually exclusive. Can you comment on this discrepancy? 33
Answer The initial population identifies patients with a primary diagnosis of Acute Myocardial Infarction (AMI) using the AMI Grouping Value Set (2.16.840.1.113883.3.666.5.3011). The denominator narrows the pool of cases through the ECG result of an acute or evolving MI using the Acute or Evolving MI Grouping Value Set (2.16.840.1.113883.3.666.5.3022). Next, the logic ensures the ECG did not include non- STEMI codes found in the STEMI Exclusions Grouping Value Set (2.16.840.1.113762.1.4.1045.36). If a STEMI exclusion code is identified, the logic stops executing and the case is not included in the measure population. 34
AMI 8a changes for 2017 Removed ED visit from the Initial Population Replaced 'Ordinality: Primary Procedure' with first (primary) PCI procedure Removed Primary Procedure value set (2.16.840.1.113762.1.4.1111.12) Removed Occurrence A from Medication Administered: Fibrinolytic Therapy Changed timing for 'Occurrence A of Encounter, Performed: Emergency Department Visit' to 'starts during Corrected variable name to '$ReasonForNoPCI Extended operators to 'starts before or concurrent with start of' and 'ends before or concurrent with start of' for the Transfer From statements Replaced Diagnosis, active with the re-specified Diagnosis datatype Changed value sets to reflect terminology updates 35
Resources Measure Specifications (ecqm Library): https://www.cms.gov/regulations-andguidance/legislation/ehrincentiveprograms/e cqm_library.html Joint Commission Reporting Requirements: https://www.jointcommission.org/performanc e_measurement.aspx ecqi Resource Center EH Measures: https://ecqi.healthit.gov/eh 36
References Brodie BR, Stuckey TD, Wall TC, Kissling G, Hansen CJ, Muncy DB, et al. Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol. 1998;32:1312-9. DeLuca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation 2004;109(10):1223-1225. 37
References (Continued) Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44-122. O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:485-510. 38
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