Welcome to Lesson 1 of this learning activity titled 30-Day Follow-Up Metrics 2 and 3, Where to Look When Things Go Wrong. The content in this lesson was developed by myself, Karen Colbert. The objectives for this learning activity are, number one, the participant will describe follow-up metrics 2 and 3, number two, be able to locate and utilize the Outcome Report Companion Guide as a reference, and number three, be able to identify the numerator and denominator for metric 2 and 3. Metric 2, 30-Day Follow-Up Records Not Submitted Among Eligible, looks at your facility's proportion of patients with TAVR that did not have a 30-day follow-up assessment entered within the 21- to 75-day timeframe post-procedure. This screenshot is from the 30-Day Follow-Up Outcome Report Companion Guide and can be found on the Resources tab on the document's homepage. It is important to note that the population in this metric is specific to TAVR cases only. The numerator only looks at the patient population with a 30-day follow-up assessment not submitted between 21- to 75-days post-procedure, and the denominator will include all patients with a discharge status of alive as coded in Sequence 9050 and will exclude all aborted procedures as coded in Sequence 6075. This is the metric where the patient entry does not want to be included in the numerator. Metric 3, Patients That Are Classifiable for 30-Day Reporting, looks at your facility's proportion of patients with TAVR that did have a 30-day follow-up assessment entered within the 21- to 75-day timeframe post-procedure. This screenshot is from the 30-Day Follow-Up Outcome Report Companion Guide. Like metric 2, it is important to note that the population is specific to TAVR patients only. The numerator only looks at the patient population with a 30-day follow-up assessment submitted between 21- to 75-days post-procedure or had a discharge status of deceased as coded in Sequence 9050. The denominator will exclude all aborted procedures as coded in Sequence 6075. This is the metric where the patient entry does want to appear in the numerator. To locate the 30-Day Follow-Up Outcome Report Companion Guide, go to the left-hand navigation bar and select Resources. From the Resources tab, select Documents. On the Documents homepage, go to the Outcome Report Companion Guide documents and download the 30-Day Follow-Up Executive Summary Measures and Metrics Companion Guide. The following is an example of the most common questions asked when a patient entry appears in metric 2. In addition, there is also a question about metric 3. Question 1. Why does the patient appear in the numerator for metric 2? Question 2. The patient information was entered for the 30-day follow-up. Where is it? Question 3. The physician scheduled the appointment too early. Can the patient still be included in the numerator for metric 3? Fourth question. The patient canceled the appointment and came back after the time frame had expired. What happens now? Question 5. What has happened when the patient does not appear in either metric 2 or metric 3? Question 6. Changes have been made to the entered data. Why aren't the changes displayed immediately? And the last question. What does classifiable mean for follow-up metric 3? The first questions we will explore are question number 1 and question number 2. Why does this patient appear in the numerator for metric 2? And the patient information was entered for 30-day follow-up. Where is it? When trying to find the reason that a patient is appearing in metric 2, the first place to start is the DQR, data quality report, to ensure that two quarters of data have been entered for follow-up. There are always two quarters of assessments due for each follow-up at data deadline. This occurs so that when sites have a patient discharged at the end of a quarter and has follow-up in the next quarter, the data for follow-up can be included or linked to the same 30-day follow-up outcome report. For example, a patient had a procedure on December 28 and was discharged on December 31 in 2019 Q4. Their follow-up occurred in 2020 Q1. For the purposes of the DQR submission, the follow-up assessment would be classified in 2020 Q1 follow-up. To link the base procedure data and the follow-up assessment quarter, submit the 2019 Q4 base and follow-up, then submit the 2020 Q1 base and follow-up. This is an example of a 2019 Q4 data quality report, or DQR, that shows the site had a green submission status for both the base and follow-up at the time of the 2019 Q4 data deadline, which was April 29, 2020. However, when looking at the 2020 Q1 base and follow-up, the first submission to the DQR did not occur until after the 2019 Q4 data deadline of April 29, 2020. When the next quarter of data is not submitted by the current data deadline, all patients who had their procedure in 2019 Q4 but their follow-up in 2020 Q1 will show up in metric 2 as a record not submitted in the numerator. The first question on this list, why does this patient appear in the numerator for metric 2, has many answers. When it has been confirmed that there are no problems with the DQR submission, then begin looking at the metric 2 drill down to determine how many patients are in the numerator and the identity of the patients. To get to the patient level drill down, go to the dashboard and select the appropriate quarter for the 30-day follow-up ending time frame. Once the correct quarter is available, click the blue hyperlink for metric 2, 30-day follow-up records not submitted. Looking at the drill down for 2019 Q4, there are three patients appearing in the numerator. These three patients can be identified by name and patient ID on the drill down. After the patient has been identified, look up each patient to see if a follow-up has been entered. If there is no entry and the follow-up information is available in the correct time frame, enter all data, rerun the quality check, and resubmit the quarter to the DQR. When the weekend aggregation occurs for an unpublished quarter, the patient will move from metric 2 to metric 3 numerator. The next place to check and see if the record was entered is the maintenance page. From the left-hand navigation bar, go to data, then data collection tool, and choose the maintenance tab. Once on the maintenance page, find the blue hyperlink in the number follow-ups column that corresponds to the quarter in question. Also pay attention to the last column to see if there are any system alerts present for that quarter. When comparing the patient level drill down for metric 2 to the available entries on the maintenance page for 2019 Q4, you can see that there is no entry for the patient Jane Doe on the maintenance page. Additionally, John Smith and James Miller both have system alerts attached to their entries, which will not allow for the patient to be reviewed by the DQR. System alerts are error codes used to validate the quality of the data submission. There are several system alerts, which include selection, date, vendor, list, and counter. The most common reason for a system alert occurs when additional data or data correction has been entered after initial submission of the patient record and the quality check was not rerun. To resolve the system alert, go to the quality check and look at each error or outlier warning to see if the coding is accurate. If there is no error and the coding is correct on the outlier warnings, go back to the maintenance page for follow-up to see if the system alert has resolved. Outlier warnings do not need to be resolved and will not affect submission to the DQR and will not affect the ability to pass the DQR. If the error is a date, list, counter, selection, or vendor error, the quality check will provide information to aid in resolving the error. Once the errors have been corrected, please remember to rerun the quality check before resubmitting the data to the DQR. This is a synopsis of question number one. Why does this patient appear in the numerator for measure two? First check were two quarters of data submitted for follow-up. You will need to check the DQR under data on the left-hand navigation bar. Second, was a follow-up submitted? Was the follow-up submitted at all and was the follow-up submitted in the correct time frame of 21 to 75 days post procedure? Third, did the entries on the maintenance page match the patients who appeared in the metric two numerator? Check to see if the patient had a system alert or any other alert to keep the entry from being reviewed by the DQR. Synopsis for question number two. The patient information was entered into the 30-day follow-up. Where is it? Check to ensure that the data was both entered into the data collection tool and was submitted to the DQR. This concludes lesson one of two of 30-day follow-up metrics two and three, where to look when things go wrong. Thank you for your participation.

Karen Colbert

Lesson 1

30-Day Follow-Up Metrics 2 and 3

Outcome Report Companion Guide

numerator and denominator