The Chest Pain MI Registry case scenario for November of 2021 will review public reporting. We are going to begin by locating the Public Reporting Dashboard. After logging into the Chest Pain MI Registry and selecting Dashboard, click on the hamburger icon next to eReports Dashboard, which will display a drop-down menu. Next, select Hospital Public Reporting from the drop-down list. This will bring the user to the Public Reporting Dashboard. It will provide the ability to view the desired ending time frame, review the calendar year DQR status, and aggregation date. In addition, the facility can view the My State Report. The eReports Dashboard reveals an observed rate of 82.5% for metric 2, while the performance, or P-score, on the Public Reporting Dashboard indicates a score of 82.11%. Our question is, why is the reported observed rate for metric 2 in the eReports Dashboard not the same as the performance, or P-score? Number one, there is a mistake with the NCDR reports. Number two, the P-score is calculated using statistical models. Or number three, publicly reported metrics are calculated based on a rolling 4 quarter. Please take a moment to review the documentation and question. And the answer is number two. The observed rate and P-score are calculated differently. Let's start by defining the observed rate. The observed rate found displayed on the eReports Dashboard in metric 2 The observed rate found displayed on the eReports Dashboard in metric 2, defect-free care, is calculated based on the numerator and denominator. As an example, metric 2, defect-free care, has an observed rate of 82.5% as 113 patients out of 137 eligible patients received defect-free care. The P-score, also known as the performance score, seen on the Public Reporting Dashboard, is not expected to be the same as the observed rate seen in metric 2 on the eReports Dashboard. The P-score is a statistical calculation reflecting the probability of patients receiving perfect acute MI care at this facility, which is 82.11% in this scenario. The P-score accounts for variations in hospital volumes. Example, an individual hospital with a small sample size and a score below the mean of all hospitals is pulled up closer to the mean score of all hospitals. Additionally, the data for the calendar year 2020 is pulled from the data aggregated at the time of the 2020 Q4 data deadline, which was March 2, 2021. Public reporting is voluntary. However, there are several requirements to participate. To be considered for public reporting, the facility must have a minimum of three quarters with a green submission status and 40 cases submitted per calendar year. The required cases to be submitted varies by registry. Once this criteria has been met, the facility must provide a one-time consent for each participating registry, which can be revoked at any time. After the consent is submitted to NCDR, it takes the business support team up to 12 business days to process. The facility's data will appear in CardioSmart within 24 hours after the consent has been fully processed. Once the P-score has been estimated, the score is converted to a star rating. The rating for urgent heart attack care is displayed as one, two, three, or four stars. It is not possible to have a star rating of zero, and only whole numbers are displayed. One star indicates the P-score is less than 75%. Two stars indicates the P-score is between 75% and 89.99%. Three stars indicates the P-score is less than 75%. Three stars indicates the P-score is between 90 and 94.99%. And four stars indicates the P-score is equal to 95%, but less than 100%, as a P-score can never be 100%. The rating for all heart attack care is displayed as one, two, three, or four stars. However, the ratings for each star are different. Again, it is not possible to have a star rating of zero, and only whole numbers are displayed. One star indicates the P-score is less than 50%. Two stars indicates the P-score is between 50 and 74.99%. Three stars indicates the P-score is between 75 and 89.99%. And four stars indicates the P-score equal to 90, but less than 100%. In addition to the individual hospital score, there will be an overall state star score displayed. Now that you know about public reporting, what is the benefit of participating? Today, there is a desire for transparency and knowledge regarding care provided in an understandable format. It promotes improvement in healthcare delivery and outcomes. Additionally, hospitals can earn 2% of the maximum possible score for U.S. News & World Report cardiology and heart surgery by opting in to publicly report their performance data from the chest pain MI registry, cath PCI registry, or EP device implant registry. Together, this has the potential to enhance a healthcare facility's standing and linkage to the community. To view all metrics which are publicly reported, please go to the eReports dashboard, click the hamburger icon, and select hospital public reporting from the drop-down list. The NCDR Public Reporting Companion Guide can be located by selecting the blue hyperlink. Click here for scoring details. Thank you for viewing the chest pain MI registry case scenario for November 2021, which highlights public reporting.

Chest Pain MI Registry

public reporting

Public Reporting Dashboard

observed rate

P-score