Welcome to the EP Device Implant Registry case scenario for November of 2022, where we will discuss appropriate use criteria metrics. Prior to reviewing this case scenario, the appropriate use criteria metric information will be provided for better understanding of how to interpret and use the AUC metric feedback. When reviewing metric feedback for CRTDs, it is important to note the denominator of both metric 27, proportion of CRTD patients that fulfill Class I, IIa, and IIb guideline indications, and metric 105, proportion of CRTD procedures not classifiable for AUC, is the total number of initial CRTD implants, and both metric denominators will always align. The numerator of metric 105, proportion of CRTD procedures not classifiable for AUC, is the total number of initial CRTD implants identified as not classifiable for the AUC. The patient level drill down will only list those patients who are not classifiable. The numerator is the total number of all initial CRTD implant devices that have been classified as appropriate, maybe appropriate, or rarely appropriate. The total number of all CRTDs classified is obtained by adding the numerators of metric 106, 107, and 108 together, which is also the denominator for all three metrics. In this example, the total number of initial CRTD implants, my hospital rolling four quarters, which would be classified, is 64. Adding each individual quarters denominator equals the my hospital R4Q denominator. This is the same for the numerator. Of note, when drilling down to the patient level, only those patients included in the numerator will be displayed. This is different from the guideline metrics, where the patient level drill down displays all patients in the numerator and denominator. The denominator is the total number of initial CRTD implants classified, which is the same for metrics 106, 107, and 108. In our example, the denominator is 17. The denominator exclusions are those patients who are enrolled in a pre-market clinical trial in sequence 7020 and those patients less than 18 years of age. It is important to remember when evaluating the AUC metrics specific to CRTD, dual chamber, primary prevention, and or secondary prevention, patients and their scenarios can be placed in one or more of four categories. For optimal review of the feedback provided, it is important to glance at the appropriate, maybe appropriate, and rarely appropriate within the same category and view the distribution rather than relying on comparing your facility score against the U.S. benchmark. In this example, the category of CRTD classifiable procedures classified as appropriate, maybe appropriate, and rarely appropriate for 2022 Quarter 2, metric 106 CRTD classified as appropriate displays 100%, meaning all of the initial CRTD devices were classified as appropriate. Therefore, both metric 107, maybe appropriate, and 108, rarely appropriate will display 0%. When evaluating metric 107 as an individual measure, this facility's performance is 0%, which when compared to the U.S. hospital rolling for quarter aggregated 50th percentile of 9.2, this facility is performing at less than the 10th percentile. On individual measures or metrics, it is desirable to be at or above the 50th percentile. However, when evaluating performance for the AUC metrics, it is best practice to evaluate the category holistically. When the category of CRTD procedures are evaluated holistically, it is clear that this facility is performing better than the U.S. 50th percentile with 100% of the CRTD device meeting the classification of appropriate for 2022 Quarter 2. A 55-year-old patient was admitted on October 28, 2022 for an initial CRTD implant. He has been on guideline-directed medical therapy since March of 2022 for ischemic cardiomyopathy after an MI and PCI to his mid-LAD, resulting in an LVEF of 40%. His current NYHA classification is 3, with a declining LVEF of 33% despite guideline-directed medical therapy for greater than six months. His ECG demonstrates persistent AFib, a left bundle branch block with a QRS duration of 155 milliseconds. Our question, is this patient included in the numerator of metric 105, 106, 107, or 108? Number one, 105, the proportion of CRTD procedures not classifiable for AUC. Number two, metric 106, proportion of CRTD procedures classified as appropriate. Number three, metric 107, proportion of CRTD procedures classified as maybe appropriate. Or number four, metric 108, proportion of CRTD procedures classified as rarely appropriate. Please take a few moments to review the documentation and the question prior to making the best selection. The answer is number one, metric 105, the proportion of CRTD procedures not classifiable in the appropriate use criteria AUC. To locate the AUC document, log in to the homepage of the EP Device Implant Registry and select Resources, then Documents. Scroll down to Quality Tools and Reference Documents and download the 2013 AUC for ICD and CRTD devices. This patient had an initial CRTD device for ischemic cardiomyopathy, worsening LVEF and persistent AFib, left bundle branch block, and a QRS duration of 155 milliseconds. AFib with a QRS duration of 120 or greater is not addressed in the 2013 AUC document. Let us see if this patient fulfills a class 1, 2A, or 2B guideline indication in metric 27, CRTD device-based therapy guideline. This patient meets the guideline device-based therapy guideline metrics with the device classification of a class 2A, level of evidence B, as the guideline metrics address atrial fibrillation to determine the appropriateness of CRTD devices. Please do review October's EP Device Implant Case Scenario if you haven't done so already. Both October's and November's case scenarios provided enhanced understanding of the AUC metrics. Thank you for viewing the EP Device Implant Registry's November 2022 case scenario regarding the appropriate use criteria metrics.

CRTD devices

EP Device Implant Registry

appropriate use criteria

AUC metrics

cardiac resynchronization therapy defibrillator