Welcome to Lesson 3 of Metric No. 40, Risk-Standardized Bleeding. In this lesson, we'll closely examine the detail lines and metric performance that support understanding of bleeding events and rates. Gaining insight into your facility's performance with respect to bleeding events is accomplished by reviewing your data on the CAHPS PCI Registry eReports Dashboard. Select Dashboard on the left navigation bar of the home page. While Executive Summary Metric 40 can be accessed on the eReports Dashboard by selecting the desired published quarter, a thorough understanding of facility performance may best be achieved through detail line analysis. Select Detail Lines from the View drop-down menu, then select the desired rolling four-quarter ending time frame and events in the Category drop-down menu. The since-retired Metric No. 37, Risk-Adjusted Bleeding Performance, is reported in the detail lines. While it is no longer an Executive Summary Metric, this measure, which reports performance according to a traditional risk model, provides a benchmarked, observed over-expected ratio, as well as a risk-adjusted rate quarterly and for the rolling four-quarters. In this way, these detail lines can serve as informative, adjunctive data to the Metric 40 Risk-Standardized Bleeding measure. The count of patients that meet bleeding model criteria for each individual quarter and the rolling four-quarters per the selection in the ending time frame menu, as discussed in Lesson 1, is reported in detail line 4838. The count of observed bleeding events, the tabulation of which is outlined in Lessons 1 and 2, is reported in detail line 4839. The expected bleeding event for the eligible population is reported next in detail line 4840. Before moving on to discussing other detail lines, it is important to highlight the patient and procedure variables that determine this rate. The eight patient variables that are used by the risk model to determine each individual's predicted probability of bleeding are age, sex, BMI, prior MI, GFR, hemoglobin, STEMI, and cardiogenic shock. Each individual's predicted probability of bleeding is then calculated to arrive at the facility's expected bleeding rate in detail line 4840, as discussed in the previous slide. To ensure that each individual's patient predicted probability of bleeding correctly calculates the patient's risk profile, it is imperative that coding instructions and target values are understood and followed. Thorough provider documentation is also essential in this effort. With respect to demographics, the risk model utilizes age, sex, the presence or absence of African American race as part of the calculation to determine GFR. Sex is also a variable that is utilized independent of GFR in the model as females have a higher tendency than males to have bleeding events. In the history and risk factor section, a patient's height and weight measurements contribute to their BMI calculation. The history of prior PCI also informs a patient's bleeding risk. Sequence number 4560, currently on dialysis, when selected yes, informs the model the patient has renal failure. As mentioned before, pre-procedure creatinine is utilized in conjunction with age, sex, and African American race to determine a patient's GFR and to what degree it may qualify as mild, moderate, or severe renal failure in the risk model. Procedure hemoglobin is independently used as a determining factor for risk of bleeding. Cardiovascular instability and specifically the presence of cardiogenic shock is one of the most predictive factors for in-hospital bleeding according to the bleeding model. Patients that are treated with PCI after a STEMI diagnosis are also at greater risk for bleeding complications and therefore any STEMI indication coded in sequence number 7825, PCI indication, will factor into the individual patient's risk profile. While the coefficients of the bleeding risk model algorithm are proprietary, one can gain a good understanding of the relative weight attributed to each of the bleeding risk variables by viewing the bedside NCDR bleeding risk score derived from the pre-procedure model available in the bleeding model manuscript. The presence of cardiogenic shock and moderate to severe dialysis-dependent carotid kidney disease followed by female sex and advanced age greater than or equal to 80 make up several of the leading risk factors that are predictive of a bleeding event. Ensure that you are referencing the variables listed in the risk standardized bleeding variable table shown on the left in the Executive Summary Measures and Metrics Companion Guide for an accurate listing of all data elements utilized in the current model. We have discussed the detail lines that inform the observed and expected bleeding events in lines 4839 and 4840 respectively. The next detail line, 4841, Observed to Expected Bleeding Ratio or OERatio, provides feedback on the comparison between the observed to the expected. When the OERatio is greater than 1, the facility experienced more bleeding events than expected. When the OERatio is less than 1, the facility experienced less bleeding events than expected. When the OERatio is equal to 1, the facility experienced the same bleeding events as the model expected. Detail line 4842 is the facility's risk adjusted bleeding rate. The risk adjusted rate is calculated by the hospital's OERatio multiplied by the registry aggregate observed bleeding rate. We have illustrated the value of examining risk adjusted bleeding detail lines. Metric 40, Risk Standardized Bleeding Detail Lines, can be viewed by selecting Detail Lines from the View drop-down menu, the desired rolling four-quarter ending time frame, and Risk Standardized Bleeding All Patients in the Category drop-down menu. Risk Standardized Bleeding Detail Lines provide the same quarterly values for the number of eligible procedures and number of observed bleeding events, as well as the total rolling four-quarter count for each, just as the risk adjusted bleeding detail lines. At the patient detail level, the participant can view the patient variables and characteristics reviewed by Metric 40. Patient level detail can be accessed from the eReports dashboard homepage by clicking Metric 40 and selecting Patient Detail, or by selecting the Patient Detail button provided in the detail lines for either Metric 40, Risk Standardized Bleeding, or Risk Adjusted Bleeding. The patient level detail informs us of the patient eligibility, and if the outcome, intrapost PCI bleeding, qualified as an observed bleed, as discussed in Lessons 1 and 2. The predicted probability of bleeding that is assigned to each individual patient based on the patient variables that we reviewed is integral to understanding the underlying patient's risk of bleeding, and in turn, identifying opportunities to mitigate bleeding events in the future. The higher the value, the higher the likelihood that the patient would experience a bleeding event. The patient level detail also provides us with data elements that factor into determining predicted probability of bleeding, such as PCI indication of STEMI, age, BMI, prior PCI, pre-procedure hemoglobin, GFR, and the presence of cardiogenic shock. Additional data elements that impact whether an observed bleed was identified are also included, such as mechanical ventricular support and bleeding at various sites, as well as cardiac tamponade, hemorrhagic stroke, and transfusion. A blank value under mechanical ventricular support indicates a null value, which is a result of the parent field ventricular support being coded no. In summary, patient level detail can be utilized to gain a deeper understanding of metric performance, including each individual patient's eligibility for inclusion or exclusion, feedback on each patient's predicted probability of bleeding, each individual patient risk factor or variable utilized by the model, and there is the opportunity to search and evaluate missing data. When metric performance isn't as expected, it is important to consider if the patient's risk profile on the patient drill down matches the risk profile in the medical record accordingly. If it doesn't, there may be opportunities to improve either abstract or understanding of the data elements, provider documentation, or both. This concludes Lesson 3 of Metric 40, Risk-Standardized Bleeding, in which we gained a further understanding of bleeding metric performance, detail lines, and patient level data. Thank you for your participation.

Metric No. 40

Risk-Standardized Bleeding

CAHPS PCI Registry eReports Dashboard

Metric 37

Risk-Adjusted Bleeding Performance