Welcome to Lesson 1 of 3 in this learning activity titled How Gaps in the Guidelines are Addressed in the AUC. The content in this lesson was developed by myself, Denise Pond. I will also be narrating this lesson. The objectives are the participant will be able to list three steps to identify fallouts in metric 27, articulate one gap addressed by the AUC, and choose one area for process improvement. The case scenarios were developed from frequently asked metric questions, however, the content does not reflect actual patient records. The focus today will be applying processes using the dashboard drill down and available resources to evaluate CRTD implants. This will assist you with choosing an area in your practice to focus on for process improvement. The 2012 focused update evaluates current recommendations and identifies a class 1 recommendation which is beneficial, such as implanting a CRTD in patients with an LVF less than or equal to 35% who are in sinus rhythm with a left bundle branch block and a QRS duration of 150 milliseconds or greater and have a New York Heart Association classification of 2, 3, or 4 despite being on guideline directed medical therapy. The 2012 focused update also identifies class 2A recommendations which may be beneficial. One example is the treatment of patients who have an LVF of less than or equal to 35% are in sinus rhythm with a left bundle branch block and a QRS duration of 120 to 149 milliseconds and a New York Heart Association classification of 2, 3, or 4 despite being on guideline directed medical therapy. Lastly, the 2012 focused update identifies what is not recommended. An example would be those patients with a New York Heart Association classification of 1 or 2 and a non-left bundle branch pattern with a QRS duration of less than 150 milliseconds. Let's review how the companion guide highlights this information. Metric 27 is based on the 2008 device-based therapy guideline and the 2012 focused update for device-based therapy. The outcome report companion guide provides the necessary details to understand metric inclusion and exclusion criteria as well as the associated algorithms. The numerator will include all initial CRTD implants that meet a class 1, 2A, or 2B guideline indication for a device. The denominator is the count of all patients who had an initial CRTD implanted for which procedure type sequence 7010 was coded as an initial generator implant and the exclusion criteria removes any patient enrolled in a clinical trial for a generator or lead which has not been approved for use by the FDA. Let's review the data elements that make up the algorithms. It is easier to use a systematic approach to break down the patient information in the dashboard for metric 27. The patient must first meet one of the four criteria listed here, non-ischemic cardiomyopathy or ischemic cardiomyopathy with an MI greater than or equal to 40 days from the implant of the device or ischemic cardiomyopathy with PCI or CABG greater than or equal to 90 days from the implant of the device or the ICD indication must be secondary. If data is missing due to missing documentation in the medical record or because of data abstraction omission or error, the patient will fall out of the metric. If one of these criteria is present, then you can proceed to identifying what the patient's LVF is, what their New York Heart Association classification is. In addition, has this patient been on guideline-directed medical therapy for at least three months or were they unable to complete it? What is the patient's atrial rhythm and do they have an intraventricular conduction delay and QRS duration that's been documented and coded? And finally, does the patient have an anticipated requirement for greater than 40% RV pacing? Let's apply this to a patient scenario. This patient was admitted for an initial CRTD implant on February the 25th, 2020 for primary prevention. She has a history of ischemic cardiomyopathy with an MI and a PCI to the RCA on December 31st, 2019. She experienced an episode of non-sustained VT on February 22nd, 2020. She has not yet been on three months of guideline-directed medical therapy. ECG reveals sinus rhythm with a left bundle branch block and a QRS duration of 155 milliseconds. Current LVF is 32% in NYHA class of three. The clinician recommends resynchronization therapy for refractory heart failure. Will this patient be included in the numerator of metric 27? Number one, no. Number two, yes. Please take a moment to review the documentation and question. The answer is number one, no. This patient does fall out of metric 27 as the patient does not meet a guideline indication for a device. Let's investigate further using our drill down to determine why. The patient did not meet the requirements for metric 27 because the PCI is 56 days from the CRTD implant. Let's look at the recommendation and the algorithm in the outcome report companion guide. Looking at the companion guide on page 32 located under resources, documents, and user guide documents, we see the algorithm for a class one recommendation number one. Our patient has all the elements highlighted in bold, ischemic cardiomyopathy with an MI greater than 40 days ago, an LVF of 32%, a New York Heart Association class of three, inability to complete guideline-directed medical therapy, sinus rhythm with a left bundle branch block, and a QRS duration of 155 milliseconds. However, our patient had a PCI less than 90 days from the implant of the CRTD, causing her to be displayed as no in the numerator of metric 27. How does the AUC evaluate this same scenario? Let's start by going to section six and specifically looking at table 6.5, as our patient has refractory heart failure with a New York Heart Association class of three, and a PCI less than 90 days ago. The current LVF is 32%, and there are no other indications for pacing. The patient's ECG reveals sinus rhythm with a left bundle branch block and a QRS duration of 155 milliseconds. The AUC indication is 229 with a rating of eight, which is appropriate. The AUC does fill this gap in the guidelines. Are there any other gaps addressed? There are other scenarios in which the AUC fills a gap in the guideline. The patient indicates that the CRTD might be appropriate. CABG, less than three months from the implant of the ICD. PCI, less than three months from the implant of the ICD. An LVF of greater than 35%. A pre-existing requirement for permanent pacing. And there are additional scenarios which include ischemic and non-ischemic cardiomyopathy with a New York Heart Association classification of one. The ICD registry has many available resources. Please go to our resources tab, select documents to view, outcome report companion guide, the 2013 appropriate use criteria document for ICD and CRTDs, and the 2012 focused update of the 2008 guideline for device-based therapy. This concludes lesson one of three. Thank you for your participation.

Denise Pond

AUC guidelines

CRTD implants

dashboard drill down

process improvement