Welcome to Lesson 2 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, and I will 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, 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 AUC indications were developed from common scenarios or anticipated uses, as well as from current clinical practice guidelines. The AUC acknowledges that in real-world scenarios, expert opinion is valuable in addressing patient populations that are either not represented in current randomized clinical trials or for treatment recommendations supported by lower levels of evidence. These appropriate use criteria should be used in conjunction with the ACC, AHA, HRS 2008 Guidelines for Device-Based Therapy for Cardiac Rhythm Abnormalities and the 2012 Focused Update. They're meant to act as a guide in clinical decision-making regarding appropriate patient selection and the timing of device implantation for ICD or CRTD in a variety of clinical scenarios, the majority of which are encountered in everyday practice. However, the writing committee feels it's important to acknowledge that patients may not always fit neatly into a given clinical scenario and that clinical judgment is necessary for assessing individual patients. Providers will use their best judgment based on the patient's history and the patient's awareness of benefits versus risks. To limit inconsistencies in interpretation, a number of general assumptions were made, several of which are listed here. It is assumed that the clinical status of the patient has been evaluated, end-of-life and advanced directives have been discussed. The consent process has occurred using a shared decision-making tool when applicable. The patient has received optimum care and guideline-directed medical therapy with reassessment of the LVEF. The LVEF has been measured within a relevant timeframe and the LVEF has been reassessed after an appropriate timeframe from an acute MI or revascularization. This document summarized the assessed level of appropriateness for a variety of clinical scenarios. Appropriate with a rating of 7 to 9 is assigned to scenarios for which there are clinical trial evidence and or clinical experience supporting the device implantation. It is considered an appropriate option and the benefits generally outweigh the risks. Maybe appropriate with a rating of 4 to 6 at times is an appropriate option in which the potential benefits is based on practiced experience as there is limited clinical trial evidence. The device implantation may be reasonable for an extenuated reason. Rarely appropriate with a rating of 1 to 3 is rarely an appropriate option as it may be harmful and there is lack of data to support a clear benefit over risk. Medical judgment must be cautiously exercised with clear documentation of the clinical reason for device implantation. In all scenarios, the provider must use their clinical judgment along with evaluation of patient's comorbidities and preferences, which should be clearly documented in the medical record. Let's look at some steps to success when using the AUC. It is easier to navigate the AUC using a systematic three-step process. The first step is to determine the applicable section. Section 1 evaluates secondary prevention ICD implants. Section 2 evaluates primary prevention ICD implants. Section 3 reviews comorbidities in the implant of an ICD. Section 4 evaluates ICD generator replacement at elective replacement indicator or ERI. Section 5 discusses dual-chamber ICD implant as opposed to single-chamber ICD implant. Section 6 evaluates CRTD with no prior implant. The second step is to determine which patient factors have been coded versus what has been documented in the medical record. And the third step is to identify the appropriate indication. The focus today will be Section 6, which evaluates CRTD implant. This 55-year-old male was admitted on March 30, 2020, for an initial CRTD implantation. He has a history of non-ischemic cardiomyopathy secondary to alcohol abuse, which was initially diagnosed in 2014. The current LVF is 35%, with a New York Heart Association class of 2. The ECG reveals sinus rhythm with a right bundle branch block and a QRS duration of 129 milliseconds. The patient's been alcohol-free for the past 6 months and compliant with the prescribed medical therapies. Will this patient be included in the numerator of metric 27 or as an indication in the AUC? Number 1, metric 27. Number 2, AUC indication. Number 3, both. Number 4, neither. Please take a moment to review the documentation and the question. The answer is number 2. This patient meets an AUC indication. Let's start by going to Section 6 and specifically look at Table 6.2, as our patient has non-ischemic cardiomyopathy with a current LVF of 35%. The patient's New York Heart Association class is 2, and the ECG reveals sinus rhythm with a right bundle branch block and a QRS duration of 129 milliseconds. The AUC indication is 213, with a rating of 3, which is rarely appropriate. Let's review why the patient fell out of metric 27. From the patient detail information displayed on the dashboard, we see that the New York Heart Association class is 2, causing the patient to be listed as no in the numerator of metric 27. How were we able to determine this? Looking at the companion guide on page 34, located under Resources, Documents, and User Guide Documents, we see the algorithm for class 2B recommendation number 2. Our patient has all the elements highlighted in bold, non-ischemic cardiomyopathy, an LVF of 35%, guideline-directed medical therapy for at least three months with sinus rhythm and a right bundle branch block and QRS duration of 129 milliseconds. However, our patient has a New York Heart Association class of 2, not 3 or 4, which is required. In this type of scenario, please check to make sure the New York Heart Association classification was coded accurately. If you need a helping hand, please go to our Resources tab, select Documents, and review the Outcomes Report Companion Guide, the 2013 Appropriate Use Criteria Document for ICD and CRTD Implantation, and the 2012 Focused Update of the 2008 Guidelines for Device-Based Therapy. This concludes Lesson 2 of 3. Now that you have completed this lesson, please proceed to Lesson 3. Thank you for your participation.

Denise Pond

Appropriate Use Criteria

cardiac rhythm abnormalities

metric 27

process improvement