Welcome to Lesson 3 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 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 to apply the processes that we learned in Lesson 1 and 2 to evaluate CRTD implants. Let's begin with a quick review of how to evaluate metric 27 and the AUC. When looking at metric 27, first evaluate does the patient have non-ischemic cardiomyopathy, ischemic cardiomyopathy with an MI greater than or equal to 40 days from the implant, or ischemic cardiomyopathy with a PCI or CABG greater than or equal to 90 days from the implant, or is the ICD indication secondary prevention? Second, is the LVF less than or equal to 35%? Has the New York Heart Association class and guideline-directed medical therapy been documented and coded? And third, what is the patient's rhythm? Is the QRS duration documented and coded, or does the patient have an anticipated requirement for greater than 40% RV pacing? The first step to interpreting the AUC successfully is to determine the applicable section, which is CRT with no prior implant, and the appropriate table. For example, Table 1 evaluates CRTD implants in patients with ischemic cardiomyopathy. The second step is to determine which patient factors have been coded versus what has been documented in the patient's medical record. And the third step is to identify the appropriate indication. Now let's apply these processes to three distinct patient scenarios. This 72-year-old female was admitted February 18, 2020 for heart failure and started on IV milrinone. Her medical history included non-ischemic cardiomyopathy. Her current LVF was 33% with a New York Heart Association classification of 4. The clinician documented the patient's rhythm as persistent AFib with a left bundle branch block and QRS duration of 158 milliseconds. She was recommended for an initial CRTD implant, as her heart failure was unresponsive to medical therapy. Will this patient be included in the numerator of metric 27 as an indication in the AUC? Number one, metric 27. Number two, AUC indication. Number three, both. Number four, neither. Please take a few moments to review the documentation and the question. The answer is both an AUC and guideline indication. Let's look at table 6.3.2 as our patient has an LVF of 33%. The New York Heart Association class is 4 and the patient has been on IV milrinone. The ECG reveals a left bundle branch block and QRS duration of 158 milliseconds. The AUC indication is 221 with a rating of 6, which is appropriate. When we look at the patient drill down, all of the appropriate data elements have been documented and coded. Let's look at the recommendation and the algorithm. Looking at the companion guide on page 33, we see the algorithm for a class 2A recommendation number 3. Our patient has all the elements highlighted in bold, non-ischemic cardiomyopathy, an LVF of 33%, a New York Heart Association class of 4, guideline-directed medical therapy, persistent AFib, and an anticipated requirement for greater than 40% RV pacing. Therefore, this patient is displayed as yes in the numerator of metric 27. Our next scenario reveals a 58-year-old male who was a late-presenting anteroceptal MI to the proximal LAD and impella insertion on March 29, 2020. He's been on guideline-directed medical therapy since an MI in 2017 and has ischemic cardiomyopathy. His current LVF is 26% with a New York Heart Association classification of 4. The ECG reveals sinus rhythm with a right bundle branch block and QRS duration of 171 milliseconds. A CRTD was implanted April 5, 2020, for primary prevention given the patient's persistent heart failure despite maximum guideline-directed medical therapy. Will this patient be included in the numerator of metric 27 or as an indication in the AUC? Number one, metric 27, number two, AUC indication, number three, both, or number four, neither? Please take a few moments to review the documentation and the question. The answer is number two, an AUC indication. Table 6.5 is utilized as our patient has persistent heart failure with a New York Heart Association of 4 and is 7 days post-MI-MPCI. The current LVF is 26% and there are no other indications for pacing. The patient's ECG reveals sinus rhythm with a right bundle branch block and a QRS duration of 171 milliseconds. The AUC indication is 231 with a rating of 7, which is appropriate. Now why did the patient fall out of metric 27? When drilling down to the patient level on the dashboard, we see the patient does not meet the requirements for metric 27 because the MI-MPCI are 7 days from the CRTD implant. Let's look at the recommendation and the algorithm. When looking at the companion guide on page 33, we see the algorithm for a class 2A recommendation number 2. Our patient has all the elements highlighted in bold, ischemic cardiomyopathy with MI and PCI, an LVF of 26%, an NYHA class of 4, guideline directed medical therapy, and sinus rhythm with a right bundle branch block and QRS duration of 171 milliseconds. However, our patient had an MI-MPCI only 7 days from the implant of the CRTD, causing her to be displayed as a no in the numerator of metric 27. The last scenario reveals a 29-year-old female admitted for a CRTD for primary prevention with anticipated RV pacing of greater than 40% due to Mobitz type 2. She's been diagnosed with lamin ACG mutation and has been having episodes of non-sustained VT. Her current LVF is 48%. Additionally, her father has cardiomyopathy due to lamin ACG mutation and has survived a cardiac arrest. 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. Or number 4, neither. Please take a few moments to review the documentation and the question. The answer is neither an AUC indication nor guideline recommendation. Let's look at table 6.4 as our patient has anticipated RV pacing of 40% due to Mobitz type 2. Her LVF is 48% and an ECG reveals a narrow QRS duration of 100 milliseconds. However, there is no New York Heart Association class as the patient does not have a history of heart failure. This patient will be listed as not classifiable. When drilling down to the patient level on the dashboard, we see that there are many data elements missing that are required to meet the criteria for CRTD. However, no matter how many data elements are missing, when the LVF is greater than 35%, the patient will not be included in the numerator of metric 27. Let's look at the algorithm. Looking at the companion guide on page 34, we see the algorithm for class 2A recommendation number 4. Our patient has anticipated requirement for greater than 40% RV pacing. However, she does not have non ischemic cardiomyopathy or ischemic cardiomyopathy or a secondary indication for a device. Her LVF is greater than 35%, a New York Heart Association classification is not available as she does not have heart failure, and guideline directed medical therapy cannot be selected when a patient has neither ischemic nor non ischemic cardiomyopathy. All these factors are causing her to be displayed as no in the numerator of metric 27. Of note, this patient does meet a class 2B number 4 recommendation for a single or dual chamber ICD. If you need a helping hand, please go to our resources tab and select documents and review the outcome report companion guide, the 2012 focused update of the 2008 guidelines for device-based therapy, and the 2013 appropriate use criteria document for ICDs and CRTDs. This concludes Lesson 3. Please proceed to the posttest. Thank you for your participation.

AUC

fallouts

CRTD implants

guideline recommendations

posttest