Welcome to Lesson 3 of 4 of this learning activity titled Mastering Performance Composite Measures. The content in this lesson was developed by Shelley Conine. I am Kate Malish and I will be narrating this lesson. The objectives for Lesson 3 of 4 NCDR Overview of Mastering Performance Measures include define and explain the difference between eligible care and the all or nothing care measurement methodology calculations. The Chest Pain MI Registry Performance Composite Measures have two types of measurement methodology, the eligible care measurement methodology and the all or nothing measurement methodology. The performance composites uses all or some of 15 individual performance measures to provide a different at-a-glance view of performance. The eligible care measurement methodology is used in five of the six performance composite measures and reports the percentage of eligible individual care measures met. The five composites that use the eligible care measurement methodology are Metric 1 Overall AMI Care, Metric 3 STEMI Performance Composite, Metric 4 NSTEMI Performance Composite, Metric 5 Acute AMI Composite, and Metric 6 Discharge AMI Composite. The all or nothing measurement methodology is the measurement of perfect care at the patient level. Metric 2 Overall Defect-Free Care is the only performance composite to use the all or nothing measurement methodology. The two measurement methodologies used in the performance composite measures are defined. The eligible care measurement methodology is a count of all the eligible care measures for each individual performance measure within the composite. The denominator is the sum of all eligible care measures. The numerator is the sum of the eligible care measures met. The all or nothing measurement methodology is the count of all the patients who are eligible for one or more individual performance measure within the composite. The denominator is the sum of eligible patients. The numerator is the sum of patients who received perfect care. All the eligible care measures are provided. The performance composites displays the individual performance measures. What does it mean when a yes, no, or blank is displayed for an individual performance measure within the composite? A yes in the individual performance measure within the composite indicates the patient was eligible for the care measure and the care measure was met. A yes will be in the numerator of the individual performance, as demonstrated with aspirin at discharge. A no in the individual performance measure within the composite indicates the patient was eligible for the care measure and the care measure was not provided. A no will be in the numerator of the individual performance measure, as with high-intensity statin at discharge. A blank or null in the individual performance measure indicates the patient was not eligible for that individual performance measure. The patient did not meet criteria of the population being measured. This occurs when the patient did not meet the denominator criteria or a denominator exclusion or denominator exception removed the patient from the denominator. The patient will not be listed in the individual performance measure. In this patient-level detail report are examples of episodes of care and how they are displayed in the composite measures, with noted reasons as to why the individual performance measures are blank. Patient 1 is an N STEMI with an EF of 55%. Patient 2 is a STEMI who received PPCI within 90 minutes and who has a past medical history of AFib on apixaban. There is documentation as to why aspirin is not administered within 24 hours of arrival and the LVEF evaluation is planned for after discharge. Patient 3 is a STEMI with an out-of-hospital cardiac arrest who received PPCI with a discharge status of deceased. With the discharge status of deceased, this patient is not eligible for any discharge care measures. Patient 4 is an N STEMI patient with an EF of 35% who did not receive high-intensity statin nor cardiac rehabilitation referral. Patient 5 is an 80-year-old STEMI patient who was transferred in who was prescribed a moderate-intensity statin at discharge. Patient 6 is a STEMI patient who was transferred out within 30 minutes for PPCI. Patient 7 is a STEMI patient who left against medical advice soon after arrival. Patient 8 is a medically treated N STEMI who was discharged on Prazegrel and did not receive high-intensity statin nor cardiac rehabilitation referral. When analyzing an eligible care measurement methodology performance composite, what does a yes or no in the composite numerator signify? A no in the numerator indicates the patient is not eligible for any care measure. This means the patient is not included in the calculated score. There are several reasons why a patient may not be eligible for any of the performance measures. Some reasons are the patient left AMA, discharge status of deceased, or discharged to another acute care facility. A yes in the numerator indicates the patient is eligible for at least one care measure. This means this patient's care is included in the calculated score. The yes in the numerator is not part of the calculated score. Only the individual performance measures will contribute to the calculated score. The eligible care measurement methodology includes only the individual performance measures in the overall score. The composite numerator is not to be a part of the overall score. Patients 1, 2, 3, 4, 5, 6, and 8 have a yes in the composite numerator, indicating the individual care measures are included in the overall score. Patient 7 has a no in the composite numerator, indicating there are no eligible individual care measures to include in the overall score. The eligible care measurement methodology in this small sample size has 47 eligible care opportunities. Of those 47 eligible care opportunities, 42 were met, indicated by a yes in the individual performance measure, and 5 were not met, as indicated with a no in the individual performance measure. The numerator is the count of all the yeses in the individual performance measures. The composite numerator is not part of the overall score. Patients 1, 2, 3, 4, 5, 6, and 8 have a yes in the composite numerator, indicating the individual care measures are included in the overall score. Patient 7 has a no in the composite numerator, indicating there are no eligible individual performance measures to include in the overall score. The total of all the yeses and noes of the individual performance measures equals the denominator in this small sample. There are a total of 47 eligible performance measures. The total sum of yeses in the individual performance measure is the numerator in this sample. There are 42 yeses. The eligible care measure methodology score for this small sample is 89%. The all-or-nothing measurement methodology provides a different view of a hospital's performance. Metric 2, Overall Defect-Free Care, is the only performance composite metric to use this measurement methodology. When analyzing an all-or-nothing measurement methodology performance composite, what does a yes or no in the composite numerator signify? A no in the numerator indicates the patient did not receive perfect care and will not be included in the numerator of the overall calculated score, however, will be included in the denominator. A yes in the numerator indicates the patient received perfect care. All eligible care measures are provided and the patient is included in the numerator of the overall calculated score. The all-or-nothing measurement methodology includes only the composite numerator in the overall score. Patients 1, 2, 3, 5, and 6 have a yes in the numerator indicating the patient received perfect care and is in both the numerator and the denominator of the overall composite score. Patients 4 and 8 did not receive perfect care with one or more individual eligible individual performance measures not met. These patients will not meet the numerator, however, will be included in the denominator of the overall composite score. Patient 7 was not eligible for any individual care measures and will not be in the patient-level drill down for metric 2 and will not be a part of the overall score for the composite. The all-or-nothing measurement methodology in this small sample size, there are five yeses and two nos in the composite numerator indicating five patients received perfect care and will be included in the numerator and the denominator of the overall composite score. Two patients did not receive perfect care as indicated with a no in the composite numerator. Patient 7 will not be included in the patient-level drill down as this patient was not eligible for any individual care measures. The total of all the yeses and nos in the composite numerator equals the denominator score of seven. The total sum of yeses equals the numerator in this sample, there are five. The all-or-nothing measurement score for this small sample is 71%. This concludes Lesson 3 of 4, Mastering Performance Composite Measures. Thank you for your participation.

Mastering Performance Composite Measures

Kate Malish

Shelley Conine

Eligible Care Measurement Methodology

All-or-nothing Care Measurement Methodology

NCDR Overview

Eligible Care

All or Nothing Care

Performance Measures