Welcome. Thanks for... I'm going to try to keep everybody awake after lunch. Sorry for the delay. We were switching around how we were gonna do this. My name is Joan Michaels. I'm the Program Manager for the STS ACC TVT Registry. So there's a body missing here and it's Carol Crone. Some of you know her, some of you maybe saw her last week at AQO in Nashville. But Carol and I run the registry together from the STS and the ACC side. Sorry, she's not here. What we wanna do today, and before I start, two comments. This is International Valve Awareness Week, if you didn't know that. So celebrate it. There's a lot of Valve Days, Valve Awareness Day. This happens to be the week, but I think today or yesterday was the actual day. So Valve Awareness is becoming a real hot topic in all aspects of healthcare. And the other thing, because I'll forget to say it later, is based on what Kathy Biggis said this morning, and we've been talking about it all morning since then, is we want this session to be conversational, informal, ask your questions, and find your people. I've met people from other hospitals that I don't know, some people I haven't seen for a while. So please follow what she says and find your peeps, find your people, introduce yourself, exchange emails, because what you probably do know is that you are kind of an island unto yourself with what you do. Valve coordinators, data managers in the TVT world, it's sort of a lonely place to be sometimes, and these types of meetings allow you to get to know people, run questions by. So make sure you leave here with a pocket full of phone numbers and emails and whatever. To a fault, I am on social media, on LinkedIn, so please do that because every morning I check in and I learn a lot about what's happening in the Valve world, what Valves are approved, what Valves are... The Altera was just approved CE in Europe, not here yet, but so we know it's coming, that's more for congenital heart. But you learn a lot from what's being posted out there. So we're building communities with our Valve coordinators, with our data abstractors, with our webinars, we're in the process of planning. What the physicians would like to do on the steering committee is maybe a quarterly approach to updates in a podcast or a webinar. So stay tuned to what's happening, because we think the information... TAVR is not stable, you would think, well, what can I tell you about TAVR? Well, of course, now we're learning more about AR, it's not just AS, it's regurgitation now too that's becoming a really important factor. Within the TVT registry, as you know, we do mitral, but tricuspid is this whole big tsunami waiting to happen. There's no coverage decision out there yet, we think we might be getting one, which would mean that more hospitals will be doing tricuspid procedures. So we can't get the information out fast enough and we're trying to say, how can we continue to educate you as we get educated? And I think it's going to be podcasts, webinars, our meetings that we have, so keep posted on that. What I wanna do is, I'm here just to introduce and then I'm gonna get off, but what I wanna also do is give you a little bit of a tease factor. You may or may not be aware that we do what we call a national slide set once or twice a year. So on Friday, we were hoping we'd have more of the data, but on Friday, I received volumes and volumes and volumes of both TAVR, TAVR low risk, intermediate risk, high risk, mitral repair, mitral clip, or tier, M tier, and then also now the tricuspid, the cases that we have... That you all have entered either by the triclip or the evoke. So all of that data, we'll be working on that after our physicians look at it, review it, clean it up, edit my mistakes. That set will be posted on the website. You might have seen the old national slide set has been posted. That, along with the presentation you're about to hear, will really help you have your fingers on, what am I doing in my hospital, in my system, and how does that compare to the national benchmarks with the national slide set. So stay tuned, because that's really hot off the press news and we'll get that out as soon as we can. But to get started, I just wanted to give you a little bit of an update and then introduce our speakers. We do have, as of July, 846 sites. And it was interesting, people sit around and say, how many sites would ever do TAVR? We always thought the cut off would be 500. Look what's happening, right? Out of the 846, there's about 547 sites that do mitral in addition to TAVR. And not that many with tricuspid, but that's growing faster than we thought it would. And this is as of December of 2023. And you'll get these slides, but again, stay tuned for a lot more detail. You'll see over 100,000 cases. And this is as of the end of 2023, this is what we had with sites. I track it and one or two, three, four sites join still every month. So you might know, if you're one of them and you're new to this world, please come see one of us after this talk and we'll hook you up with some people that could help you. And again, we like to show what happened after intermediate risk was approved and then what happened after low risk was approved. Everybody wants to know pacemaker rate. And in hospital and 30 day pacemaker rate is a hot topic. As you can see over the years, there's been a decline and now it's sort of... It went down a little bit from 10 to 9, but it's kind of flattened out. So what we also will include in this is there a difference between low risk intermediate and high risk patients getting pacemakers. Major and life threatening bleed, you can see where we are with that. Again, it's pretty stable, 2% and 1%, probably no surprise. That's a big deal in the endpoint in the risk model though, as you well know. Follow... If you were in the LAO section right before lunch and April was talking about follow the definitions, follow the definitions. Your public reporting three star hospitals follows those definitions to a T. And we could talk about that more later as well. All cause stroke. We've always said, what's the most important thing with TAVR? Patients say, as you well know, I don't mind dying, I just don't wanna have a stroke and be a burden to my family. So the one thing which I think is interesting, I'm gonna look at this a little bit more, we started tracking a cerebral protection device, the Sentinel device. And interestingly, I'll look at it a little bit more, but it's been 15%, 15%, 15% of use of Sentinel, that's dropped to 11%. And that will be included in the national slide set. Why? I don't know, maybe, I don't know, the cost or the data that's coming out, but that dropped a little bit. And then mortality has dropped down as well. I think that's the end of the slides, is like I said, the teaser for the national slide set. The data here, again, with what you're about to hear from Kristen Young, who is our quality clinical specialist at the ACC, I'm sure you've heard her on many a program and webinars. As I say when I introduce her, she makes me look smart because I have Karen, who I think is in the audience, hopefully, and Kristen. It's like, you guys ask me a question and I completely do the hotmail to them. And Kristen and Karen know every single detailed definition. And they're very annoying because they... I think it's to stump me, they'll say, well, you know, sequence number 10496, and I'm like, come on, really? Just tell me what you're talking about. But they do that just to get me. And I'm gonna mess up your last name, it's French. I say Justin Theroux, but it's not, it's Misty Terriot, so she's French. And she comes to us... You can introduce yourself. She comes to us from Lake Charles, Louisiana. And just two seconds, because I'm talking too much, met her at a valve coordinator meeting years ago. And I'm like, who is she? I need to meet her. And she's the... Lake Charles is the first hospital to acquire and attain TAVR accreditation. She is a spokesperson for that. She should work at the ACC. I thought maybe she did, and I just hadn't met her. But she, again, sidebar, if you're interested in accreditation, or is it worth the pain? Is the... What is the juice worth the squeeze, or the squeeze worth the juice? I think you'll hear quite clearly from Misty that it is. And I hope she'll tell you a little bit about, if you think your program has bumps in the road. Since TAVR's been approved, she's probably rebuilt her program maybe three or four times. She comes from Louisiana, you could fill in the blanks as to why. But they will talk to us now, and I'll shut up, about the new Power BI dashboard. We are really excited about this. We know it's a work in progress. Getting ready for this meeting, Kristen and Karen worked like crazy people to get some enhancements that weren't even there on the first outing. So we'll talk a little bit about what we plan to do in the future, what we've already done for helping with drill downs, and I will turn it over to Misty from Louisiana. Thanks, Dawn. So I just wanted to speak real quickly before Misty gets into her presentation, just wanna level set here. Whenever we get... It's gonna be her and I, we shared this slide set, so we're gonna have a little bit of banter back and forth. I am gonna be speaking specifically from the NCDR, so all the technical aspects aside, whereas she's gonna tell you more about real life, so you can ask her all the hard questions that happen in the hospitals. Thanks for that. And thank you again, Joan, for that really nice introduction. As she alluded to, I am from Louisiana, if she didn't mention that. We are an acute care community hospital. We're located in Southwest Louisiana, which is halfway between Houston, Texas and New Orleans, so a midway point. And we have an immediate population of 80,000 individuals in Lake Charles, but we have three satellite cardiology clinics as well that increases our coverage area to about 200,000 individuals. We have eight cardiologists in our group as well. So in 2018, we took on the task of starting our TAVR program, and that was with two of our interventional cardiologists, the CV surgeon and myself as the VCC and TBT registry site manager. I will mention, I didn't really know what I was getting into, and I'm sure that's a lot of you and a lot of sentiment in this room as well. When you're taking on a task like this, you're really learning as you go and relying on so many individuals around you and so many individuals at the registry as well for learning your knowledge to be able to advance and further your program. So in 2019, we took on the task of obtaining the transcatheter valve certification, and it was extremely beneficial for our program. We streamlined multiple processes, improved efficiencies, and it really taught us on how to take a deep dive into our outcomes. Look for those opportunities that we can give our patients in our community the best possible care, because at the end of the day, that is what drives us all. We want our patients to get the best care possible, and using the data in the registry provides that knowledge that you can implement. Then 2020 came crashing down. We all were faced with a COVID pandemic, and during the height of that, our area was greatly devastated by two hurricanes, a freeze, and a flood. All of these events occurred within six months of each other, had a direct impact on our population as greater than 6% of individuals moved away, and that directly in turn affected our TAVR program, as we essentially lost a large volume of patients we had scheduled. So we really started focusing on outreach, increasing education, focusing on our echo surveillance, really trying to find those patients in our health system and community that needed care. So that was about a two-year rebuilding process. During that, we did get the recertification, and I'm working on the second recertification right now. So each time, it does get a little easier, and especially when you have everything kind of implemented as you go. And really last year is when we started refocusing on streamlining processes again, improving efficiencies, focusing again, making sure that all of our outcomes were where we feel like they should be. So there's so much knowledge that really you can gain from the registry. So before we dive into the dashboard, I just want to take a moment and kind of reflect, reminisce, on how far this has come. Originally, there were the PDF quarterly reports that were released. I know I still kind of secretly miss some of them, but it is nice getting the data in more real-time. But it was about a 50-page document that would be released with your outcomes. And then in 2020 came the gift also of the dashboard, which really was nice to have an interactive way to be able to view your outcomes in more real-time. Then the most recent addition and upgrade has been the beta dashboard, which we're going to focus on primarily today. So you access this from the registry homepage under dashboards. You'll see facility beta. This launched in March of this year. And it's a streamlined version of the prior dashboard. So you can see more outcomes, drill down more items. And each time I get on it, I feel like I find another Easter egg of something that I didn't realize before. So there's so much that we all still have to learn with it. But it is exciting to be able to see the knowledge you can get from it. Kristen, I'll ask for a second. Do you know how long the prior dashboard is still going to be available? I know that they are in talks of getting ready for its retirement. So I don't have a set date to share. But the only thing that I can stress the most is that if you haven't been fiddling around in the beta dashboard, that you should start to do so. It's what's here. It's what's going to stay. And we're nurses. We learn by doing, right? The majority are nurses. So just get in there and play around with it and become really familiar with it. Because it was from feedback from participants that you want more things to do with your data. And this gives you that in regards to a lot of visual enhancements. You can see your data visually. I love that. And if you don't have access to this currently, it's imperative that you get in touch with your TBT registry site manager. Those on the structural heart team, the physicians, they should have access to this to be able to view this data in real time and on a regular basis. So when you first open the dashboard, this is what you're able to view. We're going to start looking at the top and kind of work our way down. So at the very top, you'll see there are various tabs that you can navigate through. And we're going to spend time on each of those tabs. You then are able to see a tab on your right that tells you your last benchmark time frame. So the last published quarter will be released right there for your benchmark time frame. And then your most recent quarter is what it automatically defaults to. But one thing I want to mention about that is if you see, let's see, 2024 quarter three, there's going to be an asterisk in front of it because it's an unpublished quarter. So just something to keep in mind when you're looking at it. You can tell the unpublished by having the asterisk in front of that quarter. And then you see your DQR submission status for the last four quarters. Is it green, yellow, red? If it's gray, it's missing for that quarter. So just another way to be able to look at it initially and get a glance on how your program is doing. Then the last time you had your data submitted and the last time it was aggregated or updated into the dashboard. Anything you want to add about either of those two? The only thing that I want to really stress, because we get a lot of questions of, was my data used for that weekly refresh for your unpublished quarters? And just to stress the point of the aggregated as of and then submitted as of, it'll tell you when we aggregated it. So aggregated as of is whenever we took the data out of the warehouse and put it on the dashboard. The submitted as of is the date that we're using the data that you last submitted. So this usually happens over a weekend. So that's why we stress if you're doing your submitting oftens and submitting frequently, to do it at least by Friday close of business. So whenever it happens over the weekend, you would see it either that following Monday or Tuesday. So that submitted of will tell you, did we pick up your latest submission or not? And is that what is being reported on the dashboard? You are then able to select your procedures. So if you want to look just strictly at TAVR initially, you can select that or your various transcatheter valve therapies. You can navigate through to see the individual dashboard or overview of those procedures. And if you hover over these metrics, you have a bar graph that is displayed and it will show you the trend. So again, you can get a good quick snapshot on how your program is performing with that metric. You then have the up and down arrows. So up would be performing equal or better than that selected benchmark. And the down arrow would be performing lower than that selected benchmark. So it automatically defaults to a 50th percentile, but you are able to change that benchmark percentile. I'll show you that in just a second. But the 50th is what it automatically is defaulted to. And one thing I will say about this view, this is a view that I share with administration whenever I meet with them twice a year because I feel like it gives a good overview of our volume, the demographic of patients we're treating, kind of male versus female looking at trends, but then an overview of the primary metrics. So if we have a current PI project we're working on, I can share that and say, I know maybe we're performing a little lower than the last quarter, but this is what we've implemented and this is what we've seen. So this could be a really good starting point to talk with even your heart team or with administration to get a good idea of how your program is performing. Anything else you want to add about the overview tab? No, but I do want to take a moment. No, but. Just take a moment to appreciate the visualizations on the right-hand side of your screen, because you didn't have that in the former dashboard. So like Misty was saying, it is a quick at-a-glance, and you can filter between the bar graph or the chart. You can change those depending on what your preference is, but being interactive with your data and getting a quick, you know, high-level view of where you're performing. Yeah, and I wish I had a little pointer, but you are able to change it in the graph view and the bar view too, which is a nice setting as well, just to, again, find different ways to evaluate and look at your data. Easter eggs. Another Easter egg. I know. I know. They're continuing to be there. So now we'll focus on the icons on the left-hand side of the screen. First, you'll notice the little home, and that will bring you straight back to the registry homepage, which is nice to kind of have that back button out. Then you have the little hamburger icon, which is your file and downloads. That is your release notes report, and I'll let Kristen kind of explain. Yeah, I wanted to pause here to talk about release notes report, because some of you may or may not be using, but they're very useful, especially if you've been with the registry for some time, because it's kind of like our footprint for our metrics. So I know you probably hear us harp about using your outcomes report companion guide whenever you're looking at your metrics in real time on the dashboard, but sometimes whenever you have that question like, whoa, I think something changed with this metric. So the companion guide that we have posted is going to tell you what's happening now, but your question is what happened before, and your companion guide does not tell you that. Where you find that information is in your release notes report, because that is our footprint for every time we touch a metric, where we update, edit, enhance, whatever we do with that data, it is written there, and I would like to say that it's easy to understand. It's not technical to read. It'll just kind of say this is what we changed, so we try to make it very easy to read, but it's a good resource whenever you have those kinds of questions. You then next have your little funnel icon, which is your slicer, and this allows you to change that ending time frame. So if you want to look at your last published quarter, you can change that on this option. You also can change your benchmarked percentile. So if you want to benchmark yourself against the 75th or 90th percentile, you can make that change here, and again, have a different way to be able to view how your outcomes are performing. Just curiosity, what do you guys use for your, like, whenever you're filtering for your results? So I start with the 50th, and then I like to, again, be an overachiever and move it up from there, but my goal is always to be above the 50th percentile. So if we have a metric that is below, you know, performing below that, I am laser-focused on it and doing a deep dive to figure out exactly what is going on, what do we need to implement in order to get that back up where it should be. So I think having a continual pulse check on this is really essential, but starting with the 50th percentile is a great starting point, and then you can move from there, because there's always areas we can all improve upon. Next, this is one that I've really learned to appreciate more, the bookmark tab, because if you make those changes, let's say you change it to the 90th percentile, or you sort certain views, or you look at it in a bar graph, you can save that view by adding a bookmark, and you'll see on here Pink Floyd, I'll explain more about that later, but you are able to customize it so that next time you get into the dashboard, you just click on your bookmark, and it will be able to show your favorite settings in a way, so saving you extra time and making it more customizable. Then the download option. This part I've really been playing more around with, especially with the current dashboard view. I know we had chatted about this before, but if you export that to a PowerPoint or a PDF, that would be another way that you could share this with your team. It will essentially take a screenshot of the view that you're currently looking at, but one thing, there may be some data elements that may be missing at the bottom sometimes with that screenshot, so just something to keep in mind, but Kristen's going to offer a good alternative for that in just a second. Then you have your detail report, your follow-up report, that exports to your Excel spreadsheet for those of us that are data nerds and like to analyze further and maybe do pivot tables or whatever makes your little heart happy, you still have that option with the Excel spreadsheet to be able to download, and you can access those reports on any of the tabs that you're at at the top, so it's not only available on the overview tab. Then the next one, the metric summary report, I'm going to pass off to Kristen so she can explain. Do you do pivot tables? I'm impressed. Oh, I do. I love it. I'm a data nerd. All right, so I'm going to pay homage to what Misty said in the beginning is how we used to deliver those PDF reports, so it's not 100% foolproof solution, but we're getting there, so if you haven't noticed, whenever you get into the download tab, there's this new that I have highlighted here, TVT metric summary export, and it is a PDF. Whenever you select that, it's going to download, and then hopefully my animation works on the next slide. We'll see. Why am I not going? Hold on. There we go. It'll download to this, so it is a PDF, and I'm hoping that it's going to scroll, but anyway, the point is that this is kind of replacing what you have known in the old dashboard and in the old PDFs that we delivered to you is you get this PDF now, and it now gives you all of your metrics. You just went, oh, wait. What's it doing? There you go. It gives you all of your metrics, but it is limited right now to only your base metrics, so whenever you pull that report, it is going to give you every procedure, every base metric in one download, so the alternative to just getting that screenshot of that one little page, and you may have missed some detail lines, so we have created this, and like I said, it is still in the works, but if you haven't been using it, you can start using that now if you didn't know that it was there. Yeah, that is when I started sharing at our heart team meetings for the published quarters, and it's just really nice to navigate and give you kind of a lay of the land of where you're performing in those base metrics, so really easy to navigate and, again, be able to see how your metric is performing, so the first tab we'll really focus on is your metric summary tab. This is very similar to the executive summary report that was available in the prior dashboard, and I love this heat map portion at the top because, again, it gives you a good visual to be able to see how your metrics are performing and what percentile, so those of us that are visual, this is a good way to be able to visualize it, and the pink Floyd that I mentioned earlier, that is our multidisciplinary meeting we have quarterly. This is the report I share at that meeting because, again, it gives you a good visual at the top. This is how many metrics we have performing in this percentile. This one is maybe performing lower than, but this is what we've implemented, and the really nice thing about these remaining tabs is being able to drill it down to the patient level, so at the very bottom, you'll have these nine primary outcomes that are mentioned, and they have an asterisk next to it, so if you have a metric at the bottom that has an asterisk, you can drill that down to the patient level, which gives you, again, more interactive ways that you can look just at that metric, so maybe you want to look at your mortality. Maybe you want to assess, was it a keystroke error, or is there something we need to dive further into this process? If you click on your little blue hyperlink, it will export that to an Excel spreadsheet, so you can see those patients that were captured that had that outcome, so, again, another way to be able to visualize. It also does have a bar graph on the right-hand side, as well, if you click that specific metric to further be able to see your trend. Then the metric detail, you can see there's a scroll bar on the right-hand side that's very long, so there's the amount of metrics you're able to assess in this tab. You can specify, maybe you just want to look at your TAVR outcomes. It will show only the TAVR, so you do have a way that you can kind of filter that and make it a little easier to navigate if you want. One metric we look at here a lot is our demographic mix, so what patient population of Caucasian and African-American, Hispanic patients are we treating? I get this information from this view, and also the male versus female, high, intermediate, low risk, so there are many data points you can get from your base information, and it's accessible on this tab, as well, so if you click one of these metrics, it will show, again, a bar graph at the bottom to be able to see a trend of how your program's performing. Next, the follow-up tab is pretty straightforward. It really shows your seven primary outcomes for follow-up at the very bottom, although there's not a way to drill this one down to the patient level. I don't know if that's something in the future, but you can really do that on the next tab. Yeah, yeah, there's something at this level at this age that you can do that with. Yeah, but it's a good quick snapshot to see how many follow-ups you have, how many have been completed, and see those primary follow-up outcomes, so this could be another really good report to share with your HEART team, share those multidisciplinary meetings, and with administration, as well. This is a tab I spend the most time in, the follow-up detail tab, because there are so many pertinent data points that we want to assess. So, first, starting with metric 11711, metric, Joan, throwing numbers out. So, this one is the composite site difference. It gives you the risk model, is what it is based off of, to see how your program is performing. It is the same risk model used for public reporting that assesses your five primary metrics that we'll talk about in just a moment, but this will be released each quarter. So, if you have three years of data and yellow or green DQR submission status, we'll talk about other eligibility in a moment, but those are the two primary components. So, if your program has not yet entered three years of data in here, you will not yet be eligible and will not have a score listed here, but one way I like to drill this down is first looking at the metric, clicking on the blue hyperlink, and it will go to an Excel spreadsheet, and I don't think my animation is going to work here either. Let me see. No. Okay. So, from here, you can add a filter and be able to sort your risk eligible. So, select yes under risk eligible, and I like to look at the metric all the way to the far right that shows your five primary outcomes in the risk model. So, your mortality, stroke, major in life, threatening bleeding, AKI, and moderate to severe PBL, and it will be able to show. Oh, look. It's working. It will be able to show. I'm sorry. Your patients that were not only captured in that risk model, but the ones that had any of those events occur. So, to be able to look at the patient level to drill this down further, and I'm going to let Kristen show you a little more automated way to do that as well. Yes. So, you can look at these individually, but before, well, I'll go with that first. So, if you were more interested in seeing who made up your deaths for metric 11711 or who had your strokes or who had your PBL or who had your AKI, you can do that at the individual level. So, whenever you're in the dashboard, your major category that you're going to select is TAVR 30-day composite, the risk model for the rolling three years, and then the minor category underneath that is observed outcome details, and these are based on the worst outcome. So, if your patient had two, say they had death and stroke, they're only going to appear in the death. That's how this was designed so that whenever you get your report by file delivery that's used for public reporting or the public reporting report, rather, those numbers will match. It was designed to do it that way. So, once you select these, your data will load. Okay. And then it takes you to the detail line. So, 11739 all the way down to 11744. Just for the purpose of visualization, I just selected death 11739. Once you select that, you can then download the patient details. So, now you can see what patients were feeding your mortality for metric 11711, and if you could do the same thing for stroke, what patients were feeding the stroke outcome for the model, and so on and so forth. And one thing I wanted to mention about that that we look at, too, is our O to E ratio with those five outcomes. So, in this tab as well, you can look at your O to E ratio for each of those outcomes, and if you have a ratio greater than one, that could be an area to improve upon. And I know historically bleeding across the board has been one that a lot of sites have looked at. They didn't realize they had the number of occurrences they did until they started looking at this data. So, again, another way to further drill down to find those areas of opportunity. And just for visualization, it's the columns underneath eligibility and metric performance. So, you can look at your risk-adjusted detail lines for each outcome. Okay. Let me go forward. Do you want to take this one? Sure. Yeah. So, the eligibility is another tab that we look at on a regular basis each published quarter, making sure we're maintaining those eligibility requirements to be included in public reporting, making sure that you have your baseline KCCQs, and I know there's going to be a wonderful session discussing that tomorrow that I'm looking forward to. So, making sure that you're completing the 90% or greater completeness for the KCCQ, your baseline walk, your event status being addressed at 30 days, and completing at least 60 cases during that timeframe, along with your DQR submission or kind of the primary outcomes. But if your program is not currently eligible and you're wanting to know why, this would be a good starting point to look at to see where do we need to improve. Is it the KCCQs, the walks? What exactly is that pain point that we need to work on? And then you can also see the confidence intervals, which is something that we focus on a lot as well, not only the composite site score, but your confidence interval to know exactly which way it has moved. Is it more positive, more negative? And again, what are those areas we can improve upon? And just to elaborate on those confidence intervals is that's how you can kind of predict if you're watching this metric whenever it publishes at the end of every ending timeframe, you can kind of see where your hospital would stand in the star ratings. So, if your confidence intervals, upper and lower, and your site difference cross zero, then you would know that at that point in time you would have been eligible for two stars. If all of those were above zero, those three, then you would be eligible for three stars at that time. And then of course, if everything was below zero, then that's how you would get the one star. I know I'm saying this, this may sound foreign without a visualization, but it is in your public report companion guide to how we determine star ratings. Now, moving on, I have maybe bestow upon you some good news. We have heard you. So, for the sites that don't get a site difference, you really don't get any of the detail lines and you're just left with your eligibility detail lines and kind of like, well, where did I not do well? So, we wanted to give you something to help you make that search for those patients a little bit easier because it's rolling three years of data. So, it's coming soon. It is not there yet. I took these images from our sandbox. So, just know that you know we're actively working on them. But your major category is going to be the TAB or 30-day composite as it was in my previous slide. And then whenever you select eligibility and metric performance as your minor category, your data will load. And now you will be able to have a patient drill down for those eligibility criteria. And there is three to get a site difference or to get all those detail lines as well for your mortality and stroke and all those outcomes. So, 90% compliance for your KCCQ, for your 30-day follow-up, and for the 5-meter walk test to be eligible for the metric reporting. If anything is below 90%, that's the detail line that you're going to want to select. So, here you would select the criterion that did not meet that 90% performance. And then the drill down will populate at the top as well. So, now you can drill down and see who and change the filter. Who did I not do the KCCQ on? Who did I not do the 5-meter walk test on? And did you really not do it or was that a keystroke error? Or is this something that you really need to do a process improvement project on because you want to get your site difference? You want to participate in public reporting. You want U.S. News World Report transparency points. You want all of the things. As well, I'm going to go over this briefly and then Misty's going to get into like the real-world stuff that she does in her hospital. So, you may or may not have noticed we have a new tab at the top of the dashboard, which is the DQR summary page. This was a new ad as well. Whenever you click on that, you have access to the most recent base or your follow-up submission statuses for each quarter and rolling for quarters within that ending time frame. However, what you don't have on this page is the ability to see, okay, well, I may be yellow or I may be red. What were those errors? What were those outliers? And at that point in time, you do still have to go back to the DQR submission page that you're familiar with to get to that patient-level detail. But another enhancement is your element outcomes, which probably not the best screenshot because 100 percent, but you can kind of see where you're at in terms of where you were not meeting or you're potentially not meeting that threshold and you could have had a yellow status because of it. So those painful data elements that you can also work to get documentation better. You might have gotten green but you know you were teetering on yellow so you really need this documentation to assure green in the future. So this is a quick at-a-glance detail of how you're doing with each data element. So a lot of information here and it's all written as well in the dashboard user guide. If you need reference or this after the session is over the slides are updated the companion guide has all this information and probably even more than when I just went over in there. So now that you have all of your data what do you do with it? Right that's always the million-dollar question. You know how to access the dashboard but how do you implement it in real world in your program? And the first simple step is accessing it. So getting familiar with looking at your outcomes and then sharing it because no one really knows how your program is doing until that data is shared. And it's interesting if you were to ask most of our physicians even though they view this on a regular basis they'd be like oh we didn't have any readmissions last month. I'm like well maybe we did you know. So until you look at this information you don't really know how your program is doing. And then evaluating it on a patient level. So not only to assess for the keystroke errors but to evaluate for trends. So maybe you've had an increase in bleeding events and then you do a deep dive you see those patients that did have bleeding events and you see the commonality was maybe vascular complications during the case. Okay well that needs to be discussed with the team. Is there anything that needs to be implemented in order to decrease that occurrence from happening again in the future. So really doing a deep dive and I will say one of the first metrics we really focused on were bleeding events because we saw that we had a higher outcome with that initially. And when we did a deep dive we found oddly it was related to IJ central line bleedings and this was back when we started in 2018. But the patients that were having bleeding events were bleeding from their IJ central lines and then doing a deeper dive we saw that there was no consistency in the Heparin administration during the case. So we met with anesthesia, were able to do away with central lines, able to do away with arterial lines radially as well and then come up with a set protocol for the Heparin and then we saw a dramatic decrease in our outcomes after that. So being able to implement these changes and then tracking the progress is really essential along with reviewing it regularly with the heart team. So you can start with that overview tab and then maybe look at that composite site score each published quarter as a good starting point. Pick one metric at a time to really do a deep dive into because I know it can be overwhelming when you're trying to figure out where to start but pick one metric at a time. Implement changes and then track your progress with it along with implementing morbidity and mortality reviews. I know there's going to be a session discussing that today as well but that is another great process to not only hold your team accountable but to also have those open dialogue discussions of okay well we saw this happen what can we implement for it to not occur again in the future. But let's say you're evaluating this process and you identify a need that your program has. When we did a deep dive again in bleeding events we saw that the vascular complications were something we wanted to improve upon and we really felt as though an ultrasound machine is something that would help us with that. I love this three-step process of just stating simply what is your problem, what is the potential solution, what is your data to back it up. Because if you can state your problem well that's already solving half of your problem right. So one day the CFO of our facility walked into the elevator with me and asked how our program was doing. I don't know if she's going to do that again but it was the opportune time to explain to her these are the vascular complications that we are having. We really feel as though an ultrasound machine would help decrease that. Did you know that when we have a vascular complication it's an additional $15,000 in charges and an additional $2,000 in direct cost. So when you start speaking their lingo that really goes volumes and can really go to help you advocate for your program to get what you need. We were able to get it ordered, saw a decrease and also mentioning the fact it was a billable feature as well kind of perked your ears up. But I love the concept of framing your problem beyond your silo. So what can you implement that would affect other patients outside of your little tavern special little world. And for us being able to offer that ultrasound machine in the cath lab for other procedures to be able to use was another good example that it could help improve patient care across the board. So just an idea to kind of get your mind going and always have that elevator talk ready. Have that tool ready in your toolbox. Have your data elements that you know off the top of your head and have a regular pulse check on it because it really can speak volumes. And these are some metrics just to give an example that we have really focused on throughout the years. Especially when public reporting came out and we knew that AKI was going to be in the risk model we wanted to make sure we didn't have any occurrences of AKI but what could we do to decrease the contrast we were giving during the case. So again staying up to date with what is going on with the registry having those real-world conversations decreasing our contrast from 140 a case down to 50. So brainstorming and incorporating the team in those discussions. Along with shorter procedure time we were tracking our data within the registry benchmarking it with what is released in there and how can we be more efficient. How can we do more cases in a day utilize all of our time better and we were able to start that conversation with deriving our procedure time from the registry. We talked about the bleeding events and vascular complications and readmissions has been another really close project to me because when we first started our readmission rate was close to 10 percent and we knew we could do much better. So we continue to look at our processes. What were our patients that had readmissions. We felt that over half of them were inappropriate readmissions that they were admitted because they had a recent TAVR. Right. So we worked with our IT system implemented an alert in the EMR so we would alert the ER doc to call the valve team before admission and we were able to decrease quite a few that way along with really looking at our discharge process. Who provides that education. What handouts are provided. Are family members present during those conversations. Who calls the patient afterwards. When are they followed up with and making sure that at those data points the patients knew who to call. And last year readmission rate was 1 percent. So again a lot of knowledge that you can really gain from this. I know you may be saying OK. Yeah right. You're just kind of living in a fairy world. OK. This is not real world but it really starts with having buy in with your team. So when you are assessing OK I know what we need to do in our program but how do I get there in order to implement those changes. Every change initiative needs a champion. Someone driving the ship for it and if it can't be you who in the structural heart program can do that. When I question why I had buy in in this it is because I recognize the need because if we did not have this program patients would have to travel over or close to two hours to the next major center. And we have patients that have difficulty even making it to our facility. Going to get emotional. But it's realizing why you are driven to do this. Is it the compassion to provide care to those in your community. Give them the best possible care. And at the end of the day that is the important part to reflect upon and remind yourself this is a why of why I'm doing this. And then increasing the physician buy in. So at the end of the day the physicians care about patient care and being efficient. Right. So if you can start speaking the language to them about your patient care. So this is a trend of our outcomes. What are some ideas you have that we can make your life easier and more efficient so you can do more cases in a day. You start speaking their language. OK. And then whenever I asked our physicians why they had buy in in our team he said in all three collectively said respect and trust that they respect one another they feel the respect amongst the team the facility and they trust each other. And that really is essential when you are trying to implement these changes because it can be very difficult when you have multiple disciplines working together. Right. So making sure you have that foundation where you listen you trust and you respect one another. And then I inquired the team our pre op intra op post op team. What makes you want to be a part of this. Collectively and consistently they said they are proud of the work they do because they feel like their voice is heard. And I think that is such an important moment because we are continuing to engage our team with how can we make your life easier. How can we be more efficient and continue to evolve. Right. Because we know the structural heart realm is continuing to evolve. So it's important to continue to evolve with that and not remain stagnant. So it can be increasing education. You know last year we streamlined our program quite a bit and we wanted to make sure our team was continuing to be comfortable with the changes we made. So we increased emergency simulations with them making sure everyone was comfortable in an emergency setting if we didn't have the same equipment available. So continue to have that open dialogue and then your executive buy in. How do you get the C-suite members to listen to you. And especially whenever you have a need that you have and it's learning to speak the lingo. Tell the story. Demonstrate the need. Bring the financial aspect into it. Then you start perking their ears up. And especially whenever you can show the registry data and where the registry is performing to compare where outcomes are that can really speak volumes to leverage to get what you need. And overall track your progress and share the progress. So if you've seen improvement share that with the team. If things need a pivot then you can go from there with it. So I think just really having that buy in and being able to access your data are really essential to have success in your program. Perfection. All right Joan what you got. Okay. Thanks. That was great. I just have to pause and say thank you. Thank you. Thank you. That was so good. You know they practice this but man you guys could go on the road. This is a really nice fall back. I really enjoyed it. A lot of questions some of them I think I could address real quick. One is asking do we show valve comparison and pacemaker comparison? Who has the higher pacemaker rate between valves? No we're not allowed to do that. So that's a no. When will the old dashboard be taken, the former dashboard be taken down? As Kristen said we're not sure. We know that's a comfort level but please, please start looking at the new dashboard because we'll post an announcement and give you fair warning but it will be coming down. The question about is this the same with all the registries? And when we ask, we've been working really hard to get this up for this meeting with the enhancements that Kristen explained but I do believe that they carry through with the other registries if applicable. We always see our co partner is maybe closer to the LAO registry than other registries so we always sort of check partners and say will this work for you. So tips for the other registries. I guess that's a general yes. Okay this is one of our favorites and this was, we got a standing ovation I think last year in LA when this was addressed, vascular complications. Where did they go Kristen? What do you mean where did they go? Disappeared. Oh the metrics. So they have been suppressed. They are not going to come back until we move to the VARC 3 which will probably happen with our upgrade next year. Right Joan? And what we're looking for and Dr. Brindis please write this down. We're going to solicit a request to the steering committee to only ask for vascular complications that require treatment. So not the little onion skin bruise that requires that. So hopefully we're writing the cath registries coattails on that one. But they've been suppressed thanks. It would be great to have the published data for the recently published quarter. I'm not sure what that means. I don't know what that means. Will the slides be available? Yes. For public reporting or the quality of life metrics, rolling three years at 90% goal, quarterly requirement. I think a lot of these questions you have addressed. So yes, there was some discussion about we no longer needed to do either the five meter walk or the one year follow up. Please know if you ever have that question come up, call the resource, call Kristen and Karen, call Joan. Because we hear out in the field instructions are given differently. And yes, baseline 30 day and one year KCCQ is still a requirement for all modules. And the TAVR is the only module that has the risk model and that requires a rolling three years, 60 cases over the 30 years, 90% compliance of both baseline KCCQ, baseline and only five meter walk. Five meter walk is only done at baseline and alive or dead at 30 days. So those eligibility criteria have to be met. And then we do ask for, again, KCCQ baseline 30 day and one year. I should walk around with a sandwich sign on about this because what's keeping me up at night is tricuspid. And as you well know with both triclip and evoke, the end points that everybody and their mother is worried about and concerned about and how are we going to get that to include FDA calling and saying how are you going to do this TBT registry? And that is that they want TR, they want tricuspid regurgitation at one year and they want KCCQ at one year. So if you follow the tricender, the triluminate studies, the end point that showed an improvement was quality of life. So one year quality of life when you start doing tricuspid is more important than ever. But it's still important with TAVR and mitral as well. So that's my PSA announcement. When filtering out data, is there a way to view outlier patient details? And I think you talked about, you've covered some of these. What's the difference between metric summary and metric detail? So the summary is kind of like an overview of just the metrics. So your executive summary measures and metrics, whereas the metric details, it has those incorporated, but now you're getting more of what we probably formerly called the detail lines underneath there. So you're getting a lot of more granular information as well, is what I want to say. Will the beta dashboard be more up to date with current data than the original dashboard, as in not quarters behind? You can see your last submitted. Yeah, you can see your last submitted. For unpublished quarters, we aggregate every week. So like I said, every Monday or Tuesday, if you're submitting the week prior, you're going to see that refresh that following week. Which is very nice in the new dashboard too. That's something that you could print up and feedback that we've been given is that the data's old. Well, it's if you put it in, you'll get it the next week. You can track that. I always like to question three star hospitals is, is this a surprise to you? How do you get to be three stars? What's your best practice? And hospitals that have been recurrent three star hospitals have said, it's no surprise. I know I'm three stars because I track my data and I don't have to wait for the report to come out. So check your data. The new dashboard will actually help you to be able to do that. The slides will be available, both these slides and also, as I said, the data slides to be used for the national slide set. What is the time frame for the new dashboard features to be implemented? We're pretty proud that we got as much of it as I've done. We're like... We really whipped them into shape. We're selling kidneys to the IT team back at ACC, but they're working on it and we've had some spot checks with some users and they've given us feedback and so we are. But if there's any hot topic that you'd like to see improved, let us know. Oh, can you... Wait. I'm surprised nobody asked you how you improved your pacemaker rate. Oh, they did. Somebody did say that. I'm sorry. Thank you. Thank you. I'm scrolling through the... I was like, we get that question a lot. What did you do, Misty, to increase, to decrease? I know I skipped over that one for the sake of time, but yes, whenever we first were drilling into our data, we evaluated and saw that over half of our patients who had pacemakers put in posthavir had pre existing conduction disturbances. So then we implemented a process change where our patients wear a monitor beforehand. We evaluate it with our team to see if the patients meet criteria for needing a pacemaker before. So we're not putting inappropriate pacemakers in. These are patients who are having three to five second pauses, significant bradycardia, chronotropic incompetence. I mean, legitimate reasons for needing pacemakers. So that was one way. And then we also discuss our valve sizing, oversize, undersize, and implant death significantly during our heart team meetings. And considering the patient's age, not wanting to implant one too high if it's a lower patient potentially needing valve-in-valve in the future, but making sure that we're having those conversations. And then we also will make medication adjustments ahead of time, maybe hold a beta blocker a couple of days before, have a monitor on them, make sure they're tolerating it. But collectively, I mean, we went from about a 10 percent pacemaker rate down to four. So it helped significantly. But we did find that quite a few were patients who were meeting criteria for needing one before that we didn't see strictly just by looking at an EKG. Okay. I think Jacob's telling us to cut it. But if you have any questions, we're here. And thank you so much. You guys were fantastic. Thank you. Thanks. Thanks, guys. It's so good.

STS ACC TVT Registry

beta dashboard

best practices

TAVR procedures

outcomes improvement

heart teams collaboration

data visualization

patient care

quality and safety