Hello, my name is John Geraut, Team Leader for NCDR Clinical Operations, and I want to thank you for joining this presentation entitled, Where to Go? The Quest for Registry Answers. This session will help familiarize you with all of those registry resources that support the CAF PCI Registry. An organized review of coding resources will help you recognize where to find what you need, when you need it, to help you save time and get another email to ncdr at acc.org. A dive into metric resources will improve your comfort level with metric criteria and help you detangle the report so you understand your outcomes, plus tips from fellow participants. As the purpose of this presentation is to become better acquainted with the CAF PCI Registry documents and resources, this session is designed for the new or intermediate registry abstractor. The learning objectives for this session are to discuss where to find coding help for challenging case scenarios and understand the difference between inclusion and exclusion metric criteria. To quote Ram Dass, the American spiritual teacher, psychologist, and author, information is just bits of data. Knowledge is putting them together and wisdom is transcending them. And with this presentation, I hope to help you bridge that gap between these themes relative to your important quality improvement efforts in the CAF PCI Registry. At a very high level, the goal of the CAF PCI Registry is to assess the characteristics, treatments, and outcomes of patients with cardiac disease that undergo diagnostic coronary angiogram and or percutaneous coronary intervention. And this objective is achieved by capturing data that measures adherence to ACC and AHA clinical practice guideline recommendations. So how does the registry do this? By using standardized data elements and definitions that capture patient demographics for diagnostic coronary angiography and percutaneous coronary intervention or PCI procedures, patient history and risk factors, CAF Lab visit indications, and coronary lesion information, provider and facility characteristics, and PCI indications, lesion information, intracoronary device utilization, and intra and post-procedure events. And so just some of the benefits of participation in the CAF PCI Registry include, but are certainly not limited to, a focus on the appropriate use of PCI within your facility, a reduction in avoidable bleeding complications, identification of your facility's area of excellence as well as opportunities for improvement, validation of use of best practices and application of performance measures, as well as the ability to monitor STEMI to treatment times. In summary, the value proposition that the CAF PCI Registry proposes is as such. By abstracting and submitting quality data to the registry, you in turn receive accurate reports that inform you and your program and help facilitate the identification of opportunities for improvement. As the old saying goes, garbage in, garbage out. And for the sake of NCDR registry performance feedback, the same can be said conversely. Good accurate data in will result in good accurate data out in the form of actionable quality improvement performance and measures. This of course begins with accurate abstraction and leveraging both internal resources at your facility as well as NCDR data collection resources. The patient's medical record is the entryway into this effort and partnership with clinicians to understand the importance of good thorough documentation can only work in your favor in creating an environment in which this task will seem much less than Herculean, so to speak. So let's spend some time now reviewing CAF PCI Registry coding resources that support this critical first step, the data collection process. The two most essential abstraction documents in any given registry are the data collection form and data dictionary. While a somewhat abbreviated version titled the coders dictionary is available, the full specifications version contains technical specifications that can be useful when determining certain features, such as acceptable lab value ranges, as well as establishing parent-child field relationships. Every data element featured in the CAF PCI Registry data collection tool is supported by a data dictionary data element definition, which includes the sequence number, coding instructions, and target value, and in some cases, a note and or a supporting definition to clarify abstraction in certain circumstances or provide additional definition description, as well as associated relevant source documents, respectively. The V5 data dictionary supplement with pending data element updates is an essential resource that contains complementary coding resources for challenging data elements, corrections and enhancements to data elements that are scheduled for inclusion into the data dictionary during the next version upgrade, as well as improved formatting for specific data elements with longer data definitions and coding instructions. In addition to the pending data dictionary updates, resources provided in this document focus on section G, CAF lab visit, section I, PCI procedure, section K, intra and post procedure events, and section M, follow-up. One example of a key supplemental coding resource in this document is a matrix that removes any uncertainty with respect to which PCI indication is eligible to be coded in sequence number 7825 based on the CAF lab indication or indications that are captured in sequence number 7400. To provide an example, when stable known CAD is the highest CAF lab indication value selected in sequence 7400, the applicable PCI indication can be either stable angina or CAD without ischemic symptoms, depending on the patient's symptom status to meet either definition. The V5 supplement chest pain symptom assessment resource expands on the definition of sequence number 7405 by providing approved documentation that the registry accepts to support abstraction of this data element. As well, it consolidates the data dictionary definition with multiple FAQs that clarify coding instructions and includes all information in one concise location. Intra post procedure and follow-up events, such as the example pictured here for myocardial infarction, are included in the V5 supplement to provide a more detailed, visually accurate illustration of these data elements, which contain more extensive coding instructions and supporting definitions. And lastly, important pending data dictionary updates are housed in the V5 supplement document until they can be incorporated into the data dictionary and data collection form in a version upgrade. For example, the CAF PCI steering committee made a decision in early 2020 that the CAF PCI registry would begin collecting CTFFR results, as well as non-hyperamic flow reserve ratios, such as DFR and RFR, that inform the need for a qualifying CAF lab procedure. These values are to be collected in the IFR field, sequence 7513. Pictured here are detailed instructions for the collection of these flow reserve ratios with respect to this consequential data set expansion. We've briefly discussed the data collection form, data dictionary, and in greater detail, some of the V5 data dictionary supplement with pending data element updates document. Now let's turn our attention toward other resources, starting with the coronary artery segment diagram. The coronary artery segment diagram aids abstractors with the ever-important and oft-challenging task of appropriately identifying and capturing coronary segments based on provider documentation of coronary angiographic assessment and treatment with PCI. In the example provided here, we can see that a lesion originating in the proximal LAD extends into both the mid-LAD and first diagonal. And therefore, the coronary artery segment diagram helps us to confirm that it is appropriate to capture these coronary segments as one lesion in sequence numbers 8000 and 8001, and identifying it as a bifurcation lesion as well, according to the definition in sequence number 8022. In addition to the coronary artery segment diagram, the registry provides inclusion criteria, a qualitative-quantitative crosswalk for determining stenosis percentage based on descriptive documentation, and an infographic of the Canadian Study of Health and Aging, or CSHA, clinical frailty scale, an increasingly consequential data element that asserts a patient's functional capacity prior to their first cath lab visit in an episode of care. Inclusion criteria in the CAHP PCI registry is limited to those procedures that meet the definition for diagnostic coronary angiography procedure and or percutaneous coronary intervention. Attempted PCI, wherein which a wire is advanced for the purpose of revascularization but no mechanical treatment is delivered, a not uncommon occurrence, also meets registry inclusion criteria and warrants capture, just as a successfully treated coronary segment or segments. In an effort to support registry participants in abstracting data, the CAHP PCI registry and chest pain MI steering committees have identified frequently used descriptive terms that relay the coronary artery disease stenosis observed, and developed a crosswalk to the correlating percent stenosis. This qualitative quantitative crosswalk should be used when the stenosis observed during the diagnostic and or PCI procedure is defined by a descriptive term, and a percentage is not available in the medical record. The percent stenosis identified here can be used to complete the data fields requesting this specific information, such as coronary anatomy and lesions and devices information. The example of a patient who receives a diagnostic coronary angiogram that is documented in the medical record as moderately stenosed distal RCA supports coding 50% in sequence number 7508, native coronary vessel stenosis, with the understanding that there is no evidence of an actual percentage also identified in the medical record. The Canadian study of health and aging or CSHA clinical frailty scale captured in sequence number 4561 is a nine point scale that aims to help determine if a patient is at risk for poor outcomes, and can guide communication between clinicians and patients. The infographic pictured here and provided on the registry documents page expands on the data dictionary definition by illustrating each frailty selection on the frailty continuum and providing additional coding context, as well as guidance with respect to applying the definitions to patients with a dementia diagnosis. We recommend utilizing the poster to educate physicians and abstractors alike. While the Canadian study of health and aging clinical frailty scale was designed with the elderly patient population in mind, the definitions support the assessment of any adult patient, and it is a practical and efficient tool that should support categorizing the patient condition consistently prior to the start of the first cath lab visit. Lastly, we'd like to point out some helpful coding resources available at the QII Learning Center. All NCDR recorded case scenarios are available, organized by registry, and searchable by keywords. At the time of the recording, the cath PCI registry contains over 30, and this number grows each month. Presentations such as the Category A course entitled Getting Acquainted with the Cath PCI Version 5 Dataset can be viewed here as well. With Step 1 focused on identifying and utilizing resources to accurately abstract data, we now focus our talk on resources that support the second step in the process, data submission. Successful data submission requires a combination of proactive, disciplined adherence to the call for data schedule and reliance on available submission support tools. Registry resources such as the DQR Error Code Report and DQR Companion Guide provide participants with feedback necessary to interpret their site's data quality report analysis with each submission with the objective of getting green. Reaping the benefits of cath PCI registry participation through successful data submission all comes down to getting green, and that's because data that passes the data quality report assessment with a green benchmark inclusion status are used to create the Institutional Outcomes Report. For hospitals achieving a green benchmark inclusion status for their submissions, the Outcomes Report will relay their individual performance in executive summary metrics and provide the opportunity for detailed analysis of their individual performance in relation to their volume peer group and the aggregate US cath PCI registry population. Review of this data can support insights into care variations, practice patterns, and process for quality improvement opportunities. The tools that facilitate data submission and that support your efforts in achieving green benchmark status are located under the Data tab on the left-hand navigation bar. Whether or not your site utilizes a certified third-party vendor data collection tool or the ACC DCT determines the pathway to submission to the DQR. We will discuss several documents that support understanding of the DQR process and error messages that can be found under the Documents tab. NCDR participants are encouraged to submit data early to obtain a green passing status and meet the scheduled data deadline. To achieve this, participants may perform unlimited data submissions any day leading up to the data deadline. During each quarterly submission timeframe, participants are responsible for entering data that meets the specified time parameters of patient discharges and submitting quarterly data prior to the data submission deadline. Once you have submitted your quarterly data, a Data Quality Report, DQR, will be posted shortly after each submission for your review. It is the responsibility of participating hospitals to ensure that all data issues are resolved prior to the quarterly harvest or upon receiving errors on the DQR. We encourage the submission of data on a regular basis throughout each quarter to ensure data errors are corrected in time for each data submission deadline. Achieving a green light submission status on your DQR allows your data to be included in the Executive Summary National Aggregate and ensures a complete and accurate comparison of your institution's data in relation to other institutions. Regardless of how a site submits their data, whether it be through Submit to DQR with the ACC Data Collection Tool or Upload Data Submissions if utilizing a third-party vendor tool, the DQR tab displays all data submissions for a particular site. Green, yellow, or red submission status result with each DQR submission, depending on the passage of the data submission through rigorous checks and balances defined by the Data and Completeness Assessments. CAF PCI Registry documents that support the essential step of submitting each quarter of data through the DQR submission process include the DQR V5 Companion Guide and the DQR Error Code Report. The DQR Companion Guide is used to navigate through the DQR process and supports efforts in obtaining a green benchmark inclusion status for your data submission. Pictorials such as a high-level DQR process workflow, step-by-step submission instructions, as well as explanations for necessary actions that need to be taken based on submission status are provided. Uncorrected errors may prevent the data from appearing in an outcomes report. The CAF PCI Registry DQR V5 Companion Guide also contains data completeness thresholds for every element in the data set. When a DQR submission fails to pass the completeness assessment, clicking on the Fail hyperlink brings the participant to the Completeness Assessment Summary, informing the user of the data element or elements that require attention. If any question arises on the required threshold for any data element, additional information can be found in the DQR version 5 companion guide. The CAF PCI Registry DQR Error Code Report is an Excel spreadsheet that provides a list of every warning or error code that a user might receive in the data quality report assessment, as well as information regarding the error severity, category, and error code and message. And as we did with coding resources in the last section, we'd like to point out some helpful submission resources available at the QII Learning Center, including NCDR domestic and international onboarding, what is a DQR rationale and training, and what is a quality check rationale and training. After successfully collecting data, adhering to coding instructions and target values, and then submitting that data and achieving, hopefully, green submission status, the last step in the process is gaining an understanding of your data. Through close examination and interpretation using the resources at your disposal, you will gain insight into your site's performance. In this section, we'll look at some examples of metric performance results on the eReports dashboard and the registry resources to support your interpretation of the data and help inform opportunities for quality improvement. CAF PCI Registry measure and metric performance feedback are the ultimate realization of all of the time and effort spent on data collection and data submission. At the time of this recording, the registry is proud to report a total of 42 metrics split up among different types of metrics and measures, including PCI performance measures, quality metrics, outcome metrics, diagnostic metrics, efficiency metrics, safety metrics, and lastly, appropriate use criteria metrics. Effective CAF PCI Registry metric interpretation relies on viewing and analyzing metric performance on the eReports dashboard. The registry provides several vital resources to support this endeavor. Key documents for the purpose of deep metric analysis and interpretation are located in the user guide documents category of the resources section and include the executive summary measures and metrics companion guide and the dashboard user guide, the contents of which include information relevant to understanding all CAF PCI Registry measures and metrics. Additionally, the appropriate use criteria companion guide is of value when analyzing these specific metrics. Each and every metric that the CAF PCI Registry reports on the eReports dashboard is included in the executive summary measures and metrics companion guide and is allocated to the eReports dashboard and is outlined with the description, numerator and denominator criteria, denominator exclusions and exceptions, and lastly, clinical rationale and relevant citations, providing the evidence, guideline recommendations, or expert consensus. The following example shows metric 4, PCI within 90 minutes for patients with STEMI. The denominator simply includes all PCI procedures in which an indication of immediate PCI for acute STEMI informed the procedure. The numerator includes the count of procedures. In this case, those with arrival date and time or subsequent ECG date and time to first device activation date and time of less than or equal to 90 minutes. Patients that were transferred in for immediate PCI for STEMI were excluded, and patients with a patient-centered reason for delay and a time to first device activation time of greater than 90 minutes were accepted, respectively. Procedures that were excluded or accepted are removed from the metric denominator. The dashboard user guide provides individuals the opportunity to learn the concepts and language that are utilized on the eReports dashboard so that the user can engage in meaningful analysis of their site's performance results. It is full of clarifying explanations and screenshots. In the example here, the concept of desirable or undesirable performance based on whether a metric result is higher or lower is discussed. The user guide advises to first analyze the metric name description to determine how the metric reports performance, positively or negatively. The metric numerator in the top screenshot reflects the desirable outcome or positive performance, and a review should be focused on the patients not included in the numerator to identify opportunities for improvement. The metric numerator on the bottom screenshot reflects an undesirable outcome or negative performance, and the reviewer should be focused on the patients included in the numerator to identify opportunities for improvement. Because interpretation of appropriate use criteria in the form of AUC metrics requires a keen understanding of several separate components, the AUC companion guide includes an explanation of terminology, the patient and procedure variables that the algorithm utilizes for the purpose of AUC classification, assumptions and exclusions, as well as illustrative examples of the structure of AUC classification tables and how to interpret them. And on the subject of appropriate use criteria, in conjunction with the companion guide just mentioned, the following documents listed under the appropriate use criteria reference documents heading are essential to support your full comprehension of the indications and scores that the AUC assigns to individual procedures. And we will show an example of that momentarily. Additionally, each manuscript for the 2013 Stable Ischemic Heart Disease Multimodality, 2016 AUC ACS, and 2017 AUC SA HD respectively provides insightful methodology, assumptions, definitions, and rationale to further your understanding. Through the utilization of the e-reports dashboard combined with those metric interpretation documents that we just spoke about, we have the tools and resources necessary to get the most out of our data in the way of identification of opportunities for quality improvement. To help illustrate how the aforementioned resources and documents can help to interpret metric performance on the dashboard, let's use the example of appropriate use criteria. Applying the concepts from the illustration from the dashboard user guide, we understand that metric 34, proportion of PCI procedures that were evaluated as appropriate for PCI patients with Stable Ischemic Heart Disease, is a desirable metric in which we want a higher numerator and performance percentage. Whereas we would prefer to keep our numerator low in metric 36, the case is deemed rarely appropriate by the Stable Ischemic Heart Disease AUC. So for this particular patient that we are tracking with respect to AUC, our documentation is as follows. A 58-year-old male presents with a history significant for hypertension, hyperlipidemia, diabetes, and PCI to their distal RCA in 2018. The patient's home meds upon arrival are aspirin, Lipitor, hydrochlorothiazide, and metformin. The patient had a recent positive stress echo that showed a low risk of ischemia and arrives as an outpatient for an elective coronary angiogram on November 1 of 2021. The patient denies chest pain, and his only complaint is that of mild shortness of breath with exertion. The diagnostic findings show 80% mid-LED stenosis. The interventionalist decides to perform PCI and deploys a drug-eluting stent to the patient's mid-LED. And as it turns out, this procedure was assigned to metric 36, a portion of PCI procedures that were evaluated as rarely appropriate for patients with stable ischemic heart disease. Looking at this site's performance distribution, we can see that R4q performance is just above the 50th percentile, a desirable performance. Nonetheless, we'll take the opportunity to review this procedure that made the numerator of this metric in patient detail and determine why it was classified as rarely appropriate and consider what, if anything, may have been done differently that would have earned a maybe appropriate or appropriate designation. So what do we know about metric 36? Well, by reviewing the metric criteria in the Executive Summary Measures and Metrics Companion Guide, we know the metric 36 denominator includes all PCI procedures in which patients presented with stable ischemic heart disease. And the numerator includes all procedures in the stable ischemic heart disease category that were evaluated as rarely appropriate according to the AUC guidelines. The clinical rationale provides us additional explanation that the reason a procedure is identified as rarely appropriate is because there is a lack of a clear benefit or risk advantage. OK, that's helpful information, but what was it about this procedure that earned a classification of rarely appropriate? We will need to drill down into the metric 36 patient detail. Through the patient detail view, we can appreciate the indication number and score, as well as the pertinent variables that led toward the patient's classification as rarely appropriate. We can see that all of the column data matches the specifics of the scenario according to their abstraction in the data collection tool and submission to the DQR. And lastly, we see that this procedure was assigned an indication number 1 and a score of 2. Now, in order to derive some meaning from this classification, we'll need to turn to those AUC reference documents as previously discussed. Because the patient presented with stable known CAD, we turn to the 2017 AUC for coronary revascularization of stable ischemic heart disease to provide an explanation as to why. The AUC classification tables are featured starting on page 13 with table 1.1, which happens to be the table in which the procedure was assigned based on the patient's presentation with an overall disease burden of one vessel disease. Upon closer examination of indication number 1, it is apparent that a procedure may receive a wide array of appropriateness entirely based on their anginal symptoms in conjunction with anti-anginal medications that the patient was prescribed pre-procedure. As evidenced by the drill down data, we see that this patient presented for their procedure with no anginal chest pain and with zero anti-anginal medications on board, providing the rationale behind their rarely appropriate classification in indication with a score of 2. To put it simply, greater understanding of your facility's metric performance will result in opportunities for improved patient outcomes. Through the case scenario provided in the lesson, we applied our understanding of numerator-denominator criteria along with clinical rationale provided in the Executive Summary Measures and Metrics Companion Guide in conjunction with the dashboard user guide to interpret eReport's dashboard metric performance in metric 36. We then turned to the applicable AUC reference document to recognize and identify key variables in patient drill down data that provide an explanation for why a patient is included in the numerator of a negative performance metric. And we were able to generate the following insights. Stable ischemic heart disease AUC metric performance is largely dependent on thorough provider documentation accurately capturing a patient's pre-existing conditions. Considerations prior to performing PCI include, but are certainly not limited, to pre-procedure non-invasive testing to evaluate the presence and severity of myocardial ischemia, the prescription of anti-anginal medications, and the extent of a patient's ischemic symptoms. Incorporating these considerations into practice at your facility and with your providers may lead to improved guideline-directed care, resource utilization, and patient outcomes. Although it is worth noting, the AUC is a clinical tool to help guide decision-making, and it is not expected that every procedure will be viewed as appropriate, or likewise that a site would have 0% rarely appropriate procedures. Now, we highlighted this one example of metric performance interpretation through the lens of a case scenario in which a procedure received an AUC classification. These supportive resources and documents we've identified can shore up your understanding of performance as well as illuminate opportunities for improvement in every CAF PCI Executive Summary Metric as well. As we did with coding resources in the last two sections, we'd like to point out some helpful submission resources available at the QII Learning Center, including but not limited to Understanding Metrics, CAF PCI Registry Metric 45 Cardiac Rehab Referral, and CAF PCI Registry Metric 40 Risk-Standardized Bleeding. We reached out to several seasoned quality professionals who have extensive experience working with NCDR, and in particular, the CAF PCI Registry, and asked them to share some of their experience in managing the various registry resources with their teammates, all with the objective of keeping each other on the same page. They kindly agreed to take the time to share some of their processes and practices so that we may relay this information to you. Hearing back from these talented individuals, some common themes that contribute to their success began to take shape, and those would be collaboration, organization, and communication. A special thank you to Ann Spinachy-Bartley, Shelly Pfeiffer, and Ellen Connealy for agreeing to participate and for providing their experience, insight, and some very helpful tips. Collaboration is defined by the Association for Intelligent Information Management as a working practice whereby individuals work together for a common purpose to achieve business benefit. Our participant volunteers collaborate by using technology, such as Microsoft Teams, to chat with one another for fast feedback of uncomplicated questions. Weekly or biweekly team meetings or huddles are a common practice as well so that individuals can share NCDR email responses and other pertinent information or just simply bounce questions off one another. One participant mentioned consulting and partnering up and sharing information across facilities that are in the same health system, a terrific way to not only increase everyone's knowledge base, but also to ensure correct, consistent abstraction. A place for everything and everything in its place is an old proverb that came over from Europe to the US in the 19th century and was adopted most rigorously by farmers who owned and used a wide variety of tools and pieces of equipment and who couldn't afford to leave them to rust in the rain or exposed to elements during winter. Keeping track of their tools ensured they could get to work when they needed to, and there was always plenty of work to be done. These participants have incorporated similar strategies to keep track of their tools to ensure that they can get the work done as well. Organizational efforts, such as utilizing a central database or share drive where any number of resources can be stored for future reference is a popular approach. And then arranging education content by data element sequence number or formatting the drive to allow for a search function were cited as particularly helpful. These types of centralized resources can lend themselves well to orienting new abstractors and getting them up to speed quickly. One of the questions posed to our seasoned quality professionals was, at what point do you and your team decide to communicate with NCDR via phone, email, or contact us with a registry question? The participants shared insights on similar processes that also spoke to the collaboration piece in which questions that arise are circulated among team members. It's not uncommon for questions to be raised by a team member that a colleague already has experienced answering. However, if no consensus can be found and NCDR resources don't provide any additional clarity, then the individual contacts NCDR and ultimately shares the received response. Disseminating information in this way helps maintain consistency and ensures data integrity. Some sites find it helpful to have one dedicated team member that reaches out to NCDR for purposes of process and continuity and wording questions as objectively as possible to avoid any bias. In summary, you have all of the necessary tools at your disposal to, one, accurately collect an abstract data two, submit the data and receive green benchmark status and three, make effective use of measure and metric performance feedback for the purpose of quality improvement and better patient outcomes. It's just a matter of knowing where to go. And our hope is that this presentation highlighted the processes involved in effectively leveraging CAF PCI registry resources and fulfilling this important quest. And of course, the business support operations and clinical quality advisor teams are here to support you and the important work that you do. If after your review of NCDR resources you require any clarification or further assistance, you are always encouraged to contact us through the contact us link on the homepage, emailing ncdr at acc.org or picking up the phone and calling 800-257-4737. Thank you for taking the time to join us today.

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