ACTION Registry GWTG Version 2.4 Dr. Joanne Foody Kim Hustler The following relationships exist: Dr. Foody:Janssen, Sanofi, Genzyme, Aegerion, Amarin, BristolMeyersSquibb, Abbott, Gilead, ACC, Pfizer, Merck Kim Hustler: No Disclosures Session Objectives Outline the data points that will be changing for ACTION Registry GWTG Version 2.4 Discuss the rationale and implications for the changes in the data elements 1
Disclosures Dr. Joanne Foody No Disclosures to report Kim Hustler No Disclosures to report Version 2.4 Update - Why Change? New therapies/medications Research/Clinical Guidelines Collaborative/Integrated Care Improved quality of data in registry Public reporting Physician reporting Aligning with other NCDR Registries ARS Question #1 Who did we include in the process of determining what fields to add? 1. Email suggestions 2. RSM calls 3. Focused RSM teleconferences 4. Physician committee meetings 5. All of the above 2
ARS Question #2 How did we determine what fields to remove? 1. Frequency of fields being answered 2. Current practice 3. Core data elements 4. Enough data already captured 5. All of the above ACTION -GWTG Q.I. Subcommittee Members Dr. Joanne Foody Chair Dr. Karen Alexander Dr. Donald Casey Dr. Shahriar Dadkhah Dr William French Dr. Michael Ho Dr. Mauro Moscucci Dr. Gregg Fonarow Dr. Judith Lichtman Dr. Nurcan Illksoy Dr. James Jollis Dr. Mikhail Kosiborod Process SQOC Science & Quality Oversight Committee ACTION Registry GWTG Steering Committee Stakeholder feedback NCDR Management Board 3
Registry Site Manager Calls Calls were specifically to obtain feedback from users Two Teleconferences September 27, 2011 October 6, 2011 Be Careful What You Ask For! New therapies/medications Medications Dabigatran Rivaroxaban Apixaban Statin therapy at discharge, new fields Hypothermia Protocol 4
Section E- Medications New medication: Xarelto (Rivaroxaban) Documentation: History of Atrial fibrillation Presents with symptoms of ACS Positive Troponins- NSTEMI Physician discharges patient on Xarelto ARS Question # 32 How will you enter the Xarelto in the data collection tool? 1.Do not include 2.Answer Warfarin at discharge Seq. #6220 as contraindicated 3.Answer Warfarin at discharge Seq. #6220 as yes 5
Removed fields ASA date/time & dose (1 st 24 hours) Ticlopidine date/time & dose (1 st 24 hours) Prasugrel dose (1 st 24 hours) Beta blocker date/time Duration of P2Y12 s at discharge Option of blinded Version 2.4 6
New field for Statin therapy at discharge Less than Intensive Statin Therapy Intensive Statin Therapy Unfractionated Heparin GP IIB/IIIA Inhibitors 7
Anticoagulants removed Section E- Medications Excessive dosing UFH- no PCI Documentation: Presents with N/V, left arm pain 12 lead ECG- STEMI To cath lab for primary PCI- 5000 units UFH given in cath lab Coronary arteries- clean No PCI is performed Excessive dosing UFH- no PCI The data collection form would be completed as: Reperfusion Candidate #8000 yes Primary PCI #8015 no Reason no PCI #8030- Anatomy not suitable to primary PCI Thrombolytic no, reason #8035- Expected DTB <90 min- if was expected 8
ARS Question # 4 Would this patient be included in the UFH Excessive dosing report as we are currently entering it? 1. No 2. Yes Answer: #1 (No) As of October 1, 2013 discharges Diagnostic Angiography Time Seq. #7022 is the identifying time for UFH doses administered in the cath lab If date/time of UFH Seq. #6852/6853 is prior to Angiography time, it is included If after Angiography time- dose is excluded Documentation: Section E- Medications Excessive dosing UFH Presents with N/V, left arm pain at 04:00 12 lead ECG- negative Cardiac Biomarkers elevated- NSTEMI Weight 100 kg ED starts UFH infusion at 1000 U at 05:00 To cath lab at 08:00 5000 U IV bolus in cath lab administered at 08:15 9
ARS Question # 5 Would this patient be included in the UFH Excessive dosing report as we are currently entering it? 1. No 2. Yes V2.4 Excessive dose UFH V2.4 will capture date/time for both initial doses (bolus & infusion) The dates/times provide verification of administration prior to or after arrival in cath lab Patient can only fail the Excessive Dosing metric once Aligning Registries PCI Indications Arterial access site Demographics/Race Fields Mobile ICU 10
Version 2.3 Procedure fields Coronary Stenosis % removed Version 2.4 Procedures and Tests 11
PCI Indications & arterial access site Hypothermia therapy Section F- Procedures & Tests PCI Indication V2.4 Documentation: Presents with N/V & chest pressure Chest pressure started 2 days ago Vomiting started at 08:00, worsening CP ECG- ST elevation Emergently to cath lab at 09:45 12
ARS Question # 62 What would you select for PCI Indication? 1. Primary PCI for STEMI 2. PCI for STEMI (unstable, >12 hr from sx onset) 3. PCI for STEMI (stable,, >12 hr from sx onset) Version 2.4 Additions Demographics- Race detail lines Section A- Demographics Hispanic or Latino Ethnicity Documentation: Presents meeting criteria for NSTEMI Noted in town visiting family, home Mexico Her last name is Garcia Primary language: English Secondary language: Spanish No documentation of race/ethnicity in medical record 13
ARS Question #72 How would you answer Hispanic or Latino Ethnicity Seq. #2076? 1. No 2. Yes 3. Yes, Mexican Research/Clinical Guidelines Additional In-Hospital Clinical events Home Functioning/Cognitive Status In-Hospital Clinical Events 14
Home Functioning Cocaine use COPD Atrial fib or flutter- past 2 weeks removed Cancer history added Detail under Cerebrovascular disease 15
Collaborative/Integrated Care Two FMC fields to capture non-ems FMC Non-system reason for delay for First Medical Contact Additional EMS fields & cath lab activation for FMC Two FMC fields to capture non-ems FMC Non-system reason for delay for First Medical Contact Section B- Admission Means of Transport to First Facility Documentation: EMS called to home of female with symptoms of ACS BLS unit dispatched, ALS unit arrived 5 minutes later 12 Lead ECG read- ST elevation ASA is administered ECG reading phoned into ED ALS unit transported to primary PCI hospital 16
ARS Question # 8 What would you enter for Means of Transport to First Facility? 1. Self/Family 2. Ambulance 3. Mobile ICU Section B- Admission First Medical Contact time Seq. #3106 Documentation: Presented to physician office at 11:30 with 2 hours of epigastric pain, and pain radiating down left arm ECG- STEMI EMS patient contact time 11:50- transported by ambulance to PCI hospital Immediate Primary PCI ARS Question # 9 What time would you enter in for First Medical Contact time Seq. #3106? 1. 11:30 Physician Office contact time 2. 11:50 EMS contact time 3. Leave time blank 17
Data Collection Form Starting with January 1, 2014 discharges Enter into Auxiliary field 4 the response to question: Was EMS the first medical contact? Data Collection Tool Enter Y or N into Auxiliary field 4 under Discharge Note- answer N when no first medical contact Additional EMS fields & cath lab activation 18
Improved quality of data in registry Non-system reason for delay for ECG s Geographic concerns with D 2 B patients Initial and peak lab values Non-system reason for delay for ECG s V2.4 Changes Door to ECG Quality Metric #22 Documentation: EMS arrives at scene patient in cardiac arrest Code ran 11 minutes- Defib, CPR, medsresuscitated Transported to hospital- presented in cardiac arrest at 11:05 Coded for 10 minutes-resuscitated ECG- at 11:20- STEMI Immediate Primary PCI 19
ARS Question # 10 How is the ECG captured currently? 1. 1 st ECG in metric denominator/ no numerator 2. Subsequent ECG- excluded 3. Excluded for non-system reason for delay Geographic concerns with D 2 B patients Initial & peak or lowest lab values same - check box 20
Troponin & CK-MB initial and peak date/time fields removed Public reporting/ Core Measures LVEF measured after discharge Public reporting Physician Provider Number (NPI) Admitting Procedure Discharge 21
Physician Level Dashboard Reporting Physician Quality Reporting System (PQRS) Reimbursement Promotes reporting of quality information by eligible providers Providers identified by NPI # Limited and Premier Forms- Current 140 fields in Limited vs. 280 fields in Premier Simple/Avg pt = 60-80 fields vs. 100-150 in Premier Complicated pt = 80-100 fields vs. 150-200 in Premier Non PCI centers 60 fields vs. 100 in Premier Strongly encourage participants to use Premier data set, especially P-PCI capable centers 22
Limited and Premier Forms- V 2.4 160 fields in Limited vs. 260 fields in Premier Addition of fields in Limited include: EMS fields (Mission Lifeline reporting) Reasons for no Reperfusion Location of First Evaluation Value out of range for LDL Limited and Premier Forms V2.4 25% fewer date/time fields Set to no functionality in ACC data collection tool Limited and Premier Forms V2.4 Limited form answering no to many parent fields will close child fields As few as 75 fields for Limited, 120 for Premier Referring hospitals can review their performance on care measures provided 23
Contact NCDR for questions at ncdr@acc.org or call 800-257 257-4737 24