Welcome

Mid-Atlantic Data Managers (MACDM)

2019 Spring Meeting – Tuesday, April 23, 2019

Thanks to our hostLehigh Valley Hospital – Cedar Crest

House Keeping

• Sign in and take name tags/lanyard• Review and update the data managers listing• Rest rooms• Breakfast• Lunch and snacks• Silence all smart/flip phones/electronic devices. Please try to stay off

phone texting during meeting• You can follow along with this presentation on your smart phone by

opening meeting presentation on MACDM.org, goto meetings & Minutes, select upcoming meeting for this session

• Drop name tags/lanyard in container in rear of room when leaving for the day

Attendees SurveyThe following registries were selected as discussion interest from each MACDM meeting attendee:

Attendees Locations For 2018

Attendees Introduction

Around the room introduction (hint, read off your name tag):• First name

• Last name

• Hospital, organization or retired status

• City

• State

*Let us know if this is your first MACDM regional data managers meeting!

Mission Objectives:

• Enhance the quality outcome collection and reporting of cardiovascular procedures throughout the Mid-Atlantic Region.

• Improve outcome collection and reporting by using collaboration, networking and knowledge transfer with other data managers throughout the mid-Atlantic hospitals.

• Increase any participating Mid-Atlantic data managers incite into current and future STS (The Society of Thoracic Surgeons), NCDR (National Cardiovascular Data Registry), AHA (American Heart Association) changes communicated at their meetings. This will be communicated by attending Mid-Atlantic participating data managers.

MACDM

MACDM (continued)Web site address:

MACDM.org

Data managers listing:

Print or download - Click Attendees (Go to Bottom), see MACDM Data Managers List

Rules to follow:

No one in MACDM group is paid or compensated for any work

No presenter is paid or compensated, other then free beverages/lunch

No presenter can give political presentations

What registries do we discuss:

STS (The Society of Thoracic Surgeons) – Cardiac and Thoracic

NCDR (National Cardiovascular Data Registry) – Cath/PCI

AHA (American Heart Association) – GWTG

Open discussion on TVT/LAAO/ACTION/ICD/Congenital or any other registry the group would like to

discuss

MACDM (continued)

How much does it cost to attend the meetings:

• The cost is either a $100 annual per hospital fee or a $25 per attendee/per meeting fee.

• If a hospital pays the annual $100 fee, they can send any number of staff to the meetings at no charge. To get added to annual voucher, go to MACDM.org and click enroll. There is no charge and you will get a voucher and be put on the annual voucher mailing in December for next year.

• MACDM annual voucher will be sent out in December. Your MACDM # will drop the leading zeros going forward to make it easier.

Number of planned onsite meetings per year:

• We hold two onsite meetings per year to discuss major STS, NCDR and AHA registry form changes, web site updates, reporting and important presentations from the most resent spring NCDR/fall STS annual meetings and any other sources.

• Spring MACDM meeting a few weeks after the NCDR annual conference.

• Fall MACDM meeting a few weeks after the STS annual conference.

MACDM (continued)

• Next STS Data Managers Conference:

• October 23-25th 2019 Marriott, New Orleans, LA

• Next NCDR Data Managers Conference

• October 7-9th 2020 Caribe Royale Orlando, FL

• Next MACDM Data Managers Meetings:

• Fall – Wednesday, November 13th, 2019 – Kasych 6

• *Spring – Tuesday, April 14, 2020 – Kasych 7

❖Will we still have a spring meeting for 2020 since NCDR is moving to fall meeting around same tine as STS?

❖ Do we move Spring 2020 meeting to other hospitals that have offered to host our group?

NCDR Annual Data Managers ConferenceNew Orleans - March 13-15, 2019

NCDR in New Orleans (Continued)

NCDR in New Orleans (Continued)

NCDR in New Orleans (Continued)

NCDR 2019 Keynote Speaker – Zubin Damania, MD

https://www.youtube.com/watch?v=SJ2jG2ipcLchttps://www.youtube.com/user/ZDoggMD

NCDR 2019 Posters – Same Day Discharge For Elective PCI

NCDR 2019 Posters – Same Day Discharge For Elective PCI

• Cath/PCI bleeding complication reduction – Big shift from PCI femoral to radial. Expecting large savings on overnight stays due to less bleeding complications and push to same day elective PCI’s.

• How many hospitals have not implemented but working on/discussing same day discharge for elective PCI?

• How many hospitals have already implemented a same day discharge for elective PCI workflow? Do any of these hospitals want to go over their implemented workflow at fall 2019 MACDM meeting.

• Any interest in getting the same day discharge for elective PCI poster speaker for fall meeting?

Some Other Posters:• Reduce bleeding femoral vs radial taking care of issue• Reduce first medical contact to EKG time

NCDR 2019 – Accreditations

Accreditations• Chest Pain MI

• TRIP (translating research into practice)

Conference spent 1/3 of time Thursday and Friday on accreditations. Also discussed accreditations within the other sessions. Survey asked if accreditations should be included in the conference.

15 Minute Break

Be back in 15

Cath/PCI

• Not a lot of cath/PCI field information shared at conference.

• Version 4 is now retired. You can no longer resubmit any data prior to 4-1-2018.

• High Sensitivity Troponin – If you use this, it is normally reported in ng/L (liters). NCDR wants the ng/mL (which is 1000 to 1). If your lab reports High Sensitivity Troponin <6, then value as 5 otherwise rounding will make it 0.

Cath/PCI (continued)Optional Sections/Fields

Your hospital system must decide which of the following optional sections/fields to be completed! No longer getting DQR warnings!Section A. Demographics

• Asian, Native Hawaiian, Hispanic Ethnicity further breakdown. If not, select other options under each?Section B. Episode of Care

• Admitting Provider’s Name, NPI – Fields – If you collect these, they will also need to be maintained in the NCDR registry?• Attending Provider’s Name, NPI – Fields – If you collect these, they will also need to be maintained in the NCDR registry?• Patient Restriction?• Research Study – Only includes any NCDR research studies, not outside research studies

Section D. Pre-procedure information• Seattle Angina Questionnaire (SAQ) - Section• Rose Dyspnea Scale - Section

Section L. Discharge• Discharge Provider’s Name, NPI - Fields – If you collect these, they will also need to be maintained in the NCDR registry?

Section M. Follow-up (30 day and 1 year)Entire section M optional - Out of roughly 1400 attending NCDR 2018 conference, roughly less than 12 were planning to submit follow-up

• Assessment Information• Events• Medications• Seattle Angina Questionnaire (SAQ) Follow-up• Rose Dyspnea Scale Follow-up

Cath/PCI (continued)

Cath/PCI (continued)• New NCDR dashboard reporting released for version 5, looks really

nice!

Cath/PCI – Some Exclusions

Cath/PCI – Some Exceptions

STEMI PCI Exception for Door To Balloon Calculation - Delay Reasons:

• Cardiac arrest and/or need for intubation before PCI

• Difficult vascular access

• Difficulty crossing the culprit lesion during the PCI

• Patient delays in providing consent for the procedure

• Other

Cath/PCI (continued)

• NCDR is trying to link Cath/PCI Data to CMS Data for 30 day mortality – If your not sending most PHI, not sure what they will do.

• Are there any specific questions on the Cath/PCI version 5 form? Do you want to share your pain, suffering and knowledge?

NCDR TAVR UpdatesThanks to Jen Hahn from Geisinger Holy Spirit Hospital for notes!

• NCDR will post TVT NCDR conference slides reviewed on NCDR website (not available yet).

• A speaker from Duke outlined their creation of a one-page TVT dashboard for their C-Suite. A visual of this was part of the power point (worth the time to review, once the slides from the conference become available). Liked the way the dashboard highlighted what the program was doing well and in addition focused on a few areas that need improvement.

NCDR TAVR Updates (continued)• Much discussion about the newest risk model “Composite Morbidity Mortality

Risk Model”. They stated that it will become the gold standard in defining whether an institution has a quality TAVR program. It will function much like the STS’s Star Ratings (one, two, or three stars will be assigned to the program, with 3 stars being the best).

• Public reporting will be voluntary and target of July 2020. Will include 3 years of data and look at:

• Patient Volume (TAVRs with femoral approach)• 30-day risk adjusted mortality• In Hospital risk adjusted mortality - A note about “In Hospital risk adjusted mortality”- To

have this field calculate, sites must have a greater than 90% compliance with the KCCQ baseline & the 5 Meter Walk Test. Also, the discharge status must be filled out completely.

• Version change coming next year: Will be TVT 3.0 They will be making the data devices fields clearer. Specifically, fracturing and cerebral perfusion devices. They’d like you to capture fracturing devices now under devices (if it is used to fracture an existing bioprosthetic valve). Also, you should be checking with physicians to see if they are using cerebral protection devices, if so also capture under devices.

NCDR TAVR Updates (continued)

Random Additional Comments:

• TAVR median patient age is 81

• TAVR in hospital mortality is stable at 3%

• LOS average 2-4 days

• 30 day new requirement for pacemakers has been flat at 12% for last 6 years

• CVA rate is 1.8%

• Valve-in-valve procedures comprise 7% of TAVR (patient already had a previous surgery and TAVR us placed inside the old valve)

NCDR LAAO Updates

Thanks to Jen Hahn from Geisinger Holy Spirit Hospital for notes!

• Huge growth in volume of cases being performed - 1,000 procedures in 2015 vs 20,000 in 2018

• 500 sites now participating

• Procedure success = 98%

• Adverse events rates remain low (1.49%) - great rate in this older, sicker population

• NCDR is trying to get CMS to modify the NCD to allow interventional cardiologists to document the “shared decision making”.

• 40% of sites are asking the referring MD to document this conversation• 30% of sites use a non-interventional cardiologist

• Decision aides can be videos. Check out Cardiosmart’s website for tools, still need to have documentation in the record that a shared decision-making discussion was completed with a non-interventional clinician.

NCDR LAAO Updates (continued)

• Discharge med strategy• If patient is not going home on aspirin, and/or the dose is not increased at the 6-

month mark, code reason as “hemorrhagic complication”.• If patient goes home on a DOAC instead of warfarin, then cannot code “FDA label

dosing regiment”.

• If patient has a pre-existing condition of GI bleed, and then has another GI bleed in any of the follow up windows, do not pick the bleed up as a complication. (this one surprised a lot of us!)

• Don’t code new elements in the old version’s records, may result in error code 2200. Latest version started 10/1/2018 (v1.2).

• If the EF is given in a range (like 50-55%) choose the lowest number of the range to abstract.

• Use a TEE that is done within 7 days of the Watchman, you can use one done intra-procedure if performed before venous access.

Open Discussion Other Registries

• Congenital - new version 3 rolled out for 1-1-2019 procedures• Have you installed and started to enter your 2019 procedures?

• 1 year status added (alive, dead, unknown and verification. A real concern about the work needed to get this information but do the best you can.

• ICD - For any hospitals that have dropped the ICD registry, what do we have to do to fulfill the requirements?

• ACTION?

• Any other discussion points?

10 Minute Break

Be back in 10

Gift Card Drawing

You must be present to win!

3D Printing in Medicine

15 Minute Break and Group PhotoGroup picture outside room in 15 minutes!

Half Hour Lunch Break

Lunch provided in back of room

AHA Get With the GuidelinesData Deadline Dates

Once a year last quarter data deadline March 31st, of that following year (NCDR is April 17th). March 31st deadline is important for any annual awards based on prior years data.

All other quarters can follow the NCDR Cath/PCI three other quarter deadlines.

What hospitals are inputting directly to GWTG web site?

What hospitals are using vender software to enter GWTG and export data to AHA?

MACDM Sub-GroupsRobin McKelvey, Bayhealth Cardiovascular

Sub-Groups – Conference calls and/or web ex meetings. Updates at spring/fall MACDM on-site meetings

EPIC EMR Sub-Group – Robin McKelvey, Bayhealth Cardiovascular

Do we want any registry software vender to present? Who, Lumedxetc?

Any other sub-groups to create? Who will volunteer to run them?

STS Reporting Dashboard• After many attempts, STS will not agree to a web ex with our group to discuss

the STS Reporting Dashboard

Cardiac O/E ReportO (Observed) To E (Expected)

Ex: Mortality Ratio

• The rate of patient deaths (mortality) in a hospital is shown as a mortality ratio that compares patients' actual/observed mortality to their expected mortality.

• The "observed-to-expected mortality" is a risk-adjusted measure of a hospital's mortality. This ratio is created from Observed and Expected Mortality numbers:

• Observed Mortality. The number of patient deaths in the hospital time period being measured.• Expected Mortality. The expected average of hospitalized patient deaths with a particular illness or

condition that are beyond the control of the medical center, such as age, gender and other medical problems. Very complicated but many apps to do this for you and STS calculates it in the vendor software.

Observed mortality is divided by the expected mortality to create the O/E ratio.

The meaning of an O/E ratio depends on the score (the lower the score, the better). • Equal to 1.5. The hospital's mortality is higher than expected.• Equal to 1.0. The hospital's mortality is equal to what is expected.• Equal to 0.75. The hospital's mortality is 25 percent lower than expected.• Equal to 0.50. The hospital's mortality is 50 percent lower than expected.

Cardiac O to E Report (continued)

• Website that some physicians and PAs use to calculate risk. Once you click on the procedure it shows all the information that needs to be filled in. http://riskcalc.sts.org/stswebriskcalc/calculate

• STS Cardiac risk score fields. Each STS procedure has its own risk calculator that looks at different fields. The registry fields come from all of the different STS cardiac preop information. For STS list of fields used for risk calculation: https://www.sts.org/sites/default/files/documents/ACSD_RiskModelVariables_V2_9_08312017.pdf

Cardiac O/E Report (continued)

Cardiac O/E Report (continued)

Cardiac O/E Report (continued)

Cardiac O/E Report (continued)

20 Minute Break

Be back in 20

STS Thoracic – Report Error Message

Hospital information in the Data Warehouse:

The table below lists the Hospital NPI(s) and Hospital Name(s) for all data in the current report period, which

may include data from your current data file and historic data previously submitted. Non-Analyzable

Operations will be removed from the database, but are included in contractual checks (NPI), and checks

related to systemic software issues (duplicate record id’s, invalid values, missing/invalid patient ids).

Source HospNPI Min SurgDt Max SurgDt Count Match?

Current Data 08/01/2007 12/31/2008 465 NO

Current Data 1234567890 01/06/2009 12/31/2014 1439 Yes

Ignore the message above of (Match? NO) for any data submitted prior to 1-1-2009

STS Adult Cardiac

• 30 Day Post-op Surgery Status - If a hospital has 30 day post-op surgery status of more than 2% missing/Unknown of eligible patients, that hospital will NOT receive a star ratings for that reporting period.

• What does your hospital do to collect 30 day post-op surgery status?• Every hospital has slightly different processes.

• One of our hospitals PA's calls each patient at 30 days and creates a EPIC telephone note.

• Other will look at EMR system. If they were admitted or if they had a follow-up visit, look for any mention of readmissions in any of their hospitals. If neither, they say No.

• If there is no follow-up visit, they then try to call or contact. If they can't get any contact, they mark as Unknown.

• In last 2 years we had 1 unknown for 4 hospitals. Because we are more rural, they usually come back to one of our area hospital services.

• Real Time Data Submission – New data submission allows near real time entry process. No sweat, can use same old process going forward. Can submit data for past or present time.

• Operative Death Field – Much confusion about this field and long STS discussion. STS will not use this field and determine this by the other data captured like date of death. This field will no longer be audited.

• Auditing Grace Period – No data will be audited from 7-1-2017 to 9-30-2017.

Registry Abstraction FTE EstimationNCDR CathPCI

• Diagnostic Caths take on average 1 hour to abstract/enter into the registry. Depending on the vendor, this time may vary.

• PCI cases take on average 1 hour and 15 minutes to abstract/enter into the registry.

• A facility that does an average of 1000 caths and 600 PCIs per year would require a minimum of 1 FTE associated with data abstraction only, to include primary abstraction and IRR or re-abstraction of 10% of cases. Most registries recommend 5-10% of cases be re-abstracted to ensure data accuracy/integrity. There would be an additional 0.3 FTE associated with data validation and submission, staff meetings, education, reviewing outcomes, etc. Additional time would be required if a team member is presenting data in quality meetings.

• Base FTE requirement of the volumes notes about would be 1.3 FTE. Adding in a 15% PTO/vacation factor would be 1.5 FTE.

NCDR TVT and LAAO Registry

• TVT and LAAO Registry abstraction resource requirements vary depending on process in place at the facility. Primary abstraction of the index procedure will take on average 1.5 hours. Each follow up period will take 30 minutes - 1 hour, depending on access to required documentation, as well as whether or not there was a complication, return to OR, or readmission.

• The time requirement for TAVR and Mitral Clip procedures are the same.

NCDR ICD

• ICD cases take on average 1 hour to abstract/enter into the registry/vendor.

• A facility that does an average of 15 cases per month would require 0.15 FTE.

* Information provided by Teresa Hollingsworth, Penn State Health.

Registry Abstraction FTE Estimation

STS Adult Cardiac Surgery

• The STS Registry endorses that approximately 1 FTE is required per 500 cases.

• STS Cardiac cases take anywhere from 1.5 hours on average, for a straight forward, uncomplicated CABG/Valve procedure to 3+ hours for a complex procedure with a LOS > 10 days.

• Data entry times can vary depending on vendor.

• Times noted above are for primary abstraction only and do not include any data validation, quality checks, etc.

• These times may vary slightly by facility depending on efficiencies in place, EMR, provider engagement around documentation requirements, etc. Consideration should also be given to additional time associated with data validation, second checks, follow up with operations, submitting data, creating redundancies so there are no gaps in data collection, as well as departmental/facility obligations for education, team meetings, vacation, etc.

* Information provided by Teresa Hollingsworth, Penn State Health.

MACDM Closing• Would anyone like to volunteer to present one registry. I will help you with creating presentation and

the presentation itself?

• Any future topics would you like to hear for fall/spring meeting?

• Any additional registry to discuss, specific fields discussion and process improvement?

• AHA New Web Site and report review project. We could partner with Ohio data managers and do web ex’s to come up with any AHA GWTG site/report suggestions.

• Thanks again Lehigh Valley Hospital for hosting this meeting!

• Watch MACDM.org for meeting pictures and minutes to be announced!

• Please drop lanyard and name tag in container in rear of room when you leave