[PPT] - EX PERT TO EX PERT CMS53/ AMI 8a: Pr imar y PCI R e c e ive d PowerPoint Presentation

SLIDE 1

PIO N EERS IN Q UA LITY: EX PERT TO EX PERT

CMS53/ AMI 8a: Pr imar y PCI R e c e ive d Within 90 Minute s of Hospital Ar r ival

Bo b Dic ke rso n, RRT , MHSA, T e llig e n L ynn Pe rrine , MSN, RN, L a nta na Co nsulting Gro up Ang e la F la na g a n, MSN, RN, CPHI MS, L a nta na Co nsulting Gro up

SLIDE 2

Disc ussion T

pic s
L
g ic spe c ific a tio ns fo r AMI

8a

F

re q ue ntly Aske d Que stio ns fo r AMI 8a

Cha ng e s to me a sure spe c ific a tio ns fo r 2017

re po rting

2

SLIDE 3

Bac kgr

und
Pe rc uta ne o us Co ro na ry I

nte rve ntio n (PCI ) is a pro c e dure tha t o pe ns b lo c ke d b lo o d ve sse ls a nd pre ve nts furthe r he a rt musc le da ma g e fo llo wing a he a rt a tta c k.

Must pe rfo rm PCI

q uic kly to b e e ffe c tive .

I

nitia lly pa rt o f AMI Me a sure Se t

E
spe c ifie d in 2013

3

SLIDE 4

Me asur e De sc r iption Ac ute myoc ar dial infar c tion (AMI) patie nts with ST

se gme nt e le vation on the

e le c tr

c ar

diogr am (E CG) c lose st to ar r ival time r e c e iving pr imar y PCI during the hospital stay with a time fr

m hospital ar

r ival to PCI of 90 minute s or le ss.

4

SLIDE 5

R ationale

T

he e a rly use o f prima ry a ng io pla sty in pa tie nts with ST

se g me nt myo c a rdia l

infa rc tio n (ST E MI ) re sults in a sig nific a nt re duc tio n in mo rta lity a nd mo rb idity. T he e a rlie r PCI is pro vide d, the mo re e ffe c tive it is (Bro die , 1998 a nd De L uc a , 2004).

Na tio na l g uide line s re c o mme nd the pro mpt

initia tio n o f PCI in pa tie nts pre se nting with ST

e le va tio n myo c a rdia l infa rc tio n (O'Ga ra ,

2013; a nd L e vine , 2011).

5

SLIDE 6

Var iable s

L

gic state me nts r

e use d thr

ughout a me asur

e :

Denoted with a “$”
De fine d in the Da ta Crite ria (QDM Va ria b le s) se c tio n

6

SLIDE 7

AMI 8a Var iable s

$EncounterInpatient =

"Encounter, Performed: Encounter Inpatient" satisfies all
(length of stay <= 120 day(s))
ends during "Measurement Period"

$AnotherHospitalOrHealthcareFacility =

Union of:
"Transfer From: Ambulatory Surgical Center"
"Transfer From: Transfer From Outpatient"
"Transfer From: Transfer From Emergency Department (ED)

Locations"

"Transfer From: Transfer From Inpatient"

7

SLIDE 8

AMI 8a Var iable s, c ontinue d

$ReasonForNoFibrinolyticTherapy =

Union of:
"Diagnosis, Active: Cardiopulmonary arrest"
"Procedure, Performed: Endotracheal Intubation"
"Procedure, Performed: Aortic balloon pump

insertion"

"Procedure, Performed: Ventricular Assist Device

placement"

Note : $Re asonF

r

NoF ibr inolytic T he r apy has be e n update d to $R e asonF

r

NoPCI in ve r sion 5.

8

SLIDE 9

Initial Population R e quire me nts

Pa tie nts must b e a t le a st 18 ye a rs o ld.
E

nc o unte r must inc lude princ ipa l dia g no sis

f AMI

.

Dia g no sis must b e re c o rde d during

inpa tie nt e nc o unte r o r E D visit.

E

D visit is o nly c o nside re d if it o c c urs within

ne ho ur o f inpa tie nt a dmissio n.

9

SLIDE 10

Initial Population

AND: Age > = 18 year(s) at: Occurrence A of

$EncounterInpatient

AND:
OR: "Diagnosis, Active: Acute Myocardial

Infarction (AMI) (ordinality: Principal)" starts during Occurrence A of $EncounterInpatient

OR: "Diagnosis, Active: Acute Myocardial

Infarction (AMI) (ordinality: Principal)" starts during ("Encounter, Performed: Emergency Department Visit" <= 1 hour(s) and ends before or concurrent with start of Occurrence A of $EncounterInpatient)

10

SLIDE 11

De nominator R e fine s c ase s by asse ssing AMI patie nts ide ntifie d in IP with:

ST
e le va tio n o n E

CG

Re c e ive d prima ry PCI
F

ib rino lytic the ra py no t initia te d

Denominator =

AND: Initial Population

11

SLIDE 12

De nominator – E CG

AND:

OR:
AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1

hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient

AND: Union of:
Most recent: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram

(ECG)" <= 1 hour(s) starts before start of "Occurrence A of Encounter, Performed: Emergency Department Visit"

First: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG)"

starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit“

OR:
AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends

before or concurrent with start of Occurrence A of $EncounterInpatient

AND: Union of:
Most recent: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram

(ECG)" <= 1 hour(s) starts before start of Occurrence A of $EncounterInpatient

First: "Occurrence A of Diagnostic Study, Performed: Electrocardiogram (ECG)"

starts after start of Occurrence A of $EncounterInpatient

12

SLIDE 13

De nominator – diagnosis

AND: "Occurrence A of Diagnostic Study, Performed:

Electrocardiogram (ECG) (result: Acute or Evolving MI)"

AND NOT: "Occurrence A of Diagnostic Study,

Performed: Electrocardiogram (ECG) (result: STEMI Exclusions)"

13

SLIDE 14

De nominator

PCI

AND:

OR:
AND: First: "Occurrence A of Procedure, Performed: PCI (ordinality: Primary Procedure)"

<= 1440 minute(s) starts after start of Occurrence A of $EncounterInpatient

AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends

before or concurrent with start of Occurrence A of $EncounterInpatient

AND NOT: "Occurrence A of Procedure, Performed: PCI" starts after start of
"Occurrence A of Medication, Administered: Fibrinolytic Therapy" during

Occurrence A of $EncounterInpatient

OR:
AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s)

ends before or concurrent with start of Occurrence A of $EncounterInpatient

AND: First: "Occurrence A of Procedure, Performed: PCI (ordinality: Primary Procedure)"

<= 1440 minute(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"

AND NOT: "Occurrence A of Procedure, Performed: PCI" starts after start of
"Occurrence A of Medication, Administered: Fibrinolytic Therapy" starts after

start of "Occurrence A of Encounter, Performed: Emergency Department Visit

14

SLIDE 15

De nominator E xc lusions

Pa tie nts re c e ive d a s a tra nsfe r fro m:

I

npa tie nt o r Outpa tie nt De pa rtme nt

E

me rg e nc y De pa rtme nt

Amb ula to ry Surg ic a l Ce nte r

Denominator Exclusions =

OR: $AnotherHospitalOrHealthcareFacility <= 1 day(s) starts before

start of

"Encounter, Performed: Emergency Department Visit" <= 1

hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient

OR:
AND: $AnotherHospitalOrHealthcareFacility <= 1 day(s) starts

before start of Occurrence A of $EncounterInpatient

AND NOT: "Encounter, Performed: Emergency Department Visit"

<= 1 hour(s) ends before or concurrent with start of Occurrence A

f $EncounterInpatient

15

SLIDE 16

Nume r ator

Asse sse s AMI pa tie nts who se time fro m ho spita l a rriva l to prima ry PCI is 90 minute s o r le ss.

Numerator =

AND:
OR:
AND: "Occurrence A of Procedure, Performed: PCI (ordinality: Primary

Procedure)" <= 90 minute(s) starts after start of Occurrence A of $EncounterInpatient

AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1

hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient

OR: "Encounter, Performed: Emergency Department Visit" satisfies all
<= 90 minute(s) starts before start of "Procedure, Performed: PCI"
<= 1 hour(s) ends before or concurrent with start of Occurrence A of

$EncounterInpatient

16

SLIDE 17

De nominator E xc e ptions

Pa tie nts with a spe c ifie d me dic a l dia g no sis o r pro c e dure pe rfo rme d:

Ca rdio pulmo na ry a rre st
E

ndo tra c he a l intub a tio n

Ao rtic b a llo o n pump inse rtio n
Ve ntric ula r a ssist de vic e pla c e me nt

17

SLIDE 18

De nominator E xc e ptions E xpr e ssion

Denominator Exceptions =

OR: $ReasonForNoFibrinolyticTherapy <= 90 minute(s) starts

after start of

"Encounter, Performed: Emergency Department Visit" <=

1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient

OR:
AND: $ReasonForNoFibrinolyticTherapy <= 90 minute(s)

starts after start of Occurrence A of $EncounterInpatient

AND NOT: "Encounter, Performed: Emergency

Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient

18

SLIDE 19

QDM Data E le me nts

“Procedure, Performed: Aortic balloon pump insertion" using "Aortic balloon pump insertion SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.1151)”

Cate gory: Pro c e dure Data T ype : Pro c e dure , Pe rfo rme d Value Se t: Ao rtic b a llo o n pump inse rtio n Code Syste m: SNOME

D

Code s: 175113001, 399052009, 399175004,

399217008, 432375005, 442807006, 83676006

19

SLIDE 20

Data Cr ite r ia (QDM Data E le me nts)

"Diagnosis, Active: Acute Myocardial Infarction (AMI)" using "Acute Myocardial Infarction (AMI)

Grouping Value Set (2.16.840.1.113883.3.666.5.3011)"

"Diagnosis, Active: Cardiopulmonary arrest" using "Cardiopulmonary arrest Grouping Value Set

(2.16.840.1.113883.3.666.5.748)"

"Diagnostic Study, Performed: Electrocardiogram (ECG)" using "Electrocardiogram (ECG) Grouping Value

Set (2.16.840.1.113883.3.666.5.735)"

"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit SNOMEDCT

Value Set (2.16.840.1.113883.3.117.1.7.1.292)"

"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set

(2.16.840.1.113883.3.666.5.307)"

"Medication, Administered: Fibrinolytic Therapy" using "Fibrinolytic Therapy RXNORM Value Set

(2.16.840.1.113883.3.666.5.736)"

"Procedure, Performed: Aortic balloon pump insertion" using "Aortic balloon pump insertion

SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.1151)"

"Procedure, Performed: Endotracheal Intubation" using "Endotracheal Intubation Grouping Value Set

(2.16.840.1.113762.1.4.1045.69)"

"Procedure, Performed: PCI" using "PCI Grouping Value Set (2.16.840.1.113762.1.4.1045.67)"
"Procedure, Performed: Ventricular Assist Device placement" using "Ventricular Assist Device

placement Grouping Value Set (2.16.840.1.113883.3.666.5.3015 )"

20

SLIDE 21

Data Cr ite r ia (QDM Data E le me nts)

"Transfer From: Ambulatory Surgical Center" using "Ambulatory Surgical

Center SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.687)"

"Transfer From: Transfer From Emergency Department (ED) Locations" using

"Transfer From Emergency Department (ED) Locations SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.3006)"

"Transfer From: Transfer From Inpatient" using "Transfer From Inpatient

SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.3013)"

"Transfer From: Transfer From Outpatient " using "Transfer From Outpatient

SNOMEDCT Value Set (2.16.840.1.113883.3.67.1.101.950)" Attribute: "Result: Acute or Evolving MI" using "Acute or Evolving MI Grouping Value Set (2.16.840.1.113883.3.666.5.3022)"

Attribute: "Ordinality: Primary Procedure" using "Primary Procedure

SNOMEDCT Value Set (2.16.840.1.113762.1.4.1111.12)"

Attribute: "Result: STEMI Exclusions" using "STEMI Exclusions Grouping

Value Set (2.16.840.1.113762.1.4.1045.36)"

Attribute: "Ordinality: Principal" using "Principal SNOMEDCT Value Set

(2.16.840.1.113883.3.117.1.7.1.14)"

21

SLIDE 22

F r e que ntly aske d que stions

22

SLIDE 23

Que stion

I t a ppe a rs this me a sure is missing De no mina to r E xc e ptio ns fo r why a PCI wa s no t do ne . I t lo o ks like a re pe a t o f the F ib rino lytic Re a so ns No t Do ne De no mina to r E xc e ptio ns Se c tio n fro m AMI

7a (CMS60/ NQF

164).

23

SLIDE 24

Answe r

T

he De nominator E xc e ptions for both CMS53 and CMS60 inc lude :

"Dia g no sis, Ac tive : Ca rdio pulmo na ry a rre st"
"Pro c e dure , Pe rfo rme d: E

ndo tra c he a l I ntub a tio n"

"Pro c e dure , Pe rfo rme d: Ao rtic Ballo o n

Pump I nse rtio n"

"Pro c e dure , Pe rfo rme d: Ve ntric ula r Assist

De vic e Pla c e me nt"

T

he var iable name was c or r e c te d to

“$ReasonForNoPCI” during the 2016 Annual

Update for 2017 r e por ting to align with the me asur e c onte nt.

24

SLIDE 25

Que stion

F

r ho spita ls with sa te llite ho spita l e me rg e nc y

de pa rtme nts with the sa me CCN numb e r, whe n do e s the time b e g in fo r 90 minute s o f ho spita l a rriva l? At the time o f o rig in in the sa te llite E D, o r whe n the pa tie nt a rrive s a t the ma in fa c ility?

25

SLIDE 26

Answe r

If this is tr

uly a sate llite E D and not ur g e nt c a r e , the timing would star t in the sate llite E D.

T

he nume r ator state s:

OR:
"E

nc o unte r, Pe rfo rme d: E me rg e nc y De partme nt Visit" satisfie s all <= 90 minute (s) starts b e fo re start

f "Procedure, Performed: PCI“
<= 1 ho ur(s) e nds b e fo re o r c o nc urre nt with start o f

Oc c urre nc e A o f $E nc o unte rI npatie nt

T

he ar r ival time is assoc iate d with the e nc ounte r .

If you wa nt to de te r

mine if the patie nt falls into the Nume r ator , it would de pe nd on the r e maining logic (i.e ., <= 1 hour (s) e nds be for e or c onc ur r e nt with star t of Oc c ur r e nc e A of $E nc ounte r Inpatie nt).

26

SLIDE 27

Que stion

T he g uida nc e c ha ng e d b e twe e n ve rsio n 4 a nd ve rsio n 5. Wha t ne e ds to b e c a pture d fo r re po rting Pro c e dure Pe rfo rme d: PCI ?

27

SLIDE 28

Answe r T he PCI Grouping Value Se t (OID 2.16.840.1.113762.1.4.1045.67) ide ntifie s a PCI pr

c e dur

e as pe r for me d (logic c onstr uc t Pr

c e dure , Pe r

for me d: PCI).

Do c ume nta tio n o f I

CD-10 o r SNOME D c o de s within this va lue se t will suffic e .

T

iming re q uire me nts o f a prima ry PCI pro c e dure within 90 minute s o f ho spita l a rriva l did no t c ha ng e .

28

SLIDE 29

Que stion

An o rdina lity a ttrib ute o f 'prima ry' wa s a dde d to the Pro c e dure , Pe rfo rme d PCI e le me nt. We unde rsta nd tha t 'prima ry' is c linic al, a nd do e s no t me a n 'princ ipa l' a s in a b illing c o nte xt. T he de sig na tio n o f a PCI a s prima ry is no t typic a lly fo und in the E HR in the wa y the me a sure e xpe c ts. Wha t is the e xpe c ta tio n o f ho w the E HR will c o lle c t 'prima ry' fo r the PCI pro c e dure ?

29

SLIDE 30

Answe r

Most E

HR s do not have the option to c aptur e pr imar y.

We be lie ve using 'F

IR ST ' will like ly c aptur e the inte nt in the major ity of c ase s.

Adde d c la rifying sta te me nt to the c urre nt

g uida nc e re g a rding using first to me e t the inte nt o f the me a sure in c a pturing the prima ry PCI pro c e dure pe rfo rme d during the inpa tie nt e nc o unte r.

Adde d 'F

I RST ' to re pla c e 'Ordina lity: Prima ry Pro c e dure ' to c a pture the first (prima ry) PCI pro c e dure pe rfo rme d during a n inpa tie nt e nc o unte r in the De no mina to r lo g ic fo r ve rsio n 5.

30

SLIDE 31

Que stion

T he o rdinality: Prima ry Pro c e dure c la use o f the nume ra to r se c tio n is no t inc lude d fo r E D e nc o unte rs. Ha s a ny c o nside ra tio n b e e n g ive n to o rdina lity: Prima ry Pro c e dure in E D also ?

31

SLIDE 32

Answe r

R

e move d or dinality in ve r sion 5.

R

e vise d logic :

Mo ve d fro m nume ra to r to

de no mina to r

Added ‘FIRST’ to replace

'Ordina lity: Prima ry Pro c e dure '

32

SLIDE 33

Que stion

SNOME D c o de 401314000 (Ac ute no n-ST se g me nt e le va tio n myo c a rdia l infa rc tio n

(disorder)) is present in both the “Acute Myocardial Infarction (AMI)” Grouping Value Set and the "STEMI Exclusions” Grouping Value

Se t. I f a use r do c ume nts a re sult tha t's c o de d with 401314000, it will q ua lify fo r b o th re sult a ttrib ute s, ye t the me asure lo g ic indic a te s the y sho uld b e mutua lly e xc lusive . Ca n yo u c o mme nt o n this disc re pa nc y?

33

SLIDE 34

Answe r

T

he initial po pula tio n ide ntifie s pa tie nts with a prima ry dia g no sis o f Ac ute Myo c a rdia l I nfa rc tio n (AMI ) using the AMI Gro uping Va lue Se t (2.16.840.1.113883.3.666.5.3011).

T

he de no mina to r na rro ws the po o l o f c a se s thro ug h the E CG re sult o f a n a c ute o r e vo lving MI using the Ac ute o r E vo lving MI Gro uping Va lue Se t (2.16.840.1.113883.3.666.5.3022).

Ne xt, the lo g ic e nsure s the E

CG did no t inc lude no n- ST E MI c o de s fo und in the ST E MI E xc lusio ns Gro uping Va lue Se t (2.16.840.1.113762.1.4.1045.36).

I

f a ST E MI e xc lusio n c o de is ide ntifie d, the lo g ic sto ps e xe c uting a nd the c a se is no t inc lude d in the me a sure po pula tio n.

34

SLIDE 35

AMI 8a c hange s for 2017

Re mo ve d E

D visit fro m the I nitia l Po pula tio n

Re pla c e d 'Ordina lity: Prima ry Pro c e dure ' with first (prima ry) PCI

pro c e dure

Re mo ve d Prima ry Pro c e dure va lue se t

(2.16.840.1.113762.1.4.1111.12)

Re mo ve d Oc c urre nc e A fro m Me dic a tio n Administe re d:

F ib rino lytic T he ra py

Cha ng e d timing fo r 'Oc c urre nc e A o f E

nc o unte r, Pe rfo rme d: E me rg e nc y De pa rtme nt Visit' to 'starts during‘

Corrected variable name to '$ReasonForNoPCI‘
E

xte nde d o pe ra to rs to 'sta rts b e fo re o r c o nc urre nt with sta rt o f' a nd 'e nds b e fo re o r c o nc urre nt with sta rt o f' fo r the T ra nsfe r F ro m sta te me nts

Re pla c e d Dia g no sis, a c tive with the re -specified ‘Diagnosis’

da ta type

Cha ng e d va lue se ts to re fle c t te rmino lo g y upda te s

35

SLIDE 36

R e sourc e s Me asur e Spe c ific ations (e CQM L ibrar y):

https:/ / www.c ms.g o v/ re g ula tio ns-a nd- g uida nc e / le g isla tio n/ e hrinc e ntive pro g ra ms/ e c q m_lib ra ry.html

Joint Commission R e por ting R e quire me nts:

https:/ / www.jo intc o mmissio n.o rg / pe rfo rma nc e _me a sure me nt.a spx

e CQI Re sourc e Ce nte r – E H Me asure s:

https:/ / e c q i.he a lthit.g o v/ e h

36

SLIDE 37

R e fe r e nc e s

Bro die BR, Stuc ke y T

D, Wa ll T C, K issling G, Ha nse n CJ, Munc y DB, e t a l. I mpo rta nc e o f time to re pe rfusio n fo r 30-da y a nd la te surviva l a nd re c o ve ry o f le ft ve ntric ula r func tio n a fte r prima ry a ng io pla sty fo r a c ute myo c a rdia l infa rc tio n. J Am Co ll Ca rdio l. 1998;32:1312-9.

De L

uc a G, Surya pra na ta H, Otte rva ng e r JP, Antma n E

M. T

ime de la y to tre a tme nt a nd mo rta lity in prima ry a ng io pla sty fo r a c ute myo c a rdia l infa rc tio n: e ve ry minute o f de la y c o unts. Circ ula tio n 2004;109(10):1223-1225.

37

SLIDE 38

R e fe r e nc e s (Continue d)

L

e vine GN, Ba te s E R, Bla nke nship JC, Ba ile y SR, Bittl JA, Ce rc e k B, e t a l. 2011 ACCF / AHA/ SCAI g uide line fo r pe rc uta ne o us c o ro na ry inte rve ntio n: a re po rt o f the Ame ric a n Co lle g e o f Ca rdio lo g y F

unda tio n/ Ame ric a n He a rt Asso c ia tio n T

a sk F

rc e
n Pra c tic e Guide line s a nd the So c ie ty fo r

Ca rdio va sc ula r Ang io g ra phy a nd I nte rve ntio ns. J Am Co ll Ca rdio l. 2011;58:e 44-122.

O'Ga ra PT

, K ushne r F G, Asc he im DD, Ca se y DE , Jr, Chung MK , de L e mo s JA, e t a l. 2013 ACCF / AHA g uide line fo r the ma na g e me nt o f ST

e le va tio n

myo c a rdia l infa rc tio n: a re po rt o f the Ame ric a n Co lle g e o f Ca rdio lo g y F

unda tio n/ Ame ric a n He a rt

Asso c ia tio n T a sk F

rc e o n Pra c tic e Guide line s. J Am

Co ll Ca rdio l 2013;61:485-510.

38

SLIDE 39

L ive Q&A

39