NCDR CathPCI Registry Tools That Work H. Vernon (Skip) Anderson, MD, FSCAI, FACC

 H. (Vernon) Skip Anderson, MD, FSCAI, FACC ◦ No COI or RWI information to report  Barbara Christensen, MSHA, RN, CPHQ, AACC ◦ No COI or RWI information to report

The SCAI Quality Improvement Toolkit was developed with support from founding supporter Daiichi Sankyo, Inc. and Lilly USA, LLC and AstraZeneca. The Society gratefully acknowledges this support, while taking sole responsibility for all content developed and disseminated through this effort.

Improve the quality of cardiovascular patient care by providing information, knowledge and tools; implementing quality initiatives; and supporting research that improves patient care and outcomes.

 Voluntary national data registry system assisting hospitals (and physicians) with the ability to measure, understand, and improve quality of cardiovascular care.  Providing risk-adjusted outcomes and other process measures to participants.

CathPCI Registry™ ICD Registry™ CARE Registry™ ACTION – GWTG IC 3 IMPACT

1999 National benchmark pdf reports 2011 CathPCI Registry Dashboard for Executive Summary Metrics 2012 ACTION–GWTG ICD Registry Dashboards 2013 Physician Level Dashboard Launch Q2

As of August 2013, individual physician data are available for review by physicians themselves; includes data from all submitting institutions where a physician practices.

Physicians should periodically review the new NCDR CathPCI Registry Physician Dashboard: (1) Ensure your data are being accurately documented and abstracted; (2) assess your quality of care; (3) identify opportunities for improvement.

 Powerful new tool for invasive/interventional cardiologists for self-improvement in the quality arena and worthy of the time and effort to review.  Significantly increase engagement in cath lab quality improvement efforts at the “grassroots” level.  Accountability and quality of outcomes. Highly relevant for all interventionalists.

 Confidential individual comparisons to CathPCI Registry physicians as a whole.  Individuals can compare their own data with national data.  Quality improvement will be enhanced at an individual as well as institutional level.  Additional value: Maintenance of Certification (MOC IV) Performance Improvement Modules (PIM’s) for ABIM certification/recertification.

 Demonstrate how to access the Dashboard.  Identify data incorporated your Dashboard.  Discuss the measures and metrics included.  Discuss the functionality of the Dashboard.  Identify resources for assistance.

 First, you must update your “Member Profile” with NPI number, click “Verify” and “Update Account.”  Select “NCDR Physician Dashboard” under “Lifelong Learning and MOC” on Cardiosource.  If you are denied access because NPI number has not been verified, consider logging out and then back in to Cardiosource. Pop-up blocker must be off.  You must be a paid member of ACC to access the Physician Dashboard.

 Any four consecutive quarters in rolling fashion.  Institutions can be selected individually or aggregated.  Data in five key areas: Volume Summary, Quality Metrics, Outcome Metrics, AUC Metrics, Resources.  Whisker plots compare individual to national benchmarks in a detailed multipage analysis that can be downloaded as PDF or Excel file.

 Incidence of non-obstructive CAD (elective patients)  Proportion of patients with prior positive stress or imaging study.  Median time to PCI for STEMI patients (in minutes).  Proportion of STEMI patients receiving immediate PCI within 90 minutes.

 Median fluoroscopy time.  Post-procedural complications and length of stay analysis.  Adherence to guideline recommended discharge medical therapy, such as DAPT, statins, etc.

 Proportion of diagnostic cath procedures with major vascular injury/bleeding.  Proportion of PCI procedures with MACE.  Proportion of PCI procedures with emergent CABG.  Observed/Expected mortality analysis, in both STEMI and NSTEMI patients.

 Proportion of PCI procedures categorized as Appropriate, Uncertain, and Inappropriate.  Analyzed for both ACS and Non-ACS patient populations.  Proportion of PCI procedures judged not classifiable for AUC reporting.

Currently: 1.Physician Dashboard: Guide for Physicians 2.Physician Dashboard: Guide for Cath/PCI Registry 3.Participants (institutions) 4.Other resources will be added

Q: What if I practice at more than one hospital? A: The option to select your hospital is available at the top of the page.

Q: What if errors in the data are found? A: The physician should work with the Registry Site Manager (at your site) to identify and correct errors. It is acceptable to resubmit data to correct erroneous information.

Q: Is it possible to ‘drill down’ to the patient level? A: No; it is not possible to drill down to the patient level on the physician dashboard. Your Registry Site Manager can assist you with identifying specific patients via the Hospital Dashboard.

Q: How often is the physician dashboard updated? A: Quarterly

 Physician specific and Confidential.  Data are NOT publically reported.  Comparison group: all CathPCI Registry physicians.  Over 40 metrics included.  Assists MOC Part IV Self Eval. Practice Performance.

 Powerful new tool for self-improvement.  Worth the time and effort to review periodically.  Other parameters that may have relevance may be tracked in the future.  Healthcare delivery increasingly emphasizes accountability, quality measures, and outcomes; so this tool will have the highest relevance.

 Registry Site Manager (RSM) ◦ Additional access given by RSM  NCDR recommends the following have access ◦ Medical Director ◦ CV Administrator(s) ◦ Data abstractors ◦ Other essential staff

 On NCDR.com  Via secure log-in  Registry specific (CathPCI, ICD, etc.)  Under the Dashboard tab

Executive Summary Detail Section

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How do I get more assistance? Can’t log in? Contact: ACC Resource Center (800) 253 – 4636 (X 5603) Need help interpreting the Metrics? Contact Your Registry Site Manager Or contact: NCDR (800)

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