ACTION Registry-GWTG New User Training Webinar February 7,2013

Purpose of ACTION Registry-GWTG National surveillance system for high-risk AMI patients admitted with STEMI/NSTEMI: Assess characteristics, treatments, and outcomes of this patient population Optimize outcomes and management of AMI patients through implementation of ACC/AHA evidence-based guideline recommendations in clinical practice Facilitate efforts to improve quality and safety of ACS patient care; and investigate QI methods

The History: ACTION Registry-GWTG ACTION Registry transitioned from CRUSADE and NRMI Registries January 2007 ACTION was established May 2008 ACTION merged with AHA GWTG CAD to become ACTION Registry-GWTG Current membership of 800 Hospitals 500,000 records submitted CRUSADE- How risk stratification affected outcome

Data Collection Options Web-Based Data Capture Secure, password-protected data entry system Free NCDR data collection tool Interoperability from Cath/PCI Registry to ACTION Vendor-Based Data Capture Data submitted via encrypted, password-protected file Interoperability between ACTION and Cath/PCI Registry

www.ncdr.com Participant Log In

The ACTION Registry-GWTG Webpage

Call the American Hospital Association 1-800-424-4301

The Dashboard eReports Comparator Standard Reports Executive Summary Metrics “Drill Downs” Define peer groups Facility attribute filters

Technical Data Dictionary

Outcomes Report Companion Guide

Inclusion Population Acute Myocardial Infarctions-STEMI & NSTEMI Patient must present to 1st Facility with symptoms of ACS, within 24 hours of arrival Patient must have positive ECG- ST elevation, new LBBB, or documented Posterior MI OR Positive Biomarkers- Troponin or CK-MB within 24 hours of arrival Transfer In patients- STEMI must arrive within 72 hours, NSTEMI within 24 hours If presents with any other symptoms, or procedures, the patient is excluded

Choosing the Correct Form Premier Form or Limited Form Every Hospital Has The Option To Use Either Form

ACTION Registry-GWTG Premier Form Complete quarterly Outcome Report for benchmarking Report on 17 Core Performance Measures Report on 12 Quality Metrics Sites are Eligible for Higher Level of Recognition Program

ACTION Registry-GWTG Limited Form 50% of full ACTION data set Limited quarterly Outcome Report for benchmarking Report on 17 Core Performance Measures Report on 7 Quality Metrics Lower level of Recognition

Limited Form: Pros and Cons Fewer Data Elements Less time required for data abstraction and entry Accommodating for Non PCI Centers Great form for new sites to start Cons No Excessive dosing Reports for Anticoagulants Lower Level of Recognition Limited Quarterly Outcomes Report Not all the metrics are included

Premier Form: Pros and Cons Detailed Quarterly Excessive Dosing Reports for Anticoagulants Higher level of Recognition Robust Data Set Full Quarterly Outcomes Report Cons More time required for data abstraction and entry Answering fields that are less likely to pertain to Non-PCI Centers

Demographics

Cardiac Status & History

Medications

Anticoagulants

Procedures

Reperfusion Strategy

Clinical Events & Biomarkers

Labs

Discharge

Section K- Optional Elements

Data Quality Reports (DQR)

Data Quality Reports (DQR) A way of checking the quality of your data It looks for data errors and completeness Passing ensures well-formed data Data must pass DQR to be included in the Outcomes Report Submit as you enter data through the quarter What is the DQR? It is a process that provides you with a data quality report. The Data Quality Report is the NCDR’s way of checking the quality of the patient data that your site has submitted. It is a series of checks that include, checking the data for errors, and assessing the completeness of the data. If your data has errors or has too many incomplete elements, then you will be required to make the corrections, and then resubmit the data until you have passed the DQR. Passing the DQR ensures well-formed data, and a statistically significant submission. Data that passes the DQR is used to create your Institutions Outcomes Report.

Data Assessment Results You get to this screen. The first column is the patient ID #, then the Other ID, if you use that element in the data collection tool. The 3rd column is the patients name, and arrival date to follow. The 5th column is the Error Type, which we will go into detail about in a moment. To evaluate the error, you will read through the Description column. In the first example above, the site documented “yes” to a stent, #7105, but had entered “no” to PCI, # 7100. The patient would have had to have gone to the cath lab for a PCI, in order to have had a stent placed. You will then go into your tool, for that patient, and correct either the PCI “yes” or remove the Stent “yes”. Clicking on the Number (#7105 in this example), is a hyperlink, and will provide you the Data Definition for that measure, to assist you in evaluating what correction is needed.

Failed Completeness Assessment So for a simpler example you can see there are 3 Core Composite elements that need corrections. There are no Supporting Composites that need corrections. You can see the list of Elements that have errors that will need to be addressed. This view is set up in columns of Sequence #, the type of composite, the element name, and the break down of how many times that element should have been answered, how many times it was answered, how many times the answer was missing, then how many times the answer is required to be answered (based in the elements threshold). So for this example you can see that Hispanic or Latino Ethnicity had 5 occurrences, with none of the elements answered, the report is telling you that you must complete 4 of the 5 missing fields, which would be an 80% threshold for that individual element.

ACTION Registry-GWTG National Data Slide Sets Produced every 6 months

Use of Reperfusion Therapy for STEMI Not Eligible for Reperfusion Therapy Contraindication Listed N= 2,866 (13%) No Reperfusion – No Contraindication Listed N = 1272 (6%) Primary PCI – 86%* Fibrinolytics – 13%* Both PCI + Lytics – 1%* 93% of eligible patients reperfused ACTION Registry-GWTG DATA: July 1, 2008 – June 30, 2009 * Among patients receiving reperfusion

ACTION Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients 250 240 236 230 220 223 215 212 210 200 190 180 170 169 160 158 151 156 150 Time (min) 140 130 123 120 120 116 110 103 113 102 100 96 95 90 79 80 78 75 70 74 62 60 60 57 57 50 40 30 20 10 Q1 07 Q2 07 Q3 07 Q4 07 Transfer in DTB Times Non-Transfer in DTB Times

STEMI Door-to-Balloon Times – Median Times for Transfer In and Non-Transfer In Patients 250 240 230 220 210 200 190 182 180 170 165 160 157 150 150 Time (min) 140 130 130 123 120 120 117 110 100 102 88 97 96 94 90 84 82 79 80 70 70 67 66 64 D2B 20% decrease D2B tx in 31% decrease No one is under 90 minutes 60 50 53 52 51 50 40 30 20 10 Q1 08 Q2 08 Q3 08 Q4 08 Transfer in DTB Times Non-Transfer in DTB Times

STEMI – Door to Balloon and Door to Needle Times: Cumulative 12 Month Data ACTION Registry-GWTG DATA: July 1,2008 – June 30, 2009 DTB = 1st Door to Balloon for Primary PCI DTN = Door to Needle for Lytics

NSTEMI Acute Medication Overdosing Trends * Infusion (> 15 units/kg/hr) or bolus (> 70 units/kg) # Initial dose (> 1.05 mg/kg) or total 24 hr dose (> 10 mg over recommended) ACTION Registry-GWTG DATA: July 1, 2008 – June 30, 2009

Quarterly Outcomes Reports

Composite Measure

Composite Measure Overall AMI Performance Graph

Performance Measures Acute/In-hospital Measures Aspirin Arrival STEMI - Any reperfusion (PCI or Lytic) STEMI - Lytic -Door to Needle (Median Time and % <30min) STEMI - PCI – D2B (Median Time and % <90min STEMI - D2B Transfer in (Median Time) LVSD Evaluation Discharge Measures Aspirin B-blocker ACE or ARB (EF <40%) Statin for LDL ≥100mg/dL Smoking cessation (among smokers) Cardiac rehabilitation 52 52

Performance Measure Graph: Aspirin at Arrival

Quality Metrics ACTION Metrics Door to EKG (within 10 min) STEMI- Acute ADP Receptor Inhibitor Therapy within 24 hours of arrival_ Revascularized Patients Discharged on ADP Receptor Inhibitors ADP Receptor Inhibitors Prescribed at Discharge for Medically Treated Patients LDL assessment (in-hospital) NSTEMI - Excessive Initial UFH Dosing (>70 U/kg bolus, >15 U/kg/min infusion Excessive Initial Enoxaparin Dosing (SQ >1.05 mg/kg) Excessive Initial GP IIb/IIIa Dosing (Full doseTirofiban if CrCl<30& Full dose Eptifibatide CrCl <50, or dialysis with either) STEMI - Anticoagulant- UFH, enoxaparin, bivalarudin or fondaparinux (first 24 hours) Aldosterone Blocking Agents at Discharge(EF<40%, with DM, or HF)

ACTION Registry-GWTG Recognition Program

Recognition Criteria Patient Volume 10 NSTEMI within each quarter; and/or 10 STEMI within past quarter Must maintain uninterrupted data submission for Q1 – Q4 90% compliance

Recognition Thresholds Award Levels Must meet compliance on composite measures Participate in Platinum 90% compliance >= 8 consecutive quarters entering data Premier Gold Premier or Limited Silver 90% compliance >= 4 consecutive quarters entering data

Criteria for STEMI’s STEMI composite: ASA on Arrival DTN<=30 minutes DTB<=90 minutes) discharge ASA discharge beta-blocker,            discharge ACE-I/ ARB (ideal patients) discharge statin (exclude if contraindicated or LDL<100mg/dl and not discharged on statin) smoking cessation counseling, cardiac rehabilitation,   

Criteria for NSTEMI’s NSTEMI composite: ASA on Arrival discharge ASA discharge beta-blocker                                    discharge ACE-I/ ARB (ideal patients) discharge statin (exclude if contraindicated or LDL<100mg/dl and not discharged on statin)             smoking cessation counseling cardiac rehabilitation

Thank you for your participation in (800) 257-4737 or email ncdr@acc.org Thank you for your participation in ACTION Registry-GWTG! 60