Implantable Cardioverter Defibrillator: Overview of the NCDR Data Methodology Christie Lang, RN, MSN Associate Director, ICD Registry American College of Cardiology Heart Rhythm Society Conference San Francisco, California May 15, 2008

Objectives Review the development process of an NCDR Registry Product Understand NCDR committee structures Provide update regarding V2.0 Leads and Peds.

National Cardiovascular Data Registry NCDR is initiative of the American College of Cardiology with partnerning support from many societies, for the ICD Registry: Heart Rhythm Society. NCDR mission is to improve the quality of CV patient care by providing information, knowledge and tools, implementing quality initiatives; and supporting research that improves patient care and outcomes.

Uses of NCDR Data Registries –Quality Improvement Measure/manage individual patient care Study, develop and monitor care processes Track outcomes of care. Assess hospital and provider performance –Public Reporting Quality-base payment Certification & privileging, meet regulatory needs –Post Market Surveillance & Clinical Trials –Influence Clinical Practice Guidelines

NCDR Management Board Scientific Oversight Committee Research & Publications Clinical Supp.Team SteeringCommittee Registries CathPC I Registr y CARE Registr y ICD Registr y Committee Structure for each Registry Includes 30day outcomes ACTIO N Registr y IC3 Steering Committee Registry Projects ACHIEVE Steering Committee ICD Longit. Steering Committee TAKE ACTION Planning Work Group QI Projects D2B Project managed through ACTION and PCI Steering committees ambulatory longitudinal Committee Structure and Project Summary Over 130 of our nations CV Outcomes experts involved

Governance: NCDR Management Board Each NCDR Registry is governed by NCDRs Management Board and a committee structure that provide oversight and direction dedicated to its mission. NCDR Management Board provides oversight and direction for NCDR activities, which include: –Accountability for financial performance, –Accountability for the quality of the Registry products and services. –Review and approval of Registry policies and strategic and operational plans, –Advocate, promote and influence key groups regarding the Registrys activities; and –Set the high level agenda for the NCDR within the ACC community.

The ICD Steering Committee shall provide scientific and clinical support to the development of the National ICD Registry. Their tasks include the following: –Identify and approve list of quality indicators reported to participating institutions as well as CMS. –Identify data elements /definitions needed to calculate selected quality indicators and enhance the utility of the registry. –Determine appropriate report content and display format. –Provide guidance in developing content for training manuals. –Assist in providing relevant and consistent answers to user questions on data elements. Research & Publications Clinical Supp.Team SteeringCommittee Committee Structure for each Registry

Governance: ICD Steering Committee The Steering Committee consists of a chair and 6-8 members including 2 ACC representatives, 2 HRS representatives, and one biostatistician specializing in cardiovascular care. Stephen Hammill, MD, FHRSChair Ralph Brindis, MD, MPH, FACCMember Alan Kadish, MD, FACCMember Mark Kremers, MD, FACCMember Bruce Lindsay, MD, FACCMember Michael Mirro, MD, FACCMember Martha Radford, MD, FACCMember Lynne Warner Stevenson, MD, FACCMember Joel Harder, MBALiason:HRS Christine Lang, RN, MSNLiason:ACC

It Takes a Team! How many people are involved prior to an NCDR Registry product launch? Staff Working Group External Peer reviewers α-testers Β-testers CSO CMO Registry Steering Committee Data Set Registry Product Vendors Staff Science oversight Committee Launch

ICD Registry V1.08 Product Development ScientificDevelopment Technical Development Testing Tool Release IT Application Development & Testing Alpha Pilot Maintenance Launc h CharterDevelopment Each Registry develops a Charter that provides: PurposePurpose Business CaseBusiness Case Project OverviewProject Overview Goals and ObjectivesGoals and Objectives BudgetBudget Stakeholder IdentificationStakeholder Identification Milestone ScheduleMilestone Schedule Project AssumptionsProject Assumptions Project ConstraintsProject Constraints RisksRisks Source DocumentsSource Documents Document Version HistoryDocument Version History

During Scientific Development Phase: Steering Committee reviews list of key outcomes measures, clinical questions, etc to be reported: ICD Registry was developed as part of CED by CMS to determine if patients receiving ICDs in the general population (real world) were comparable to patients enrolled in the randomized clinical trials of ICD therapy? Specifically were the Patients, hospitals, indications, complications, and outcomes comparable to the studies Scientific Development Scientific Development MEASUREMENT IS KEY!

Scientific Development: Data Elements 1.Based on Hypothesis and Executive Summary Metrics establish preliminary list of data elements for registry inclusion 2.Use existing Clinical Data Standards. ICD Registry data elements are derived from ACC/AHA Electrophysiology Data Standards. 3.Review clinical trials, practice guidelines, performance measures, existing registries 4.Include fields for patient, device, facility and provider information, disease process. Scientific Development

ICD Registry Key Outcomes Measures: Incidence of Lead Dislodgement Scientific Development

Dataset review, recommendations and approval: Alpha testers Steering Committee Science Oversite Committee Chief Medical Officer Chief Science Officer Scientific Development Scientific Development

ICD Registry V1.08 Product Development Timeline ScientificDevelopment TechnicalDevelopment Testing Tool Release IT Application Development & Testing Alpha Pilot Maintenance Launc h CharterDevelopment

Technical Development: Data Collection Tool Map dataset against current NCDR registries for consistency of key core data elements Format data elements in consistent sections –Patient demographic –History/risk factors –ICD Procedural information –Medications –Device –Adverse Events –Discharge Technical Specifications created Technical Development

Technical Development – data dictionary Technical Development

Online data collection tool features include: Access from any web browser Submit data to the NCDR Data completeness reminders Online data collection tool features include: Access from any web browser Submit data to the NCDR Data completeness reminders

Data Collection Hospital collects and submits to DQR Successfully submitted data is analyzed Data is pooled for many uses Algorithms are used to combine data for participants reports and other uses Data is returned to Hospital as an Outcome Report

ICD Registry V1.08 Product Development Timeline ScientificDevelopment TechnicalDevelopment Testing Tool Release IT Application Development & Testing Alpha Pilot Maintenance Launc h CharterDevelopment

Testing Alpha Testing Pilot testing of the form Assessing flow of form in practice Feasibility of data collection Comprehension of data elements and definitions in practice Beta Testing Vendor certification Usability Check Feasibility Check Consistency Check Testing

ICD Registry V1.08 Product Development Timeline ScientificDevelopment TechnicalDevelopment Testing Tool Release IT Application Development & Testing Alpha Pilot Maintenance Launc h CharterDevelopment

Release Training and Roll out needed: Webinars, Training Manuals, FAQs developed. Client and Contract support for Participants. Software Vendors go thru intensive certification process. Medications and devices tables are up to date and subject for review as needed Tool Release

ICD Registry V1.08 Development Timeline ScientificDevelopment TechnicalDevelopment Testing Tool Release IT Application Development & Testing Alpha Pilot Maintenance Launc h CharterDevelopment

Maintenance Phase- Evaluation Quarterly Outcome Reports Participant FAQs for clarification Feedback from Committees –Steering Committee –Research and Publications Committee Metric change Literature Review Guideline Recommendations Maintenance Is it Time for a Revision?

Enhancements needed for V 1.08 Specific data element oversights –Long QT, HCM etc Pulse generator focused –No lead information except CS lead placement Medicare primary prevention focus –Secondary prevention, non-Medicare –Pediatric

Coming Soon! Version 2.0: Peds and Leads The ICD Registry Working Group met bi- weekly for the past year to revise the data collection form. May 07: Working Group met with the FDA to begin discussion to incorporate Leads. November 07 at AHA ICD Registry Working group met with PACES (Pediatric and Congenital Electrophysiology Society ) and the FDA to incorporate Pediatrics and Leads in to the ICD Registry. Version 2.0 launch scheduled mid 2009.

Coming Soon! Version 2.0: Peds and Leads Includes pediatric patients receiving ICDs Data will provide insight on pediatric SCD and ICD impact Adding Leads will clarify the benefits, risks and performance of this technology in adults and pediatric patients.

Version 2.0: Leads and Pediatrics Data to be collected will include: Atrial, ventricular, defibrillator, and left ventricular leads at the time of implantation, revison, replacement and removal. This will improve lead surveillance following implantation. Lead ID Lead Data Lead Location Lead Placement Issues Lead Function Issues Lead Integrity Issues

Maintenance Phase- Audit The purpose of the Data Quality Program is to ensure that data submitted to the NCDR are complete, consistent, and accurate ultimately to improve the overall quality of the Registry. For a participants data submission to be included in national and peer group benchmarks, the submission must pass all composite category inclusion thresholds of completeness established in the threshold reports. This report presents the threshold results for all core elements, as well as the number of unique records, % valid and invalid values, as well as missing values. Inclusion threshold criteria were chosen for their clinical and structural pertinence. Maintenance

Maintenance Phase- Audit Onsite Auditing will begin % Hospitals will be randomly selected for the audit to compare the data entered into the Registry with the original patient data in the hospital record system. Also, auditing will include selected hospitals where the data is inconsistent. Examples of inconsistent data will include hospitals reporting no complications or reporting an MD as board certified in EP who is not listed with the ABIM Each hospital will receive a confidential audit report which displays their audit score and individual accuracy for each element. Maintenance

Take Home Message Process is long, thorough, but 100% guided by science. Incredible teamwork needed for ultimate success. Your feedback and involvement is the key to its success!

THANK YOU