SBAR: NCDR Registries Initiation and Feedback Phase Title: NCDR Registries CECCV-36 Situation: Less than ~76% of TH procedure sites belong to NCDR Registries. Background: Registries ensure evidenced-based cardiovascular care; improve patient outcomes and lower health care costs. TH system office contracted for ereports (corporate level data for all sites reporting) in the Fall 2017. Assessment: An assessment of the current NCDR reports indicated the following: ~Incomplete participation in registries. ~Incomplete data to improve care. ~Lack of "systemness" and standardization. A survey of TH ministries was completed to understand the current deployment of five registries and variation was found to exist. Recommendation: Require all programs who perform procedures to participate in the NCDR registries for those procedures (excluding PVI but including STS registry for heart surgery) Specifically: AFib, CathPCI, ICD, LAAO and TVT References/ Citations: NCDR Use Within Trinity Health presentation Final Decision and Action Planning Phase CEC Decision for Implementation: 1. Final Decision is to require all programs that perform procedures to belong in the NCDR registries for those procedures. 2. Regional ICLT is responsible for communicating the decision to their functional teams and areas. Those ministries without registries are to begin budget planning to support the standard registry deployment. 3. CEC to review Master NCDR Corporate List January 2019. Teams Actions When CMO Support budgetary efforts to join NCDR registries Per ministry financial cycle for FY20 plan. CNO Ensure personnel to cover registry input for increased reporting Per ministry financial cycle for FY20 plan.
Informatics Quality System RDG teams to collaborate with Epic to support all NCDR registries Quality leaders work closely with functional procedure areas to support additional registries By January 1st Per ministry financial cycle for FY20 plan. Submitted by: Mary Lynn MacKool, Director CV CEC; Stephen Rosenblum, Medical Director CV CEC CEC/CLG/CSG: CEC Date October 1, 2018
NCDR Use Within Trinity Health Stephen Rosenblum MD FACC Medical Director, CV Services Trinity Health April 3, 2018
2500 hospitals > 2000 cardiologists 50 million+ clinical records
Metrics statistically compared nationally Granular data on procedural, demographic, and outcomes metrics 2018 Trinity Health 21
Metrics statistically compared within system
Multiple uses for registry data Quality Appropriateness/Compliance Elimination of unjustified variation Guidance for clinical transformation and decision making Improving clinical and cost outcomes Research You Can t Fix What You Don t Measure 2018 Trinity Health 23
Trinity Health NCDR Issues 2018 Trinity Health 24
Lack of Full Participation Name Disease or Device National Registry Sites TH Procedure Sites TH Registry Sites CathPCI Percutaneous coronary interventions Diagnostic catheterizations 1,730 38 29 ICD Implantable cardioverter defibrillators 1,872 35 27 ACTION Acute coronary syndrome STEMI and NSTEMI 1,084 93? 17 PVI Carotid artery revascularization Lower extremity 218 35 1 STS/ACC TVT Transcatheter Valve Therapy 290 13 13 LAAO Left atrial appendage occlusion 350 7 5 AFib Ablation Atrial Fibrillation Ablation 75 32 3 LAAO & TAVR required for Medicare reimbursement
Lack of consistent processes Staffing Training Abstracting Uploading data to registries Data validation Quality improvement processes 2018 Trinity Health 26
Recommendations: 1. Require all programs who perform procedures to participate in the registries for those procedures, including STS registry for heart surgery, but excluding PVI registry 2. Form an ad hoc Subject Matter Expert (SME) team to consider and make recommendations regarding best practices for CV registries including topics such as requiring participation in ACTION registry 2018 Trinity Health 28
NCDR Summary Recommendation Require all programs who perform procedures to participate in the NCDR registries for those procedures (including STS registry for heart surgery but excluding PVI) Require a local quality program at each Ministry to track registry data and improve care Form an ad hoc SME Team to consider and make recommendations regarding best practices for CV registries including topics such as: Require all programs participate in the ACTION acute MI registry Specific Vote or CEC Actions Needed Vote Vote Vote Measure of Success Endorse requirement 100% participation by July 1, 2019 realistic goal? TH currently at ~83% Endorse requirement All 4 quarters reported on annual basis Team formation by July 31, 2018