executive summary measures and metrics companion guide

Executive Summary Measures and Metrics Companion Guide

The mission of the NCDR® is to 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.

The NCDR® is an initiative of the American College of Cardiology Foundation, with partnering support from the Society of Cardiovascular Angiography and Interventions for the CathPCI Registry.

CONFIDENTIALITY NOTICE This document contains information confidential and proprietary to the American College of Cardiology Foundation. This document is intended to be a confidential communication between ACCF and participants of the CathPCI Registry and may involve information or material that may not be used, disclosed, or reproduced without the written authorization of the ACCF. Those so authorized may only use this information for a purpose consistent with the authorization. Reproduction of any section of this document with permission must include this notice.

of 50 ©2018 by American College of Cardiology Foundation Author: K. Lavin & C. Anderson Updated: May 18, 2021 Confidential – Not for Release.

Contents:

Overview ........................................................................................................................ 3

Frequently Used Terminology ............................................................................................ 3

Metric Specifications Explained.......................................................................................... 4

Retired Metrics............................................................................................................... 5

Specifications for Executive Summary Measures and Metrics .................................................6

Section I: Performance Measures............................................................................ 6

Section II: Quality Metrics .................................................................................. ..10

PCI – Process Metrics ................................................................................. 10

PCI – Outcome Metrics ............................................................................... 22

Diagnostic Coronary Angiography – Process Metric ........................................ 29

Diagnostic Coronary Angiography – Outcome Metric ...................................... 30

Efficiency Metrics ...................................................................................... 31

Section III: Appropriate Use Criteria (AUC) Metrics .................................................. 34

Risk Models ................................................................................................................... 41


Overview

The CathPCI Registry Institutional Outcomes Report provides detailed analysis of a hospital’s individual

performance in relation to the entire registry population. This gives insight in to care variations and

quality improvement opportunities. The report provides the opportunity to compare hospital practice

patterns to NCDR benchmarks.

Frequently Used Terminology

R4Q (Rolling Four Quarters)

The four (4) consecutive quarters included in the report. (Example: The 2018Q1 report includes 2017Q2, 2017Q3, 2017Q4 and 2018Q1. The “Q” in “R4Q” indicates the last quarter of the rolling four quarters).

Benchmark Inclusion Status

Indicates whether a submission will be included in the R4Q aggregated data (benchmark) and comparison group statistics. “Green”, “Yellow” and “Red” stoplights denote the status.

Green status A “Green” status indicates the submission (one quarter/timeframe) is included in the benchmark and comparison group statistics. The data has successfully passed all data assessment and completeness checks.

Yellow status A “Yellow” status indicates the submission (one quarter/timeframe) is not included in the benchmark and comparison group statistics. Data is displayed in the quarterly column but is not included in the “My Hospital R4Q” summary. The data has not passed the overall completeness assessment checks.

Red status A “Red” status indicates the submission (one quarter/timeframe) is not included in the benchmark or comparison group statistics. Data is not displayed in the quarterly column.

Null status A null or blank status indicates no submission has been received for that quarter/timeframe. Data is not displayed in the quarterly column.

My Hospital R4Q The values for a metric/measure (over R4Q) of data submitted by your facility with a Benchmark Inclusion status of “Green”.

All Hospital 50th Pctl The median (or midpoint or 50th percentile) of all participants’ aggregated data for the metric or measure. Half of all participants will be above the median, and half will be below. This value will correspond to the midpoint of the box/whisker plot.

All Hospital 90th Pctl The 90th percentile of all participants aggregated for the metric or measure. 10% of all participants will be above the 90th percentile value, and 90% will be below. This value will correspond to the right-most endpoint of the box/whisker plot.

Data Quality Report The online system used to check that data are well formed and complete. Data must first be submitted to the Data Quality Report (DQR) to be included in the Outcomes Report.

Registry Aggregate Benchmarking data that includes all registry participants who submitted complete data.

My Hospital Aggregate The total number of procedures performed over a R4Q period. This is adjusted for the number of quarters in which valid submissions were received during the R4Q period.

Volume Group A grouping of sites with similar annualized procedure volumes.

Volume Aggregate The total number of procedures performed over the R4Q period within the volume group.


Metric Specifications Explained Numerator: Count of patients/procedures who meet the processes or outcomes expected for each patient, procedure, or other unit of measurement defined (e.g. PCI patients who received aspirin at discharge). Denominator: Count of patients/procedures who remain after denominator exceptions/exclusions are applied to the eligible metric population. Denominator Exclusions: Patients/procedures that are removed from the eligible metric population (e.g. PCI patients who received comfort measures only and are therefore not required to receive aspirin at discharge). Denominator Exceptions: Patients/procedures that have not met the metric numerator criteria and have acceptable rationale such as a medical reason or patient reason are removed from the eligible metric population. (e.g. PCI patients with a medical reason for not receiving aspirin at discharge). In this way, the metric is only considering “eligible” patients/procedures.

Median: The median is the 50th percentile (e.g. middle value for a set of data that was arranged in order of magnitude). It is less affected by outliers and skewed data. Median population: Patients/procedures who remain after population exceptions/exclusions are applied to the eligible metric population. Clinical Rationale/Guideline Recommendation: Executive summary metrics are selected based on supporting evidence, guideline recommendations or expert consensus. References to supporting documents (e.g. ACC/AHA Task Force citations) are provided for metrics as applicable. Risk Adjusted: Indicates the measure is based on a non-hierarchical risk model, which only includes patient-level risk factors. Risk Standardized: Indicates the measure is based on a hierarchical risk model, which includes both facility-level and patient-level risk factors.


Retired Metrics

7. Median fluoro time (in minutes) 11. Proportion of patients with vascular access site injury requiring treatment or major bleeding 13. Proportion of patients with post-procedure myocardial infarction (among hospitals routinely

collecting post-PCI biomarkers)

14. Proportion of patients with post-procedure myocardial infarction (among hospitals that do not routinely collect post-PCI biomarkers)

15. Proportion of patients with acute kidney injury 20. Incidence of non-obstructive CAD 23. Median post-procedure length of stay (in days) for PCI patients with no STEMI 26. Proportion of PCI procedures with biomarkers assessed post-PCI for elective inpatients 37. PCI in hospital risk adjusted rate of bleeding events (all patients)


Specifications for Executive Summary Measures and Metrics

Section I: Performance Measures Measures that are suitable for public reporting, external comparisons, and possibly pay-for-performance

programs, in addition to quality improvement. Performance measures are developed using the ACC/AHA

methodology, often in collaboration with other organizations, and include the process of public comment

and peer review.

1. PCI in-hospital risk adjusted mortality (all patients)

Description: The hospital risk adjusted mortality rate for all patients having PCI

Numerator

See risk model technical specifications – pages 41-43

Denominator

Time Period

Four consecutive quarters

Clinical Rationale/ Recommendation

Although death in patients with serious heart disease is not completely unexpected, the rate (adjusted for case mix/patient factors) is sensitive to a number of controllable factors such as case selection, procedural judgement and operator skill, as well as institutional support and overall quality of care. The NCDR™ risk adjustment model analyzes multiple elements to account for patient risk factors that are present prior to PCI. Risk adjustment “levels the playing field” among participating institutions and adjusts the “actual” mortality rate based on these factors. In other words, if you have several very sick patients die, your risk adjusted mortality rate would be lower than your actual mortality rate. If you had several very healthy patients die unexpectedly, your risk adjusted mortality rate would be higher than your actual mortality rate. Please refer to the detail section of the report and the risk adjustment technical notes for more information.

Relevant Citations

1. Brennan JM, Curtis JP, Dai D, et al., on behalf of the National Cardiovascular Data

Registry. Enhanced mortality risk prediction with a focus on high-risk percutaneous coronary intervention. J Am Coll Cardiol: Cardiovascular Interventions. 2013;6: 790-799.

2. Peterson ED, Dai D, DeLong ER, et al., for the NCDR Registry Participants.

Contemporary mortality risk prediction for percutaneous coronary intervention. J Am Coll Cardiol. 2010;55:1923-1932.

This measure has been endorsed by the National Quality Forum. Measure #0133


40. PCI in-hospital risk standardized rate of bleeding events (all patients)

Description: The hospital risk adjusted rate of bleeding events for patients having PCI

Numerator


Denominator

Time Period



Bleeding complications after PCI are associated with increased morbidity, mortality and costs. This measure is helpful in providing risk-adjusted feedback on bleeding complications, informing clinical decision-making, and directing the use of bleeding avoidance strategies to improve the safety of PCI procedures.

Relevant Citations

1. Rao SV, McCoy LA, Spertus JA, et al. An updated bleeding model to predict the risk

of post-procedure bleeding among patients undergoing percutaneous coronary intervention: A report using an expanded bleeding definition from the National Cardiovascular Data Registry CathPCI Registry. J Am Coll Cardiol: Cardiovascular Interventions. 2013;6:897-904.



38. Composite: Guideline medications prescribed at discharge

Description: Percentage of PCI patients who were prescribed all medications (aspirin, statin and/or P2Y12 Inhibitor) for which they were eligible

Numerator

• Patients with a stent placed who were prescribed* aspirin, statin and a P2Y12

inhibitor (10205) at discharge, or;

• Patients without a stent placed who were prescribed* aspirin and statin (10205) at discharge

*Patients with a medical or patient reason for not prescribing a medication will still meet the numerator IF they were prescribed all other medication(s) for which they were eligible. *Patients not prescribed aspirin but were prescribed an anticoagulant and a P2Y12 inhibitor will still meet the numerator IF they are prescribed all other medications for which they were eligible.

Denominator

Patients with PCI (7050)

Denominator Exclusions

Patients with any of the following:

• Comfort measures only (10075) • Death during hospitalization (10105) • Left against medical advice (10110) • Discharge to another acute care hospital (10110) • Discharge to hospice care (10115)

Denominator Exceptions

Medical and/or patient reason for not prescribing aspirin AND statin AND all P2Y12 inhibitors (10205) at discharge

Time Period



See individual metrics: 8, 9 and 10

Relevant Citations

See individual metrics: 8, 9 and 10


Notes: Publicly reported measure


43. High-intensity statin at discharge (UNDER REVIEW – NOT REPORTING)

Description: Percentage of PCI patients with STEMI or NSTE/ACS prescribed a high-intensity statin at discharge

Numerator

Patients who are prescribed a high-intensity statin (10207) at discharge

Denominator

PCI patients (7050) with STEMI or NSTE/ACS (7825)



• Comfort measures only (10075) • Death during hospitalization (10105) • Left against medical advice (10110) • Discharge to another acute care hospital (10110) • Discharge to hospice (10115)


• Medical or patient reason for not prescribing a high-intensity statin (10205) at

discharge, or; • Patients > 75 yo prescribed a moderate-intensity statin (10207) at discharge

Time Period



High-intensity statin therapy is associated with a reduction in atherosclerotic cardiovascular disease events such as death, recurrent MI, cerebrovascular disease, and coronary revascularization in those with known coronary atherosclerosis. (1)

High-intensity statin therapy should be initiated or continued as first-line therapy in women and men <= 75 years of age who have clinical atherosclerotic cardiovascular disease, unless contraindicated. (ACC/AHA Recommendation Class I, Level of Evidence: A). (2)

Relevant Citations

1. Jneid H, Addison D, Bhatt DL, et al. 2017 AHA/ACC clinical performance and

quality measures for adults with ST-elevation and Non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2017;70:2048-90.

2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the

treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2889-934.


Section II: Quality Metrics Metrics that support self-assessment and quality improvement at the provider, hospital, and/or health care system level.

PCI - Process Metrics

2. PCI procedures with positive stress or imaging study

Description: Percentage of elective PCI procedures for stable patients with a prior positive stress or imaging study or FFR ratio or iFR ratio

Numerator

Procedures with a positive stress or imaging study (5201, 5202, 5204) performed within 6 months (182 days) of procedure or a fractional flow reserve (FFR) ratio of <=0.8 (7512), instantaneous wave-free ratio (iFR) of <= 0.89 (7513) or any positive novel non-hyperemic measurement (7513) performed.

Denominator

Elective PCI procedures (with/without dx coronary angiography) (7050, 7800)


Procedures with any of the following:

• Cath Lab visit indication of post cardiac transplant (7400) • Cath Lab visit indication of Pre-operative evaluation (7400) and Solid organ

transplant surgery = yes (7469) • Severe Aortic Stenosis (7450, 7451) • Staged PCI (7821) • PCI status of urgent, emergency or salvage (7800) • PCI indication of STEMI (7825) • PCI indication of new onset angina <= 2 months (7825) • PCI indication of NSTE-ACS (7825)


None

Time Period



In situations where angiography reveals coronary narrowing with questionable hemodynamics, the use of invasive measurements such as fractional flow reserve (FFR) may be useful in determining the need for revascularization. An FFR of <= 0.80 is abnormal and consistent with downstream inducible ischemia. (1)

The 2017 appropriateness criteria for stable ischemic heart disease utilizes objective measures of ischemia such as stress testing in order to stratify patients into low-risk or intermediate-/high-risk findings along with intracoronary physiological testing in order to inform clinicians as to the reasonable utilization of procedures to improve symptoms and health outcomes. (2)

Relevant Citations

1. Levine GN, Bates ER, Blakenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44-122.

2. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/

ASNC/SCAI/SCCT/STS 2017 Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease. J Am Coll Cardiol. 2017;69:2212-41.


3. Median time to immediate PCI (procedures with STEMI)

Description: Median time (in minutes) from arrival (or subsequent ECG) to first device activation time of PCI procedures for STEMI procedures

Median

Median time from arrival date/time (3001) or subsequent ECG date/time (7836) to first device activation date/time (7845)

Population

PCI procedures (with/without dx coronary angiography) (7050) with an indication of immediate PCI for acute STEMI (7825)

Population Exclusions

Transferred in for immediate PCI for STEMI (7841)

Population Exceptions

Patient centered reason for delay in PCI (7850) and a time to first device activation time of > 90 minutes (7845, 3001)

Time Period



Primary PCI is the recommended triage strategy for patients with STEMI with the system goal of first-medical-contact to device time of 90 minutes or less. (ACC/AHA Recommendation Class I, Level of Evidence: B).

Early successful PCI greatly decreases the complications of STEMI that result from longer ischemic times or unsuccessful fibrinolytic therapy, allowing earlier hospital discharge and resumption of daily activities.

Relevant Citations

1. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the

management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78-140.


4. PCI within 90 minutes (patients with STEMI)

Description: Percentage of PCI procedures for STEMI with a time from arrival (or subsequent ECG) to first device activation time of <90 minutes

Numerator

Procedures with arrival date/time (3001) or subsequent ECG date/time (7836) to first device activation date/time of < 90 minutes (7845)

Denominator

PCI procedures (with/without dx coronary angiography) (7050) with an indication of immediate PCI for acute STEMI (7825)


Transferred in for immediate PCI for STEMI (7841)


Patient centered reason for delay in PCI (7850) and a time to first device activation time of > 90 minutes (7845, 3001)

Time Period



Primary PCI is the recommended triage strategy for patients with STEMI with the system goal of first-medical-contact to device time of 90 minutes or less. (ACC/AHA Recommendation Class I, Level of Evidence: B).

Early successful PCI greatly decreases the complications of STEMI that result from longer ischemic times or unsuccessful fibrinolytic therapy, allowing earlier hospital discharge and resumption of daily activities.

Relevant Citations




5. Median transfer time from door to door (patients with STEMI)

Description: Median time (in minutes) from arrival (or subsequent ECG) at referring facility to arrival at the PCI receiving facility

Median

Median time from ED presentation at referring facility date/time (7842) or STEMI noted on subsequent ECG date/time (7836) to Arrival date/time (3001)

Population

PCI procedures (with/without dx coronary angiography) (7050) transferred in for immediate PCI for STEMI (7841)


None


None

Time Period



Immediate transfer to a PCI-capable hospital for primary PCI is the recommended strategy for patients with STEMI who initially arrive at or are transferred to a non- PCI-capable hospital, with a first medical contact-to-device time system goal of 120 minutes or less. (ACCF/AHA Recommendation Class I, Level of Evidence: B).

System related reperfusion delays correlate with higher rates of mortality and morbidity.

Relevant Citations




6. Median time to immediate PCI (transfer patients with STEMI)

Description: Median time (in minutes) from arrival (or subsequent ECG) at the referring facility to first device activation time at the receiving facility

Median

Median time from ED presentation at referring facility date/time (7842) or STEMI noted on subsequent ECG date/time (7836) to first device activation date/time (7845)

Population

PCI procedures (with/without dx coronary angiography) (7050) with an indication of immediate PCI for acute STEMI (7825) and transferred in for immediate PCI for STEMI (7841)


None


Patient centered reason for delay in PCI (7850) and a time to first device activation time of > 120 minutes (7842, 7836, 7845)

Time Period



Immediate transfer to a PCI-capable hospital for primary PCI is the recommended strategy for patients with STEMI who initially arrive at or are transferred to a non- PCI-capable hospital, with a first medical contact-to-device time system goal of 120 minutes or less. (ACCF/AHA Recommendation Class I, Level of Evidence: B).

When delays for primary PCI exceed 120 minutes from first medical contact the survival advantage of primary PCI over fibrinolysis was negated.

Relevant Citations




41. Median time to PCI for in-house STEMI (NEW)

Description: Median time (in minutes) from STEMI diagnosis to treatment with PCI

Median

Median time from subsequent ECG with STEMI or equivalent date/time (7836) to first device activation date/time (7845)

Population

PCI procedures (with/without dx coronary angiography) (7050) with an indication of immediate PCI for acute STEMI (7825) and STEMI or equivalent noted on subsequent ECG (7835)


• Transferred in for immediate PCI for STEMI (7841), or,

• Subsequent ECG obtained in the emergency department (7840)


Patient centered reason for delay in PCI (7850) and a time to first activation date/time of > 90 minutes (7836, 7845)

Time Period



Treatment of patients with in-hospital STEMI is more complex and challenging than treatment of patients who develop out-of-hospital STEMI, leading to delays in diagnosis and triage and less frequent use of reperfusion therapy.

Three areas of delay in the treatment of patients who develop in-hospital STEMI that warrant particular attention are: delays in ECG acquisition, delays in ECG interpretation, and delays in activating existing STEMI systems of care.

Relevant Citations

1. Levine GN, Dai X, Henry TD, et al. In-hospital ST-segment elevation myocardial

infarction: improving diagnosis, triage, and treatment. JAMA Cardiol. 2018;3:527- 531.


8. Aspirin prescribed at discharge

Description: Percentage of PCI patients who were prescribed aspirin at discharge

Numerator

Patients who were prescribed aspirin (10205) at discharge

Denominator




• Comfort measures only (10075) • Death during hospitalization (10105) • Left against medical advice (10110) • Discharge to another acute care facility (10110) • Discharge to hospice (10115)


• Medical or patient reason for not prescribing aspirin (10205) at discharge, or; • An anticoagulant (Warfarin, Apixaban, Dabigatran, Edoxaban or Rivroxaban) and a

P2Y12 inhibitor (Clopidogrel, Prasugrel, Ticagrelor or Ticlopidine) (10205) are prescribed at discharge

Time Period



After PCI, aspirin should be continued indefinitely. (ACCF/AHA/SCAI Recommendation Class I, Level of Evidence A). (1)

Relevant Citations

1. Levine GN, Bates ER, Blakenship JC, et al. 2011 ACCF/AHA/SCAI guideline for

percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44-122.

2. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline focused update on

duration of dual antiplatelet therapy in patients with coronary artery disease. J Am Coll Cardiol. 2016;61:1082-115



9. P2Y12 inhibitor prescribed at discharge

Description: Percentage of PCI patients with a stent implanted who were prescribed a P2Y12 inhibitor at discharge

Numerator

Patients who were prescribed a P2Y12 inhibitor (10205) at discharge

Denominator

Patients with PCI (7050) and stent implantation (8028)





Medical and/or patient reason for not prescribing all P2Y12 inhibitors (10205) at discharge

Time Period



Recommendations for the duration of dual antiplatelet therapy (DAPT) in patients with symptomatic ischemic heart disease (SIHD) who are treated with PCI include:

a. In patients with SIHD treated with DAPT after bare metal stent (BMS) implantation, P2Y12 inhibitor therapy should be given for a minimum of 1 month. (ACC/AHA Recommendation Class I, Level of Evidence: A).

b. In patients with SIHD treated with DAPT after drug eluting stent (DES) implantation, P2Y12 inhibitor therapy should be given for at least 6 months. (ACC/AHA Recommendation Class I, Level of Evidence: B).

Recommendations for the duration of dual antiplatelet therapy in patients with Acute Coronary Syndrome (ACS) who are treated with PCI include:

a. In patients with ACS treated with DAPT after BMS or DES implantation, P2Y12inhibitor therapy should be given for at least 12 months. (ACC/AHA Recommendation Class I, Level of Evidence: B).

Relevant Citations

1. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline focused update on

duration of dual antiplatelet therapy in patients with coronary artery disease. J Am Coll Cardiol. 2016;61:1082-115.



10. Statin prescribed at discharge

Description: Percentage of PCI patients who were prescribed a statin at discharge

Numerator

Patients who were prescribed a statin (10200) at discharge

Denominator






Medical or patient reason for not prescribing a statin (10205) at discharge

Time Period



Statin therapy has been shown to reduce all-cause mortality and cardiovascular events including recurrent myocardial infarction and coronary revascularization as well as delay coronary atherosclerosis progression. (1)

High-intensity statin therapy should be initiated or continued as first-line therapy in women and men <= 75 years of age who have clinical atherosclerotic cardiovascular disease, unless contraindicated. (ACC/AHA Recommendation Class I, Level of Evidence A). (2)

If treatment with a high-intensity statin is contraindicated a moderate intensity statin should be used if tolerated. (ACC/AHA Recommendation Class I, Level of Evidence A). (2)

Relevant Citations



2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the

treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.



24. Pre and post-procedure creatinine

Description: Percentage of PCI procedures with both pre and post-procedure creatinine obtained

Numerator

Procedures with creatinine assessed pre-procedure (6050) and post-procedure (8510) or at discharge (10060)

Denominator

PCI procedures (with/without dx coronary angiography) (7050)


• Death during the procedure (10120), or, • Post-procedure length of stay <= 24 hours (10101, 7005)


None

Time Period



Patients should be assessed for risk of contrast-induced acute kidney injury (AKI) before PCI. (ACCF/AHA/SCAI Recommendation Class I, Level of Evidence: C). (1)

Acute kidney injury (AKI) is a potential complication of PCI that in some cases progresses to the need for hemodialysis. Post PCI acute kidney injury is associated with an increased risk of bleeding, myocardial infarction, and death. If the injury progresses to the need for dialysis these risks significantly increase. (2)

Relevant Citations


percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44-122

2. Tsai, TT, Patel, UD, Chang, TI, et al. Contemporary incidence, predictors, and

outcomes of acute kidney injury in patients undergoing percutaneous coronary interventions: insights from the NCDR Cath-PCI Registry. J Am Coll Cardiol Cardiovascular Interventions. 2014;7:1-9


42. Radiation Dose (NEW)

Description: Percentage of PCI procedures where radiation measurements were thoroughly recorded

Numerator

Procedures with all of the following radiation exposure measurements recorded:

• Fluoro time (7214) • Cumulative air kerma (7210) • Dose area product (7220)

Denominator



None


None

Time Period



Cardiac catheterization laboratories should routinely record relevant available patient procedural radiation dose data (e.g., total air kerma at the international reference point, air kerma air product), fluoroscopy time, number of cine images) and should define thresholds with corresponding follow-up protocols for patients who receive a high procedural radiation dose. (ACCF/AHA Recommendation Class I, Level of Evidence: C). (1)

Patient dose and imaging time monitoring should be conducted with two purposes: • To identify trends for excessive dose and imaging times in group data from

overall facility experience. • To identify individual outlier procedures that receive excessive exposures. (2)

Relevant Citations



2. Hirshfeld JW Jr, Ferrari VA, Bengel FM, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT

expert consensus document on optimal use of ionizing radiation in cardiovascular imaging: best practices for safety and effectiveness: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2018;71:e1-e69.


45. Cardiac rehabilitation referral (NEW)

Description: Percentage of patients who received a cardiac rehabilitation referral after PCI

Numerator

Patients with a cardiac rehabilitation referral (10116)

Denominator






Medical or health care system reason (10116) for not providing a cardiac rehabilitation referral

Time Period



Medically supervised exercise programs (cardiac rehabilitation) should be recommended to patients after PCI, particularly for moderate – to high-risk patients for whom supervised exercise training is warranted. (ACCF/AHA/SCAI Recommendation Class I, Level of Evidence: A). (1)

Participation in a cardiac rehabilitation program is associated with a reduction in all- cause mortality and recurrent myocardial infarction. Participants can also experience improved exercise tolerance, decreased cardiac symptoms, improved lipid levels, decreased stress, improved compliance with medical treatments/medications and improved feelings of well-being. (1)

Relevant Citations





3. Thomas RJ, Balady G, Banka G, et al. 2018 ACC/AHA clinical performance and

quality measures for cardiac rehabilitation: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures: J Am Coll Cardiol. 2018.


PCI - Outcome Metrics

12. Emergency/Salvage CABG post PCI

Description: Percentage of PCI patients who had emergency or salvage CABG post-procedure

Numerator

Patients having emergency or salvage CABG (10035, 10011) after a PCI procedure (7000, 7050)

Denominator



None


None

Time Period



Emergency CABG following PCI is a major adverse event which is associated with increased rates of in-hospital mortality and morbidity.

The indications for emergency CABG after PCI are most often related to acute or threatened vessel closure, dissection, perforation, failure to cross the lesion or equipment malfunction such as stent dislodgement or fractured guidewire.

Emergency CABG is recommended after failed PCI in the presence of ongoing ischemia or threatened occlusion with substantial myocardium at risk. (ACCF/AHA Recommendation Class I, Level of Evidence: B).

Relevant Citations

1. Hills LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary

artery bypass surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58:e123-310


16. Intra/post-procedure stroke

Description: Percentage of PCI procedures with intra/post-procedure stroke

Numerator

Procedures with an intra/post-procedure ischemic; hemorrhagic or undetermined stroke (9001)

Denominator



PCI procedures with any of the following concomitant procedures during the same cath lab visit (7066):

• LAAO • Mitral Clip • Peripheral intervention • Structural repair • TAVR • EP study

OR

Patients with any of the following interventions during the hospitalization (10031): • CABG • Cardiac surgery (non-CABG) • Surgery (non-cardiac) • Valvular intervention • Structural Heart intervention (non-valvular) • EP study

OR

Patients discharged to another acute care hospital (10110) Denominator Exceptions

None

Time Period



Factors associated with an increased risk of stroke include: administration of thrombolytics prior to PCI, cerebrovascular disease, the indication for PCI of STEMI, utilization of an IABP, advanced age and female sex. (1)

Stroke is one of the major complications that can occur during or after a PCI procedure. Patients who experience a post PCI stroke have increased rates of in-hospital mortality and morbidity. (2)

Relevant Citations

1. Levine GN, Bates ER, Blakenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:e44-122.

2. Myint PK, Kwok CS, Roffe C, et al. Determinants and outcomes of stroke

following percutaneous coronary intervention by indication. Stroke. 2016;47:1500-1507.


17. Composite: Major adverse events (all PCI patients)

Description: Percentage of PCI patients who experienced a major adverse event

Numerator

Patients with any one of the following:

• Discharge status of deceased (10105) • Emergency/salvage CABG (post PCI) (10035, 7000, 10011) • Stroke (hemorrhagic, ischemic, or undetermined) (9001) • Emergency/salvage repeat target segment revascularization (7050, 7800,

8001) *Repeat target segment revascularization is defined as a repeat PCI procedure on the same segment during the same Episode of Care

Denominator



None


None

Time Period



This metric represents a composite of major adverse events associated with the PCI procedure.


44. Composite: Major adverse events (select PCI patients) (NEW)

Description: Percentage of patients who experienced a major adverse event associated with the PCI procedure

Numerator Patients with any one of the following:

• Discharge status of deceased (10105) • Emergency/salvage CABG (post PCI) (10035, 7000, 10011) • Stroke (hemorrhagic, ischemic, undetermined) (9001) • Emergency/salvage repeat target segment revascularization (7050, 7800,

8001) *Repeat target segment revascularization is defined as a repeat PCI procedure on the same segment during the same Episode of Care

Denominator



PCI procedures with any of the following concomitant procedures during the same

cath lab visit (7066):


OR Patients with any of the following interventions during the hospitalization (10031):

• Elective or urgent CABG • Cardiac surgery (non-CABG) • Surgery (non-cardiac) • Valvular intervention • Structural Heart intervention (non-valvular) • EP study


None

Time Period



This metric represents a composite of major adverse events associated with the PCI procedure.


18. PCI in-hospital risk adjusted mortality (patients with STEMI)

Description: The hospital risk adjusted mortality rate for patients with ST-elevation MI having PCI

Numerator

See risk model technical specifications – pages 41-43 Denominator

Inclusion Criteria

Patients with PCI for STEMI (7050, 7825)

Time Period



See measure #1

Relevant Citations

See measure #1

19. PCI in-hospital risk adjusted mortality (STEMI patients excluded)

Description: The hospital risk adjusted mortality rate for patients without ST-elevation MI having PCI

Numerator


Denominator

Inclusion Criteria

Patients with PCI for indication other than STEMI (7050, 7825)

Time Period



See measure #1

Relevant Citations

See measure #1


25. Transfusion post-PCI

Description: Percentage of PCI procedures where patients received an intra or post-procedure transfusion

Numerator

Procedures with a transfusion of red blood cells within 72 hours (9277)

Denominator



PCI procedures with any of the following concomitant procedures during the same cath lab visit (7066):


OR

Patients with any of the following: • Currently on dialysis (4560) • Transfusion and a pre-procedure Hgb <= 8g/dL (9277, 6030) • Any of the following interventions during the hospitalization (10031):

− CABG − Cardiac surgery (non-CABG) − Surgery (non-cardiac) − Valvular intervention − Structural Heart intervention (non-valvular)

− EP study


None

Time Period



The purpose of this metric is to allow identification of the potential overuse of transfusion after PCI procedures.

A study by Sherwood et al., found variations in blood transfusion practices for those undergoing PCI. Transfusions were provided to patients with and without bleeding events. Transfusions post PCI are associated with an increased risk of adverse outcomes including in-hospital stroke and mortality.

Relevant Citations

1. Sherwood MW, Wang Y, Curtis JP, et al. Patterns and outcomes of red blood cell

transfusion in patients undergoing percutaneous coronary intervention. JAMA. 2014; 311 (8): 836-843.


39. PCI in-hospital risk adjusted acute kidney injury (all patients)

Description: The hospital risk adjusted rate of acute kidney injury for all patients having PCI

Numerator


Denominator

Inclusion Criteria


Time Period



Acute Kidney Injury (AKI) is a serious complication after PCI and is associated with increased incidence of in-hospital and follow-up myocardial infarction, dialysis, and death. Furthermore, small increases in serum creatinine have been associated with increased hospital length of stay and excess costs. This metric is helpful in providing risk-adjusted feedback on AKI, informing clinical decision-making, and directing the use of strategies to avoid AKI and improve the safety of PCI procedures.

Relevant Citations

1. Gurm H, Seth M, Kooiman J, et al. A novel tool for reliable and accurate prediction

of renal complications in patients undergoing percutaneous coronary intervention. J Am Coll Cardiol. 2013;61(22):2242-2238.

2. Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of

contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44(7):1393-1399.

3. Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an

initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31.


Diagnostic Coronary Angiography – Process Metrics

47. Radiation Dose (NEW)

Description: Percentage of diagnostic coronary angiography procedures where radiation measurements were thoroughly recorded

Numerator

Procedures with all of the following radiation exposure measurements recorded: • Fluoro time (7214) • Cumulative air kerma (7210) • Dose area product (7220)

Denominator

Diagnostic coronary angiography procedures (No PCI) (7045)


PCI procedure (7050) during the same Cath Lab visit as diagnostic coronary angiography (7045)


None

Time Period



Cardiac catheterization laboratories should routinely record relevant available patient procedural radiation dose data (e.g., total air kerma at the international reference point, air kerma air product), fluoroscopy time, number of cine images) and should define thresholds with corresponding follow-up protocols for patients who receive a high procedural radiation dose. (ACCF/AHA Recommendation Class I, Level of Evidence: C). (1)

Patient dose and imaging time monitoring should be conducted with two purposes:

• To identify trends for excessive dose and imaging times in group data from overall facility experience.

• To identify individual outlier procedures that receive excessive exposures. (2)

Relevant Citations



2. Hirshfeld JW Jr, Ferrari VA, Bengel FM, et al. 2018 ACC/HRS/NASCI/SCAI/SCCT

expert consensus document on optimal use of ionizing radiation in cardiovascular imaging: best practices for safety and effectiveness: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2018;71:e1-e69.


Diagnostic Coronary Angiography – Outcome Metrics

21. Access site injury or major bleeding among diagnostic angiography procedures

Description: Percentage of diagnostic coronary angiography procedures with access site injury or major bleeding

Numerator Procedures with any one of the following

• Bleeding at access site (9001) • Hematoma at access site (9001) • Retroperitoneal bleeding (9001)

• Other vascular complications requiring treatment (9001)

Denominator Diagnostic coronary angiography procedures (7045)


PCI procedure during the same Episode of Care (7050)

OR Diagnostic coronary angiography procedures with any of the following concomitant procedures during the same cath lab visit (7066):


OR Patients with any of the following interventions during the hospitalization (10031):

• CABG • Cardiac surgery (non-CABG) • Surgery (non-cardiac) • Valvular intervention • Structural Heart intervention (non-valvular) • EP study


None

Time Period


Clinical Rationale /Recommendation

Vascular complications can cause significant discomfort and disability for patients. While rates of complications will be sensitive to patient characteristics, there is evidence that hospitals can significantly influence overall complication rates. This can be accomplished through monitoring and analyzing the cause of complications, developing policies and procedures that minimize the risk of complications and developing policies that assure operation and cath team competency.

Relevant Citations

1. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report form the Bleeding Academic Research Consortium. Circulation. 2011;123:2736-2747.


Efficiency Metrics

22. Median post-procedure length of stay (patients with STEMI)

Description: Median time (in days) from the start of the PCI procedure to discharge for all STEMI patients Post-procedure Length of Stay (LOS)

Time from the index (first) STEMI procedure end date/time (7005) to discharge date/time (10101) *A 24-hour period = 1 day; days are reported with two decimal precision

Facility Median

Median of the patient calculated LOS values

Population



• Patients discharged to another acute care facility (10110), or: • Patients who die during the procedure (10120)


None

Time Period



Length of stay (LOS) is a measure of efficiency and resource utilization. Reporting the median LOS is preferred over the mean LOS because outliers with either short or extended LOS can skew the mean.

Length of stay can be affected by facility processes, provider availability, discharge needs/placement, and procedure related complications.

Prolonged LOS following primary PCI for STEMI is associated with higher rates of mortality and major adverse cardiac events. Several clinical features associated with an increased LOS include co-morbid conditions, multivessel disease, complex coronary lesions, vascular complications, transfusion, IABP utilization, shock or heart failure, and renal insufficiency. (1, 2)

Relevant Citations

1. Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous

coronary intervention: An expert consensus document update from the society for cardiovascular angiography. Catheter Cardiovasc Interven. 2018;1-15.

2. Swaminathan RV, Rao SV, McCoy LA, et al. Hospital length of stay and clinical

outcomes in older STEMI patients after primary PCI: A Report from the National Cardiovascular Data Registry. J Am Coll Cardiol. 2015;65:1161-1171.


46. Median post-procedure length of stay (patients with uncomplicated STEMI) (NEW)

Description: Median time (in days) from the start of the PCI procedure to discharge for uncomplicated STEMI patients

Post-procedure Length of Stay (LOS)

Time from the index (first) STEMI procedure end date/time (7005) to discharge date/time (10101) * A 24-hour period = 1 day; days are reported with two decimal precision

Median

Median time from the index (first) STEMI procedure start date/time (7000) to discharge date/time (10101)

Population



PCI procedures with any of the following concomitant procedures (7066) during the same cath lab visit:


OR


• Cardiac arrest pre-procedure (Out-of-hospital cardiac arrest (4630), cardiac arrest at transferring facility (4635), or cardiac arrest at this facility (7340))

• Cardiogenic shock (7415) • Refractory cardiogenic shock (7415) • Ventricular Support (7420) • Thrombolytics (7829) • Discharged to another acute care hospital (10110) • Death during the procedure (10120) • Creatinine increase > 0.3 (from pre to post-creatinine) (6050, 8510) • Hemoglobin drop of > 4g/dl (from pre to post-hemoglobin) (6030, 8505) • TIMI flow (post-intervention) of “0” or “1”(8026) • Any of the following interventions during the hospitalization (10031):

− CABG − Cardiac Surgery (non-CABG) − Surgery (non-cardiac) − Valvular intervention − Structural Heart intervention (non-valvular) − EP study

Time Period




Length of stay (LOS) is a measure of efficiency and resource utilization. Reporting the median LOS is preferred over the mean LOS because outliers with either short or extended LOS can skew the mean.

Length of stay can be affected by facility processes, provider availability, discharge needs/placement, and procedure related complications. Prolonged LOS following primary PCI for STEMI is associated with higher rates of mortality and major adverse cardiac events. Several clinical features associated with an increased LOS include: co-morbid conditions, multivessel disease, complex coronary lesions, vascular complications, transfusion, IABP utilization, shock or heart failure, and renal insufficiency. (1, 2)

Relevant Citations

1. Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous

coronary intervention: An expert consensus document update from the society for cardiovascular angiography. Catheter Cardiovasc Interven. 2018;1-15.

2. Swaminathan RV, Rao SV, McCoy LA, et al. Hospital length of stay and clinical outcomes in older STEMI patients after primary PCI: A Report from the National Cardiovascular Data Registry. J Am Coll Cardiology 2015;65:1161-1171.


Section III: Appropriate Use Criteria (AUC) Metrics The American College of Cardiology and its collaborators believe that an ongoing review of one’s practice using the Appropriate Use Criteria will help guide more effective, efficient, and equitable allocation of healthcare resources, and ultimately lead to better patient outcomes. The intent of the Appropriate Use Criteria is to provide a framework to evaluate overall clinical practice and improve the quality of care.

30. PCI procedures not classifiable for AUC reporting (all patient presentations)

Description: Percentage of PCI procedures that were not able to be classified by the AUC

Numerator

Procedures that could not be mapped to an Appropriate Use Criteria indication

Denominator

PCI procedures (with/without diagnostic coronary angiography) for patients with ACS or SIHD


None


None

Time Period



An AUC indication cannot be identified to associate with the patient’s clinical scenario due to either missing or indeterminate variables (e.g. stress test results).

Relevant Citations

1. Hendel RC, Lindsay BD, Allen, JM, et al. ACC Appropriate use criteria methodology:

2018 Update: A report of the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2018;71:935-948.

2. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate use criteria for coronary revascularization in patients with acute coronary syndromes: A report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:570–91.

3. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: A report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:2212–41.


31. PCI procedures that were evaluated as Appropriate (PCI patients with acute coronary syndromes)

Description: Percentage of PCI procedures for acute coronary syndromes that were evaluated as Appropriate by Appropriate Use Criteria guidelines

Numerator

Procedures for acute coronary syndromes (ACS) that were evaluated as “Appropriate” according to the AUC guidelines

Denominator

PCI procedures (with/without diagnostic coronary angiography) for patients with ACS


None


None

Time Period



The procedure is an appropriate option for the management of patients in this population due to the benefits generally outweighing the risks; an effective option for individual care plans, although not always necessary depending on physician judgement and patient-specific preferences (i.e., procedure is generally acceptable and is generally reasonable for the indication/clinical scenario).

Relevant Citations





32. PCI procedures that were evaluated as May Be Appropriate (PCI patients with acute coronary syndromes)

Description: Percentage of PCI procedures for acute coronary syndromes that were evaluated as May Be Appropriate by Appropriate Use Criteria guidelines

Numerator

Procedures for acute coronary syndromes that were evaluated as “May Be Appropriate” according to the AUC guidelines

Denominator



None


None

Time Period



At times, the procedure is an appropriate option for the management of patients in this population due to variable evidence or agreement regarding the risk-benefit ratio, potential benefit on the basis of practice experience in the absence or evidence, and/or variability in the population; effectiveness for individual care must be determined by the patient’s physician in consultation with the patient on the basis of additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication/clinical scenario).

Relevant Citations





33. PCI procedures that were evaluated as Rarely Appropriate (PCI patients with acute coronary syndromes)

Description: Percentage of PCI procedures for acute coronary syndromes that were evaluated as Rarely Appropriate by Appropriate Use Criteria guidelines

Numerator

Procedures for acute coronary syndromes that were evaluated as “Rarely Appropriate” according to the AUC guidelines

Denominator



None


None

Time Period



The procedure is a rarely an appropriate option for the management of patients in this population due to the lack of clear benefit/risk advantage; rarely, an effective option for individual care plans; exception should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication/clinical scenario).

Relevant Citations 1. Hendel RC, Lindsay BD, Allen, JM, et al. ACC Appropriate use criteria methodology:




34. PCI procedures that were evaluated as Appropriate (PCI patients with stable ischemic heart disease)

Description: Percentage of PCI procedures for stable ischemic heart disease that were evaluated as Appropriate by Appropriate Use Criteria guidelines

Numerator

Procedures for stable ischemic heart disease that were evaluated as “Appropriate” according to the AUC guidelines

Denominator

PCI procedures (with/without diagnostic coronary angiography) for patients with SIHD


None


None

Time Period



The procedure is an appropriate option for the management of patients in this population due to the benefits generally outweighing the risks; an effective option for individual care plans, although not always necessary depending on physician judgement and patient-specific preferences (i.e., procedure is generally acceptable and is generally reasonable for the indication/clinical scenario).

Relevant Citations



2. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS

2017 Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: A report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:2212–41.


35. PCI procedures that were evaluated as May Be Appropriate (PCI patients with stable ischemic heart disease)

Description: Percentage of PCI procedures for stable ischemic heart disease that were evaluated as May Be Appropriate by Appropriate Use Criteria guidelines

Numerator

Procedures for stable ischemic heart disease that were evaluated as “May Be Appropriate” according to the AUC guidelines

Denominator



None


None

Time Period



At times, the procedure is an appropriate option for the management of patients in this population due to variable evidence or agreement regarding the risk-benefit ratio, potential benefit on the basis of practice experience in the absence or evidence, and/or variability in the population; effectiveness for individual care must be determined by the patient’s physician in consultation with the patient on the basis of additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication/clinical scenario).

Relevant Citations



2. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS

2017 Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: A report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:2212–41.


36. PCI procedures that were evaluated as Rarely Appropriate (PCI patients with stable ischemic heart disease)

Description: Percentage of PCI procedures for stable ischemic heart disease that were evaluated as Rarely Appropriate by Appropriate Use Criteria guidelines

Numerator

Procedures for stable ischemic heart disease that were evaluated as “Rarely Appropriate” according to the AUC guidelines

Denominator



None


None

Time Period



The procedure is a rarely an appropriate option for the management of patients in this population due to the lack of clear benefit/risk advantage; rarely, an effective option for individual care plans; exception should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication/clinical scenario).

Relevant Citations





Risk Models

Metric 1 PCI in-hospital Risk Adjusted Mortality (all patients)

The most recent PCI risk adjusted mortality model revision was developed using patients discharged between July 1, 2009 and June 30, 2011. A total of 1,208,137 admissions with patients undergoing PCI at 1,252 hospitals in the United States were included in the model development and validation cohort.

Model Specifications

I. Outcome:

Mortality - Discharge status = deceased (10105)

II. Timeframe:

Rolling four (4) quarters

III. Model Eligibility and Population Definition:

1) Model eligibility at the facility level:

a) Data submissions that pass the NCDR data inclusion thresholds.

2) Model eligibility at the patient level:

a) Include patients with a PCI procedure performed during the episode of care.

b) Include only index PCI procedures when patients have multiple PCI procedures (procedure variables for subsequent PCI procedures during the same episode of care are excluded).

c) Exclude patients who transfer to “other acute care facility” on discharge (10110).


Risk Adjusted Mortality detail line labels and explanations:

▪ Eligible Patients – all patients who receive a predicted probability value from the model

▪ Observed Mortality (among eligible) – count of occurrences of mortality (number of deceased patients)

▪ Expected Mortality (among eligible) – predicted rate of mortality for the eligible patients (number of patients expected to die)

▪ Observed/Expected Mortality Ratio (O/E Ratio) – provides feedback on the comparison between the observed to expected. If the O/E ratio is > 1 then the facility had more deaths than expected. If the ratio is equal to 1 then the facility had the same number of deaths as expected. If the O/E ratio is < 1 then the facility had less deaths than expected.

▪ Risk Adjusted Mortality Rate (%) – your hospital risk adjusted mortality rate. A risk adjusted mortality rate will not be reported for those facilities that have no mortalities during a particular R4Q period.

o Calculation: Facility O/E Ratio x Registry Aggregate = Risk Adjusted Rate

▪ Registry Aggregate Observed Mortality Rate (%) – the registry mortality rate is reflective of the patients included in all participating facilities during the reporting period. It is therefore dynamic, and changes based on the data from each quarter and R4Q.

Note: Reference the NCDR Risk Model Documents found on the Documents Home Page for additional insight

PCI in-hospital risk adjusted mortality variables:

Variable Variable Type Elements

ST-segment elevation MI Boolean (yes or no)

Percutaneous Coronary Intervention Indication (7825) = any of the following: STEMI - Immediate PCI for STEMI, or STEMI - Stable (<=12 hrs from Symptoms), or STEMI - Stable (>12 hrs from Symptoms), or STEMI - Unstable (>hrs from Symptoms), or STEMI (after successful lytics), or STEMI - Rescue (after unsuccessful lytics)

Age <=70 Number DOB (2050) and Arrival Date/time (3001)

Age >70 Number DOB (2050) and Arrival Date/time (3001)

BMI <=30 Number Height (6000) and Weight (6005)

BMI >30 Number Height (6000) and Weight (6005)

Cerebrovascular Disease Boolean (yes or no) Cerebrovascular Disease (4551)

Peripheral Arterial Disease Boolean (yes or no) Peripheral Arterial Disease (4610)


Chronic Lung Disease Boolean (yes or no) Chronic Lung Disease (4576)

Prior PCI Boolean (yes or no) Prior PCI (4495)

Diabetes Mellitus Boolean (yes or no) Diabetes Mellitus (4555)

Mild GFR > 45-60 Boolean (yes or no) Pre-procedure Creatinine (6050), age (2050,3001), sex (2060) and African American race (2071)

Moderate GFR > 30-< 45 Boolean (yes or no) Pre-procedure Creatinine (6050), age (2050,3001), sex (2060) and African American race (2071)

Renal Failure (GFR <30 or Dialysis)

Boolean (yes or no)

Pre-procedure Creatinine (6050), age (2050,3001), sex (2060) and African American race (2071) or Currently on Dialysis (4560)

Ejection Fraction Number Ejection Fraction (7061) or if not available (5116)

PCI Status Value set PCI status (7800) = any of the following: Elective, Urgent, Emergency or Salvage

Cardiogenic Shock Boolean (yes or no) CV Instability (7410) = yes and Type (7415) = Cardiogenic Shock

NYHA IV Boolean (yes or no) NYHA (4011) = Class IV

NYHA I, II, III Boolean (yes or no) NYHA (4011) = Class I, II or III

Cardiac Arrest Boolean (yes or no)

Cardiac Arrest out of Healthcare Facility (4630) or Cardiac Arrest at Transferring Hospital (4635) or Cardiac Arrest at this facility prior to Cath lab (7340)

PCI on Left Main Boolean (yes or no) Segment Number (8001) = (11a, 11b or 11c)

PCI on Proximal LAD Boolean (yes or no) Segment Number (8001) = 12

PCI of Chronic Total Occlusion

Boolean (yes or no) Chronic Total Occlusion (8005)

In-stent Thrombosis Boolean (yes or no) In-stent Thrombosis (8012) = yes

Multivessel Disease Boolean (yes or no)

Segment Number (7507), Native Stenosis (7508) and Dominance (7500) Multivessel Disease = (LM Stenosis>=50) or (LAD+RCA+Circ)>1 or (LAD + Left Dominant) or (Circ + Left Dominant)


Metric #40: PCI in-hospital Risk Standardized Bleeding (all patients)

The prior PCI risk-adjusted bleeding model was updated in 2017 to a parsimonious hierarchical model. This means the updated risk model utilizes fewer patient variables to determine individual patient risk of bleeding and the model considers the risk relationships within and amongst hospitals. Additionally, the hemoglobin parameter used to determine if a post-PCI bleeding event has occurred, has been revised to assess an absolute hemoglobin (Hgb) decrease from pre-PCI to post-PCI of > 4g/dL (previously 3g/dL).

The Risk Standardized Bleeding model provides an accurate estimate of post-PCI bleeding risk and is helpful in providing feedback on bleeding complications, informing clinical decision-making, and directing the use of bleeding avoidance strategies to improve the safety of PCI procedures.

Model Specifications I. Outcome: PCI bleeding is defined as any one of the following:

1) Bleeding event* (access site, gastrointestinal, genitourinary, hematoma at access site, retroperitoneal, or other (9001/9002) that occurred between the start of the procedure (7000) and 72 hours after PCI (7005/9003); or

2) Hemorrhagic stroke (9001/9002); or

3) Tamponade (9001/9002/9003); or

4) RBC Transfusion (9275) with a pre-procedure Hgb >8 g/dL (6030) and pre-procedure Hgb (6030) not missing; or

5) Absolute Hgb decrease from pre-PCI (6030) to post-PCI (8505) of >= 4 g/dL with either a pre-procedure Hgb <=16 g/dL (6030) or a mechanical support device was not used (7422)

* Note: A bleeding event (9001/9002) with a missing event date/time (9003) will automatically be

considered to have occurred with 72 hours of the PCI procedure

II. Timeframe:




a) Data submissions that pass the NCDR data inclusion thresholds

b) Facilities must have at least one patient with a pre-PCI (6030) or post-PCI Hgb (8505) value to be eligible for analysis


a) Include patients with a PCI procedure performed during the episode of care

b) Include only index PCI procedures when patients have multiple PCI procedures (procedure variables for subsequent PCI procedures during the same episode of care are excluded)


c) Include patient procedures with non-missing values for outcome variables of bleeding event(s) (9001/9002) or transfusion (9275)

d) Exclude patients who died within 24 hours of the PCI procedure [Discharge date/time (10101) - Procedure start date/time (7000) and Discharge status = deceased (10105)]

e) Exclude patients with interventions this hospitalization (10030) = yes and intervention type = CABG (10031)

Risk Standardized Bleeding detail line labels and explanations:


▪ Observed Bleeding Event – count of occurrences of bleeding events (number of patients with a bleeding event)

▪ Risk Standardized Bleeding Ratio – provides feedback on the comparison between the predicted number of bleeds and the expected number of bleeds for a facility. If the ratio is < 1 then the facility had fewer bleeds than the model predicted. If the ratio is equal to 1 then the facility had the same number of bleeds the model predicted. If the ratio is > 1 then the facility had more bleeds than the model predicted.

o The predicted value from a hierarchical model is based on patient factors and hospital specific factors.

o The estimated value from a hierarchical model is based on patient factors only.

▪ Risk Standardized Bleeding Rate (%) – your hospital risk standardized rate adjusted for patient case mix and hospital characteristics.

o Calculation: Facility P/E Ratio x Registry Aggregate = Risk Standardized Rate

▪ Registry Aggregate Observed Bleeding Event Rate (%) – Percent of PCI procedures (number of PCI procedures which experienced a bleed divided by the total number of PCI procedures in the measure) for ALL facilities in the registry. (in development)

Risk Adjusted Bleeding detail line labels and explanations:


▪ Observed Bleeding Event (among eligible) – count of occurrences of bleeding events (number of patients with a bleeding event

▪ Expected Bleeding Event (among eligible) – predicted rate of bleeding events for the eligible patients (number of patients expected to experience a bleeding event)

▪ Observed/Expected Bleeding Ratio (O/E Ratio) – provides feedback on the comparison between the observed to expected. If the O/E ratio is > 1 then the facility had more bleeding events than expected. If the ratio is equal to 1 then the facility had the same number of bleeding events as expected. If the O/E ratio is < 1 then the facility had less bleeding events than expected.

▪ PCI in-hospital Risk Adjusted Bleeding Rate (%) – your hospital risk adjusted bleeding rate. A risk


adjusted bleeding rate will not be reported for those facilities that have no bleeding events during a particular R4Q period.


▪ Registry Aggregate Observed Bleeding Rate (%) – the registry bleeding rate is reflective of the patients included in all participating facilities during the reporting period. It is therefore dynamic, and changes based on the data from each quarter and R4Q.

Note: Reference the resources located under the heading “NCDR Risk Model Documents” for additional insight.

PCI in-hospital risk standardized bleeding variables:




Age <=70 Number DOB (2050) and Arrival Date/time (3001)

Age >70 Number DOB (2050) and Arrival Date/time (3001)

BMI <=30 Number Height (6000) and Weight (6005)

BMI >30 Number Height (6000) and Weight (6005)

Female Boolean (yes or no) Sex (2060)

Pre-procedure Hgb <= 13 Boolean (yes or no) Pre-procedure Hemoglobin (6030)

Pre-procedure Hgb > 13 Boolean (yes or no) Pre-procedure Hemoglobin (6030)

Prior PCI Boolean (yes or no) Prior PCI (4495)


Moderate GFR > 30-< 45 Boolean (yes or no) Pre-procedure Creatinine (6050), age (2050,3001), sex (2060) and African American race (2071)


Boolean (yes or no)




Metric #39: PCI in-hospital Risk Adjusted Acute Kidney Injury (all patients)

The PCI risk-adjusted acute kidney injury model was developed using patients in the CathPCI Registry discharged between July 1, 2009 and March 31, 2010. A total of 1,028,811 patients undergoing PCI at 1,231 hospitals in the United States were included in the model development and validation cohort.

Model Specifications

I. Outcome: Post-PCI acute kidney injury is defined as any one of the following:

1) Increase in serum creatinine of > 0.3 mg/dL from baseline (6050 and 8510)

2) Increase in serum creatinine of 50% or more from baseline (6050 and 8510)

3) New requirement for dialysis (9001/9002)

II. Timeframe:




a) Data submissions that pass the NCDR data inclusion thresholds


a) Include patients with a PCI procedure performed during the episode of care

b) Include only index PCI procedures when patients have multiple PCI procedures (procedure variables for subsequent PCI procedures during the same episode of care are excluded).

c) Exclude patients missing a pre-procedure Creatinine (6050) or post-procedure Creatinine (8510) and New Requirement for Dialysis = “No” (9001/9002)

d) Exclude patients “currently on dialysis” (4560)

e) Exclude patients discharged (10101) on the same day as their PCI procedure (7000)


Risk Adjusted Acute Kidney Injury (AKI) detail line labels and explanations:


▪ Observed AKI (among eligible) – count of occurrences of AKI (number of patients who had AKI)

▪ Expected AKI (among eligible) – predicted rate of AKI for the eligible patients (number of patients expected to have AKI)

▪ Observed/Expected AKI Ratio (O/E Ratio) – provides feedback on the comparison between the observed to expected. If the O/E ratio is > 1 then the facility experienced more AKI than expected. If the ratio is equal to 1 then the facility had the same number of AKI as expected. If the O/E ratio is < 1 then the facility experienced less AKI than expected.

▪ Risk Adjusted AKI Rate (%) – your hospital risk adjusted AKI rate


▪ Registry Aggregate Observed AKI Rate (%) – the registry AKI rate is reflective of the patients included in all participating facilities during the reporting period. It is therefore dynamic, and changes based on the data from each quarter and R4Q.

Risk Adjusted Dialysis detail line labels and explanations:


▪ Observed Dialysis (among eligible) – count of occurrences of dialysis (number of patients who had a new requirement for dialysis)

▪ Expected Dialysis (among eligible) – predicted rate of dialysis for the eligible patients (number of patients expected to require dialysis)

▪ Observed/Expected Dialysis Ratio (O/E Ratio) – provides feedback on the comparison between the observed to expected. If the O/E ratio is > 1 then the facility had more new cases of dialysis than expected. If the ratio is equal to 1 then the facility had the same number of new cases of dialysis as expected. If the O/E ratio is < 1 then the facility experienced less new cases of dialysis than expected

▪ Risk Adjusted Dialysis Rate (%) – your hospital risk adjusted dialysis rate


▪ Registry Aggregate Observed AKI Rate (%) – the registry dialysis rate is reflective of the patients included in all participating facilities during the reporting period. It is therefore dynamic, and changes based on the data from each quarter and R4Q.

Note: Reference the resources located under the heading “NCDR Risk Model Documents” for additional insight.


PCI in-hospital risk adjusted AKI variables:


IABP in place at start of procedure

Boolean (yes or no)

Mechanical Support (7422) = Yes and Device (7423) = IABP and Device Timing (7424) = In place at start of Procedure

Recent Heart Failure Boolean (yes or no)

Newly Diagnoses Heart Failure (4012) = yes or Heart Failure (4001) = yes and NYHA Class (4011) = Class II, III, or IV or Cardiovascular instability type (7415) = acute heart failure symptoms


Moderate GFR > 30-< 45

Boolean (yes or no) Pre-procedure Creatinine (6050), age (2050,3001), sex (2060) and African American race (2071)


Boolean (yes or no)


Diabetes Boolean (yes or no) Diabetes (4555) = yes

Age Number DOB (2050) and Arrival Date/time (3001)

Prior Heart Failure Boolean (yes or no) Prior Heart Failure (4001) = yes and Newly Diagnosed Heart Failure (4012) = no or null

Cerebrovascular Disease Boolean (yes or no) Cerebrovascular Disease (4551) = yes

Non-ST-segment elevation MI or Unstable Angina

Boolean (yes or no) Percutaneous Coronary Intervention Indication (7825) = NSTE – ACS





Cardiac Arrest Boolean (yes or no)

Cardiac Arrest Out of Healthcare Facility (4630) or Cardiac Arrest at Transferring Healthcare Facility (4635) or Cardiac Arrest at this facility (7340)

Anemia Number Pre-procedure Hemoglobin (6030) < 10g/dL