“Improving LTFU using the “SNOOPP” Approach” Nilima Lovekar, MPH

1. “Improving LTFU using the “SNOOPP” Approach” • Nilima Lovekar, MPH

2. When did we start • Data collection since 2011 • Started with 4 modules CEA,PVI, Bypass and AAA • Currently participate in10 modules: CEA,CAS,EVAR,HD, Infra and Supra Inguinal Bypass, Open AAA, PVI, TVAR and IVC filters

3. Not an easy task…. • 6 physicians, one data abstractor, and 10 modules…….doesn’t look easy • Generally we have anywhere between 70+ cases and of course emergent procedures. • The follow ups are done by our physicians for all vascular procedures at 1 week, 1 month, 3-6-9-12 months and each yearly follow-up • Long turn follow-up data for VQI bi-annually: for all procedures follow-up data is drawn for 21 months prior to meeting about 3 months ahead of meeting • Initially it was like twilight zone…. ‘SNOOPP’ for help

4. Using Analytics & Reporting Engine...it helps EVAR Follow-up rate disaster

5. PVI Follow-up rate disaster

7. Starter’s hitch • Resistance from hospital admin and surgeons • No funding was available or allotted to hire and set up QA measure personnel for the Vascular division. • Physician unfamiliarity with VQI protocols, suboptimal documentation and limited resources for data collection and entry. • Acute need for training new/incoming data abstractors by lead hospital managers. • As we know similar problems are evident particularly in newly enrolled centers and affects center-specific, regional and national data. • Overcoming these challenges requires an organized approach that involves all members of the healthcare team.

8. Our algorithm is outlined in the acronym • “SNOOPP”. • S: Social Security Death Index: Utilization to verify unreported patient deaths • N: Nursing home/Rehab facility: Contact to facilitate follow up visits of patients discharged to that facility. • O: Obituaries: Following obituary announcements from newspaper and web sources. • O: Office strategies: We have created flyers that outline LTFU protocol requirements. The VQI coordinator has created an Excel spreadsheet on a share drive where physicians and staff have access to patients with upcoming follow up date and requirements so they can plan patient visit and appropriate tests. • P: Primary Care Physician: Contact to obtain relevant information. • P: Phone Calls: Patients unable to come to the office are offered telephone interviews to collect necessary clinical data and schedule • necessary tests.

9. Searching the EMR Along with….. • PACS • Sizing charts: From Companies • Vascubase • Outside medical records • Thorough reading of pre, para and post op notes • Notes from other physicians who are treating the same patient • No paper form allowed. Electronic data maintenance keeps it clean and sane.

10. Office Strategies: Keep it simple and clean The Beautiful world of Excel Able to keep track of the huge data at a click • Procedures done • Follow ups for each module • Dates and outcome of follow-up call • Aim for data input within 3 months of procedures • Schedule calls and data input for LTFUP after every 4 months approximately 3 times a year

13. Office strategies • We have created flyers that outline LTFU protocol requirements. • The VQI coordinator has created an Excel spreadsheet on a share drive for patients upcoming follow up date and tests • Share on Outlook calendar 3 months before the visit window the details for patients in enrolled in a project.

14. Challenges met • Lack of proper records system. • Not recording important parameters required for the modules • Main culprits: dare I say; of course surgeons, fellows and residents. • Missing the correct tools for abstraction of data: Scans, blood reports, measurements on aneurysms, etc. • Attending’s compliance with their obligations • Quality money allocation based on compliance

15. Possible solutions • Approaching surgeons for the missing data: balancing the mood and time of the surgeon is another challenge but I digress; I would swear persistence pays • Gentle reminders to Vascular fellows regarding reporting the important data points need for the module; also sometimes chasing or hunting them down and reiterating the importance of important parameters like Fluoro time, contrast volume, etc. • Incorporating data forms: an impossible task but to start anywhere would be worth it • Having develop auto generating data from emr which can get exported to Excel directly.

16. Training data abstractors • Reading scans • Measurements • Most importantly knowledge about • Vascular ds (through brochures and attending seminar-lectures) • Procedures done at the hospital • Getting familiar with the prosthetic devices used in the procedures • Also self study helps; you need to be driven to complete insufficiencies in what you know by what can you learn….

17. Communication is the key • Fellows, Attending and Resident monthly VQI update meeting to go over important changes in modules for VQI • Review past month procedures (way to reconfirm all procedures included) missed/unrecorded mandatory parameters on modules • Train residents on taking h&p and recording important variables • Training Fellows on writing brief-op notes on required variables like fluoro time and volume and mGy dosage

18. An organized approach based on an effective algorithm should include: • Utilization of several available resources. • Adherence to VQI LTFU protocols. • Ongoing team education and engagement. • Enhanced communication within the team and with other providers is essential for sustaining high rates of LTFU.

19. Conclusion Attending engagement has resulted in more timely completion of procedural data and consistent recording of important VQI parameters (postop EVAR sac measurements, revisions and postop complications, etc.) that facilitate data abstraction. Physician involvement has helped improve some of our measures towards procedure outcomes procedures included) missed/unrecorded mandatory parameters on modules

20. Something to think about • Amongst all this the most important aspect for bringing in success is actually listening to others at • Regional and Vascular annual conferences where we get lot of information about and know how. • It also helps us to compare ourselves not in comparison but getting successful help. • I personally think that only data managers meeting for 30-60 min depending on time has been beneficial • for my region’s data managers (well for those who attended) • Last fall at the meeting the idea of collaborative project took shape. Our center with Rochester will be • presenting paper on the TCAR data at VAM

21. Vascular Quality Initiative Regional Quality Report Spring 2018

22. Now we can say its applicability and effectiveness on the basis of VQI bi-annual reports and have been successful in maintaining our LTFU at higher level.

23. Vascular Quality Initiative Regional Quality Report Spring 2018