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NCDR.13 Case Scenario Presentation
Cath PCI Registry
Dashboard Implications of
Some Major Metrics
Disclosures
• Tony Hermann has nothing to disclose
• Mark Hutcheson has nothing to disclose
• Cornelia Anderson has nothing to disclose
• Issam Moussa has nothing to disclose
• Discuss inclusion & exclusion criteria from five
Outcomes Reports metrics
• Discuss specific data collection and
definitions related to medications for the Cath
PCI Registry
• Demonstrate knowledge of data abstraction
through participation with the ARS
Objectives
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Proportion of Patients with Death,
Emergency CABG, Stroke or Repeat Target
Vessel Revascularization
Section G PCI ProcedureSeq#7020 (PCI Status) & Seq#7035 (PCI Indication)
Documentation:
• 47yo male c/o midsternal CP x2hrs
• Presents ambulatory to Triage/ER
• PMH: None, +Family History
• Meds: None
• ST Elevation leads II & III
• STEMI diagnosis
• STEMI protocol initiated
ARS Question # 1
What is the PCI Status and PCI Indication?
1. Urgent/Immediate PCI for STEMI
2. Urgent/Rescue PCI
3. Emergency/Immediate PCI for STEMI
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ARS Question #1
Documentation:
47yo male c/o midsternal CP x2hrs
ST Elevation leads II & III
STEMI diagnosis
STEMI protocol initiated
What is the PCI Status and PCI Indication?
1. Urgent/Immediate PCI for STEMI
2. Urgent/Rescue PCI
3. Emergency/Immediate PCI for STEMI
Section K DischargeSeq#9005 (CABG Status) & Seq#9010 (CABG Indication)
Documentation:
• Right femoral access
• Prox RCA 95%, Mid LAD 70%, Mid Cx 70-80%
• Culprit RCA lesion stented 4.0 BMS
• Pt decompensates after stent placement
• Unable to visualize Left System CP 10/10
• SBP 70’s, IABP inserted, Dopamine
• Pt prepared for CABG
ARS Question #2
What is the CABG Status and CABG Indication?
1. Urgent/PCI failure without clinical
deterioration
2. Emergency/PCI complication
3. Salvage/PCI complication
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ARS Question #2
Documentation:• Pt decompensates after stent placement
• Unable to visualize Left System CP 10/10
• SBP 70’s, IABP inserted, Dopamine
• Patient prepared for CABG
What is the CABG Status and CABG Indication?
1. Urgent/PCI failure without clinical
deterioration
2. Emergency/PCI complication
3. Salvage/PCI complication
ARS Question #3
Will this patient be included in the Numerator
for Metric 17?
1. Yes 2. No
ARS Question #3
Documentation:• Culprit RCA lesion stented 4.0 BMS
• Pt decompensates after stent placement
• Unable to visualize Left System CP 10/10
• SBP 70’s, IABP inserted, Dopamine
• Emergency CABG due to PCI Complication
Will this patient be included in the Numerator
for Metric 17?
1. Yes 2. No
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Section H Lesions and DevicesSeq#7145-7160
Documentation:
• 80 y.o. female s/p elective right hip
replacement
• PMH: Hyperlipidemia, HTN, Arthritis, stent to
mid Circumflex
• C/o chest tightness 3rd day post op
• Abnormal ECG
• Troponin 0.56, NSTEMI dx
• Cath reveals mid Circ lesion 90% - DES placed
ARS Question #4
How will Seq#7145 Previously Treated Lesion be
coded?
1. No 2. Yes
ARS Question #4
Documentation:
• PMH: Hyperlipidemia, HTN, Arthritis, stent to
mid Circumflex
• Cath reveals mid Circ lesion 90% - DES placed
How will Seq#7145 Previously Treated Lesion be
coded?
1. No 2. Yes
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ARS Question #5
How will Seq#7155 Treated with Stent be
coded?
1. No 2. Yes
ARS Question #5
Documentation:
• PMH: Hyperlipidemia, HTN, Arthritis, stent to
mid Circumflex
• Cath reveals mid Circ lesion 90% - DES placed
How will Seq#7155 Treated with Stent be
coded?
1. No 2. Yes
ARS Question #6Will this patient appear in the Numerator for
Metric 17?
1. Yes
2. No
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ARS Question #6 Documentation:
• 80 y.o. female s/p elective right hip
replacement
• Troponin 0.56, NSTEMI dx
• Cath reveals mid Circ lesion 90% - DES placed
Will this patient appear in the Numerator for
Metric 17?
1. Yes
2. No
Metric 17-Your hospital’s proportion of
(unadjusted) death, emergency CABG, stroke
or repeat target vessel revascularization
Medications
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Section D – Cath Lab Visit SEQ # 5300 - 5325 (Procedure Information)
Documentation:
• Stress test: a large area of reversible ischemia
• Cardiac cath:
– 40% RCA lesion
– 35% second OM lesion
– 98% mid-LAD between first and second diagonal
• PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis.
– Fluoro time - 7.8 min., contrast 215cc
ARS question #1
What is the Fluoro Dose in mGy?
1. Unknown, leave blank
2. 3300 mGy
3. 7.8 mGy
4. Ask your physician
ARS question #1
What is the Fluoro Dose in mGy?
1. Unknown, leave blank
2. 3300 mGy
3. 7.8 mGy
4. Ask your physician
Documentation:
• Stress test: a large area of reversible ischemia
• Cardiac cath:
– 40% RCA lesion
– 35% second OM lesion
– 98% mid-LAD between first and second diagonal
• PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis
Fluoro time - 7.8 min., contrast 215cc
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ARS question #2
What Procedures are coded?
1. Diagnostic cath only
2. PCI only
3. Both Diagnostic cath and PCI
4. Diagnostic cath, PCI and Other Procedure
ARS question #2
What Procedures are coded?
1. Diagnostic cath only
2. PCI only
3. Both Diagnostic cath and PCI
4. Diagnostic cath, PCI and Other Procedure
Documentation:
• Stress test: a large area of reversible ischemia
• Cardiac cath:
– 40% RCA lesion
– 35% second OM lesion
– 98% mid-LAD between first and second diagonal
• PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis.
Fluoro time - 7.8 min., contrast 215cc
Section G – PCI ProcedureSEQ # 9500 (Procedure Medications)
Documentation:
• Ms. Jansen has 500u unfractionated Heparin added to
flush
• Loading dose of 300mg Clopidogrel
• A PCI with a 3.0 x 18mm DES Rx with 0% post stenosis
• Fluoro time was 7.8 min
• Contrast 215cc
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ARS question #3
What Procedure Medication(s) are coded?
1. Unfractionated Heparin only
2. Unfractionated Heparin and Clopidogrel
3. Unfractionated Heparin and Glycoprotein IIb/IIIa
4. Clopidogrel only
ARS question #3
What Medication(s) are coded?
1. Unfractionated Heparin only
2. Unfractionated Heparin and Clopidogrel
3. Unfractionated Heparin and Glycoprotein IIb/IIIa
4. Clopidogrel only
Documentation:
• Ms. Jansen has 500u unfractionated Heparin added to
flush
• Loading dose of 300mg Clopidogrel
• A PCI with a 3.0 x 18mm DES Rx with 0% post stenosis
• Fluoro time was 7.8 min
• Contrast 215cc
Section H – Lesions and DevicesSEQ # 7225 (Intracoronary Device(s) Used)
Documentation:
• A PCI with a 3.0 x 18mm Resolute Integrity Rx
• IVUS post procedure of LAD due to haziness
• Stent patent with lack of expansion of stent struts
• Additional inflation with balloon from stent to 8 atm
• Repeat IVUS shows full expansion of the stent, 0%
stenosis
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ARS question #4
What Elements of the Device(s) are coded?
1. IVUS diameter and Resolute Integrity diameter and length
2. Resolute Integrity leave diameter and length blank
3. IVUS diameter and leave length blank
4. Resolute Integrity diameter and length
ARS question #4
What Elements of the Device(s) are coded?
1. IVUS diameter and Resolute Integrity diameter and length
2. Resolute Integrity leave diameter and length blank
3. IVUS diameter and leave length blank
4. Resolute Integrity diameter and length
Documentation:
• A PCI with a 3.0 x 18mm Resolute Integrity Rx
• IVUS post procedure of LAD due to haziness
• Stent patent with lack of expansion of stent struts
• Additional inflation with balloon from stent to 8 atm
• Repeat IVUS shows full expansion of the stent, 0% stenosis
ARS question #5
What Device(s) are coded?
1. Resolute Integrity Rx, Resolute Balloon
2. Resolute Integrity Rx
3. IVUS and Resolute Integrity OTW
4. IVUS, Resolute Integrity Rx, Resolute Balloon
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ARS question #5
What Device(s) are coded?
1. Resolute Integrity Rx, Resolute Balloon
2. Resolute Integrity Rx
3. IVUS and Resolute Integrity OTW
4. IVUS, Resolute Integrity Rx, Resolute Balloon
Documentation:
• A PCI with a 3.0 x 18mm Resolute Integrity Rx
• IVUS post procedure of LAD due to haziness
• Stent patent with lack of expansion of stent struts
• Additional inflation with balloon from stent to 8 atm
• Repeat IVUS shows full expansion of the stent, 0% stenosis
Section K – DischargeSEQ # 9505 (Discharge Medications)
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
ARS question #6
What Medication(s) are coded as “Yes” for discharge?
1. ACE, ARB, ASA
2. ACE, ARB, Lipid Lowering Non-Statin
3. ARB, ASA, Lipid Lowering Statin, Thienopyridine(P2Y12)
4. ARB, Lipid Lowering Statin, Thienopyridine(P2Y12)
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ARS question #6
What Medication(s) are coded as “Yes” for discharge?
1. ACE, ARB, ASA
2. ACE, ARB, Lipid Lowering Non-Statin
3. ARB, ASA, Lipid Lowering Statin, Thienopyridine(P2Y12)
4. ARB, Lipid Lowering Statin, Thienopyridine(P2Y12)
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
ARS question #7
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
ARS question #7
Would this patient be included in the numerator for
Metric #9, Proportion of patients with a P2Y12 inhibitor
prescribed at discharge?
1. No
2. Yes
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
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ARS question #8
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
ARS question #8
Would this patient be included in the denominator for
Metric #9, Proportion of patients with a P2Y12 inhibitor
prescribed at discharge?
1. No
2. Yes
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
ARS question #9
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
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ARS question #9
Would this patient be included in the denominator for
Metric #38, Composite Medications on Discharge?
1. No
2. Yes
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
ARS question #10
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
ARS question #10
Would this patient be included in the numerator for
Metric #38, Composite Medications on Discharge?
1. No
2. Yes
Documentation:
• A Mynx – M5 is used
• Patient discharged home the next morning
• Discharge medications Diovan 80mg qd, due to an adverse
reaction to ACE I
• Simvastatin the same as prior to admission
• New Meds - ASA, Plavix 80 mg, daily
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Dashboard
Post Procedure MI with/without Biomarkers
Objectives:
• Demonstrate how to capture post procedure MI
Seq#8000
• Demonstrate the differences in the criteria and
timeframe
• Demonstrate the impact of the element in the
Outcomes Report
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2007
2012
Metric 13:
Metric 14:
Metrics 13 & 14 Inclusion Criteria
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Causes of Procedural/PeriProcedural MI
Include:
• Acute Artery Closure
• Embolization
• No reflow
• Side Branch Occlussion
• Acute stent Thrombosis
• Dissection
http://content.onlinejacc.org/cgi/content/full/51/21/2068
Patient Drilldown view in Dashboard
Select
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Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)
Documentation:
• Patient presents to ED w/ angina on 10/16/12 @ 1200
• STEMI diagnosed
• Pt has a PCI to Mid Lcx, baseline CK-MB was 4.5 ng/ml
• Post PCI CK-MB drawn 8 hrs was 17.3 ng/ml
• Pt con’t to have STE and taken back to the lab
• Previously placed stent in the Mid Lcx occluded
• PCI performed, additional stent deployed
ARS Question #1
Would this be captured as a post procedure event in
Seq#8000?1. Yes
2. No
Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)
Documentation:• Patient presents to ED w/ angina on 10/16/12 @ 1200
• STEMI diagnosed
• Pt has a PCI to Mid Lcx, baseline CK-MB was 4.5 ng/ml
• Post PCI CK-MB drawn 8 hrs was 17.3 ng/ml
• Pt con’t to have STE and taken back to the lab
• Previously placed stent in the Mid Lcx occluded
• PCI performed, additional stent deployed
Would this be captured as a post procedure event in
Seq#8000?
1. Yes
2. No
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ARS Question #2
If this facility collects pre/post biomarkers on all
patients, would this patient be included in the metric
13 denominator?
1. Yes
2. No
Post Procedure MI with/without Biomarkers
Documentation:
• Patient presents to ED w/ angina on 10/16/12 @ 1200
• STEMI diagnosed
• Pt has a PCI to Mid Lcx, baseline CK-MB was 4.5 ng/ml
• Post PCI CK-MB drawn 8 hrs was 17.3 ng/ml
• Pt con’t to have STE and taken back to the lab
• Previously placed stent in the Mid Lcx occluded
• PCI performed, additional stent deployed
If this facility collects pre/post biomarkers on all
patients, would this patient be included in the metric 13
denominator?
1. Yes 2. No
Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)
Documentation:
• Pt scheduled for elective cath on 09/18/12 @ 0910
• Mild disease in LAD and Lcx
• Anamolous RCA, which had a 20% stenosis in the prox RCA
• Baseline Troponins I normal
• 09/20/12 @ 0700 the patient was taken back to lab w/ STE
• Trop I 5.6 ng/ml prior to the procedure
• Spiral dissection of the RCA, resulted in PCI
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ARS Question #3
How should Seq#8000 be captured for the 1st cath lab
visit?
1. Yes
2. No
3. N/A
Section J – Intra/Post Procedure Events
Seq# 8000 (Myocardial Infarction)Documentation:
• Pt scheduled for elective cath on 09/18/12 @ 0910
• Mild disease in LAD and Lcx
• Anamolous RCA, which had a 20% stenosis in the prox RCA
• Baseline Troponins I normal
• 09/20/12 @ 0700 the patient was taken back to lab w/ STE
• Trop I 5.6 ng/ml prior to the procedure
• Spiral dissection of the RCA, resulted in PCI
How should Seq#8000 be captured for the 1st cath lab visit?
1. Yes 2. No 3. N/A
Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)
Documentation:
• Patient comes to ED w/ STE
• Multi-vessel CAD, culprit artery LAD treated on 9/15/12
• Trop T not drawn pre PCI, post Trop T 21.5 n/gl
• Elective Staged PCI on 9/20/12 of the Ramus/OM1
• Pre procedure biomarkers were normal
• Stents deployed, Trop T drawn 2hrs post 7.2 n/gl
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ARS Question #4
How should Seq#8000 be coded for the 2nd cath lab
visit?
1. Yes
2. No
Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)
Documentation:
• Patient comes to ED w/ STE
• Multi-vessel CAD, culprit artery LAD treated on 9/15/12
• Trop T not drawn pre PCI, post Trop T 21.5 n/gl
• Elective Staged PCI on 9/20/12 of the Ramus/OM1
• Pre procedure biomarkers were normal
• Stents deployed, Trop T drawn 2hrs post 7.2 n/gl
How should Seq#8000 be coded for the 2nd cath lab visit?
1. Yes 2. No
ARS Question #5
Would this patient be included or excluded from the
metric?
1. Included
2. Excluded
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Post Procedure MI with/without BiomarkersDocumentation:
• Patient comes to ED w/ STE
• Multi-vessel CAD, culprit artery LAD treated on 9/15/12
• Trop T not drawn pre PCI, post Trop T 21.5 n/gl
• Elective Staged PCI on 9/20/12 of the Ramus/OM1
• Pre procedure biomarkers were normal
• Stents deployed, Trop T drawn 2hrs post 7.2 n/gl
Would this patient be included or excluded from the metric?
1. Included
2. Excluded
ARS Question #6
Is the patient placed in the numerator or denominator
for the metric?
1. Numerator
2. Denominator
Post Procedure MI with/without BiomarkersDocumentation:
• Patient comes to ED w/ STE
• Multi-vessel CAD, culprit artery LAD treated on 9/15/12
• Trop T not drawn pre PCI, post Trop T 21.5 n/gl
• Elective Staged PCI on 9/20/12 of the Ramus/OM1
• Pre procedure biomarkers were normal
• Stents deployed, Trop T drawn 2hrs post 7.2 n/gl
Is the patient placed in the numerator or denominator for
the metric?
1. Numerator 2. Denominator
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Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)
Documentation:
• Patient has elective cath on 12/01/12 @ 0700
• Pre-procedure biomarkers normal
• Successful PCI is performed on the LAD
• Post procedure labs drawn on 12/2/12 @ 1301
• CK-MB 6.5 n/gl, no chest pain or ECG changes
• Taken to the cath lab, stent was patent
• IVUS performed, NC balloon used for malposition
ARS Question #7
This Post MI should be captured in Seq#8000 for the 1st
visit?
1. True
2. False
Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)
Documentation:
• Patient has elective cath on 12/01/12 @ 0700
• Pre-procedure biomarkers normal
• Successful PCI is performed on the LAD
• Post procedure labs drawn on 12/2/12 @ 1301
• CK-MB 6.5 n/gl, no chest pain or ECG changes
• Taken to the cath lab, stent was patent
• IVUS performed, NC balloon used for malposition
This Post MI should be captured in Seq#8000 for the 1st
visit?
1. True 2. False
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Keys to evaluating Post MI Seq#8000
• Determine the initial CAD Presentation (ACS)
• Lab results pre/post, knowing ULN
• Troponins vs. CK-MB
• Knowing the criteria <24hrs, >24hrs, Peri-
CABG
• Intra/Post procedure events
Risk Adjusted Mortality
Outcomes Report Measure #1
Executive Summary Measure #1 Risk Adjusted Mortality
Documentation:
• 85 y.o. male s/p cardiac arrest
• Transported via EMS to tertiary care, trauma/STEMI ctr
• Cardiogenic shock upon arrival to the cath lab
• CPR ongoing, PCI performed under Salvage status
• Pt deceased during salvage PCI
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ARS Question # 1: Considering the associated risk
factors for mortality, how does this patient’s death
influence the hospital’s RAM outcome?
1. All deaths worsen the RAM outcome.
2. The severity of his risk factors increase the risk of
mortality to a point that it is reflected in the
expected mortality. This will then balance ratio
between the observed and expected mortality.
3. This is a tertiary care center, so their rate is already
likely higher then the mortality rate at a county
hospital. This patient will not change that trend.
How does this death influence the RAM?
1. All deaths worsen the RAM outcome.
2. The severity of his risk factors increase the risk of mortality to a
point that it is reflected in the expected mortality. This will
then balance ratio between the observed and expected
mortality.
3. This is a tertiary care center, their rate is already likely higher
then the mortality rate at a county hospital. This patient will
not change that trend.
Documentation:
• 85 y.o. male s/p cardiac arrest
• Transported via EMS to tertiary care, trauma/STEMI ctr
• Cardiogenic shock upon arrival to the cath lab
• CPR ongoing, PCI performed under Salvage status
• Pt deceased during salvage PCI
Rationale to incorrect responses
1) All deaths worsen the RAM outcome.
• This is not true. The RAM is a ratio of observed over expected
mortalities.
3) This is a tertiary care center, their rate is already likely higher then
the mortality rate at a county hospital. This patient will not change
that trend.
• This is not true. The Risk Adjustment allows all hospitals to be
compared equally.
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Dashboard RAM