VOLUME 32, ISSUE 1

Davide Cattano, MD, PhD, FASA

Professor, Department of Anesthesiology
McGovern Medical School, University of Texas
Houston, TX

Richard P. Dutton, MD, MBA, FASA

Adjunct Professor, Department of Anesthesiology
Texas A&M University College of Medicine
College Station, TX

The Pros and Cons of Quality Measurement

Failure to report performance under the Merit-based Improvement Payment System (MIPS) in 2019 will cost clinicians a 9% penalty to their Medicare payments in 2021.1 Not surprisingly, in 2018 more than 95% of all anesthesiologists reported under MIPS, most of them at a level just sufficient to avoid penalties. But does MIPS measurement improve clinical quality?

The American Society of Anesthesiologists (ASA) Qualified Clinical Data Registry (QCDR) for reporting MIPS data is the National Anesthesia Clinical Outcomes Registry (NACOR). More than 15,000 anesthesiologists used NACOR in 2018, and thousands of others used various proprietary QCDRs with similar measures. Because ‘topped out’ measures are removed from the set by CMS, all QCDRs serving anesthesiologists are required to constantly update and replace their measures every year.

Adapting to the constantly changing landscape of quality data measurement is a significant burden for most groups and clinicians and requires nimble information technology and support services. From the ASA side, there is an ongoing need to develop and promote new measures.

This year 4 new metrics have been proposed for testing by the ASA: prevention of arterial line blood stream infection, perioperative anemia management, intraoperative antibiotic redosing, and ambulatory glucose management).2

Measure development is an evolving art. On the one hand, the measure needs to be logistically feasible, related to direct actions of the anesthesiologist and, generally, non-embarrassing to practitioners. On the other hand, the measure should be directly linked to an important patient outcome. Failure to achieve logistic feasibility will result in un-useable measures and failure to tie measurements to real clinical care will promote cynicism in anesthesiologists, leading to a lack of engagement.

One way to assess proposed measures in anesthesia would be referencing them to our specialty’s collective goals for improving patient safety. The Anesthesia Patient Safety Foundation (APSF) has recently published a list of the top 12 priorities (Table).3

Table 1. APSF Perioperative Patient Safety Priorities

  1. Preventing, detecting, and mitigating clinical deterioration in the perioperative period
  2. Safety in non-operating room locations
  3. Culture of safety
  4. Medication safety
  5. Perioperative delirium, cognitive dysfunction, and brain health
  6. Hospital-acquired infections and environmental microbial contamination and transmission
  7. Patient-related communication issues, handoffs, and transitions of care
  8. Airway management difficulties, skills, and equipment
  9. Cost-effective protocols and monitoring that have a positive impact on safety
  10. Integration of safety into process implementation and continuous improvement
  11. Burnout
  12. Distractions in procedural areas

Of these, existing MIPS measures for anesthesia cover number 6 well (infection control), and number 7 partially (patient satisfaction). Several current MIPS measures do not address APSF priorities at all, including measures intended to reduce smoking, postoperative pain, and perioperative nausea/ vomiting. Meanwhile, the majority of the APSF measures are either unaddressed (medication safety, nonoperating room anesthesia, perioperative delirium, burnout and distraction), or have been addressed in the past but are no longer included in the MIPS or QCDR measure set (perioperative mortality, intraoperative cardiac arrest, reintubation), because the results have been too uniformly good; i.e., the measure is topped out.

Clearly, alignment could be better. The act of measurement — and the associated documentation and information technology required — sends a strong daily measure regarding the value of the activity being studied. Good recent examples from the ASA QCDR that contribute to improved patient care include measures on the assessment and mitigation of obstructive sleep apnea and the promotion of multimodal analgesia across a wide range of cases. This kind of alignment of measurement and outcome will improve clinician engagement even without local quality improvement activities based on the results. Engagement, in turn, will reduce cynicism and directly address one of the other APSF priorities: reducing physician burnout.

The Texas Society of Anesthesiologists can play a role in this discussion. As one of the largest state component societies in the ASA, the opinion of our members on the alignment between the need for measurement and the clinical value of individual measures could be influential. One approach might be a combined effort of the TSA’s Patient Quality and Safety, Practice Management and Long Range Planning Committees to delineate strategic goals for the next 3-5 years of quality improvement in anesthesiology. We propose this as an activity for the coming year.

References:

  1. https://www.adsc.com/blog/what-you-need-to-know-about-mips-macra-2019 accessed 11/20/2019
  2. https://www.asahq.org/quality-and-practice-management/quality-improvement/public-comment-opportunities accessed 11/20/2019
  3. https://www.apsf.org/article/apsf-highlights-12-perioperative-patient-safety-priorities-for-2018/ accessed 11/20/2019

Next