Author: Emily Richardson, MD
ASA Monitor 11 2015, Vol.79, 36-38.
Emily Richardson, M.D. is Chief Quality Officer, Encompass Medical Partners, Fort Collins, Colorado.
Collection of data is all well and good, but improvement in patient outcomes requires the ability to turn information into action. The AQI Practice Quality Improvement Committee (PQIC) will collect and present examples of this principle so that all of us can learn from those who are doing it well. Learn more about quality improvement at www.aqihq.org/quality.aspx.
Federal Quality Reporting Programs and Performance Outcomes: The Evolution Continues
In 2014, the Anesthesia Quality Institute’s NACOR was named a Qualified Clinical Data Registry (QCDR) by the Centers for Medicare & Medicaid Services (CMS). A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients.1 This designation allowed for the first specialty-specific outcome measures to be reportable under the Physician Quality Reporting System (PQRS), the federal program that encourages medical professionals to report information on the quality of care they provide.
Differences between process and outcome measures
Prior to 2014, the only measures applicable to general anesthesia providers under the PQRS were process measures, such as administration of prophylactic antibiotics.2 Process measures assess the activities carried out by health care professionals, reflect how care is provided, and are direct measures of quality of care only when a link has been demonstrated between a given process and outcome.3
Outcomes reflect the health status of the patient and can include measures such as mortality, laboratory test results, and patient-reported health states such as functional status and symptoms.4 Patient outcomes represent the final common product of all clinical activity and are the cornerstone of performance measurement.5 The validity of performance measurement based on outcomes is a function of data quality, risk adjustment, sample size and the accuracy of the outcomes themselves.5 Outcome measures are preferred over process measures because improving health outcomes is a central goal of health care.6
Creating measures meaningful to anesthesia providers
The creation of QCDRs provided a new avenue for individual EPs to satisfy PQRS requirements while simultaneously capturing outcome measures of interest to their specialty. Each QCDR has the flexibility to develop measures that will best achieve the goal of improving the quality of care furnished by providers. This reporting mechanism has allowed specialty societies, such as the ASA working with AQI, to develop meaningful measures that reflect profession-specific priorities and instances of care.7 The AQI was quick to identify several measures indicative of quality anesthesia care. Although some of the 11 original QCDR measures were process measures, seven were outcomes measures.8 In 2014, the available measures included perioperative mortality rate, perioperative cardiac arrest rate, reintubation rate, and arterial injury or pneumothorax after central line placement. In late March 2015, AQI expanded the available QCDR measures set to a total of 27.9
What is the role of the AQI?
As the largest anesthesia registry in the country, AQI’s vision is “to be the primary source of information for quality improvement in the clinical practice of anesthesiology. Through education and quality feedback, AQI will help to improve the quality care of patients, lower anesthesia mortality and lower anesthesia incidents.”10 Anesthesia providers are now able to meet federal quality reporting requirements while simultaneously collecting outcome measures that are meaningful to them and their patients.
Available outcome measures
Satisfactory participation in the PQRS QCDR program currently requires the reporting of at least two outcomes measures of the nine quality metrics required for each eligible professional. Outcomes measures available for the 2015 reporting period through the AQI QCDR include the following:9
|ASA#10||Composite Anesthesia Safety|
|ASA#11||Immediate Perioperative Cardiac Arrest|
|ASA#12||Immediate Perioperative Morality Rate|
|ASA#13||PACU Re-intubation Rate|
|ASA#14||Short-term Pain Management|
|ASA#15||Composite Procedural Safety for Central Line Placement|
|ASA#18||Perioperative Temperature Management|
|ASA#22||Corneal Injury Diagnosed in the PACU/Recovery Area after Anesthesia Care|
|ASA#23||CABG: Prolonged Intubation|
|ASA#25||CABG: Post-operative Renal Failure|
|ASA#28||Rate of Post-operative stroke or death in asymptomatic patients undergoing Carotid Artery Stenting (CAS)|
|ASA#29||Rate of Post-operative stroke or death in asymptomatic patients undergoing Carotid Artery Endarterectomy (CAE)|
|ASA#30||Rate of Endovascular aneurysm repair (EVAR) of small or moderate non-ruptured abdominal aortic aneurysms (AAA) who expire while in the hospital|
|ASA#31||Total Knee Replacement: Venous thromboembolic and cardiovascular Risk Evaluation|
|ASA#33||Unplanned Hospital Readmission within 30 days of Principle Procedure|
|ASA#34||Surgical Site Infection|
Composite Anesthesia Safety (ASA Metric # 10)
Of particular interest to many clinicians is ASA#10. This measure is defined as the percentage of patients who underwent an anesthetic without the occurrence of a major adverse event. Major adverse events (Table 1, page 38) are defined according to the 2009 Committee on Performance and Outcomes Measurement annual report work product “Development of the ASA Critical Incidents Reporting System.”11 Assessing the rate of these adverse events provides an opportunity for both national benchmarking and driving quality improvement at the local level.
Measuring immediate and longitudinal outcomes
While many of the QCDR measures reflect outcomes that occur in the operating room or in the post-anesthesia recovery (PACU) area, several indicate outcomes that may occur remote from the immediate perioperative period. Successful collection and reporting of such outcomes data will require collaboration and data sharing between multiple stakeholders. Some providers may argue that complications such as death, renal failure, postoperative MI, respiratory failure and strokes cannot be classified as anesthesia-related versus surgery-related. However, several thought leaders in anesthesia quality would disagree. In the 2011 article Performance Measurement at a “Tipping Point,” Glance et al. state: “… the absence of a validated algorithm to identify anesthesia-related outcomes does not mean that anesthesiologists should escape accountability for these outcomes. After all, if the performance of cardiac surgeons is profiled, why not that of cardiac anesthesiologists? In actuality, anesthesiologists and surgeons are part of a multidisciplinary team, and interact in a complex manner with one another, and with hospital factors, to affect patient outcomes.”5 The assessment and reporting of longitudinal outcomes will likely increase as ASA and AQI committees, along with physician leaders, update and create measures for the upcoming 2016 reporting year.
MACRA, MIPS and the future of quality
With the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April of this year, we saw the creation of a new payment-for-value program, the Merit-Based Incentive Payment System, or MIPS. There is a strong indication that the structure of and measures in the PQRS and QCDR programs will remain an important piece of MIPS. Under the MIPS, eligible professionals will receive a composite performance score based on four components: quality measures, resource use, meaningful use of electronic health records, and clinical practice improvement activities.12 Beginning in 2019, payment adjustments will be based on the professionals’ score relative to a performance threshold. The performance threshold will be based on the mean or median (as selected by the secretary) of the composite score for all MIPS-eligible professionals. Providers participating in an alternative payment model will not be subject to MIPS. However, the alternative payment model must include quality measures comparable to those used in the MIPS.12
While performance measurement is an imperfect science, it is undoubtedly becoming a mainstay in the national quality improvement agenda.3,13 The coming months and years will see further change as the evolution of outcome measures continues.
Medicare Program; revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to Part B for CY 2014. Red Regist. December 10, 2013;78(237):74230–74823.https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014-Medicare-Physician-Fee-Schedule-Final-Rule.pdf. Accessed September 11, 2015.
2013 Physician Quality Reporting System (PQRS): Claims/Registry Measure Specifications Manual. Baltimore, MD: Centers for Medicare and Medicaid Services; 2013.
Mant J . Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001;13(6):475–480.
Selecting health outcome measures for clinical quality measurement. Agency for Healthcare Research and Quality website.http://www.qualitymeasures.ahrq.gov/tutorial/HealthOutcomeMeasure.aspx. Last updated June 18, 2015. Accessed August 13, 2015.
Glance LG, Neuman M, Martinez EA, Pauker KY, Dutton RP . Performance measurement at a “tipping point”. Anesth Analg. 2011; 112(4):958–966.
Guidance for Evaluating the Evidence Related to the Focus of Quality Measurement and Importance to Measure and Report. Washington DC: National Quality Forum; January, 2011.
Dutton RP, ed; American Society of Anesthesiologists Committee on Quality Management and Departmental Administration (QMDA). Manual for Anesthesia Department and Organization and Management. Summer 2015 ed. Schaumburg, IL: American Society of Anesthesiologists; 2015.http://www.asahq.org/quality-and-practice-management/quality-improvement/qmda-toolkit/manual-for-anesthesia-department-organization-and-management. Accessed September 11, 2015.
AQI QCDR Measure Specification: Year 2014. Schaumburg, Illinois: Anesthesia Quality Institute; 2014. http://www.aqihq.org/files/AQI%20non-PQRS%20Measures%20Narrative%20070114%282%29.pdf. Accessed September, 2015.
AQI QCDR Measure Specification: Year 2015. Schaumburg, Illinois; 2015.http://www.aqihq.org/files/pqrs/2015_QI_non-PQRS_Measures_Narrative__Final.pdf. Accessed September 11, 2015.
About us, . Anesthesia Quality Institute website.https://www.aqihq.org/about-us.aspx. Accessed July 30, 2015.
American Society of Anesthesiologists Committee on Performance and Outcomes Measurement. Development of the ASA Critical Incidents Reporting System. Anesthesia Quality Institute website.http://www.aqihq.org/files/CPOM-registry-data-set.pdf. Published August 23, 2009. Accessed September 11, 2015.
H.R.2 – Medicare Access and CHIP Reauthorization Act of 2015, 114th Cong (2015-2016). Congress.gov. https://www.congress.gov/bill/114th-congress/house-bill/2. Accessed September 11, 2015., Page 129 STAT. 93-99.
Glance LG, Kellermann AL, Hannan EL, et al. The impact of anesthesiologists on coronary artery bypass graft surgery outcomes. Anesth Analg. 2015;120(3):526–533.