Although anesthesiologists have always paid attention to blood pressure and its effects on both immediate and postoperative patient outcomes, only recently have anesthesiologists had better definitions and criteria to assess management of a patient’s blood pressure. The question for anesthesiologists and their groups is how best to deploy these definitions, collect data, and assess how managing a patient’s blood pressure may affect outcomes.

Just before the COVID-19 pandemic, Cleveland Clinic partnered with ePreop (now Provation) to create a quality measure assessing intraoperative hypotension among nonemergent noncardiac surgical cases. The measure initially relied upon electronic data, a plus for gathering support for its inclusion in payment programs, but some groups have been able to collect the required data by using other instruments and documentation. The measure assesses the percentage of noncardiac, nonemergency general anesthesia cases in which mean arterial pressure (MAP) fell below 65 mmHg for a cumulative total of 15 minutes or more.

This measure falls within an important category of quality measures where complete compliance, or rather a “100% score,” is not necessarily attainable or desirable. These measures are sometimes referred to as “Goldilocks measures” because a good score might have high, but not perfect, performance. Indeed, the measure acknowledges that “some patients could have a MAP that falls below 65 for reasons outside a provider’s control.” Other measures that fall into this category include glycemic management in diabetes as well as conversion to general anesthesia for obstetric patients.

The Centers for Medicare & Medicaid Services (CMS) appreciates these “Goldilocks” measures because performance on these measures often results in scores that can be differentiated on a 10-point scale. As participants in the Merit-Based Incentive Payment System (MIPS) know, patient safety measures usually top out quickly, resulting in few opportunities to reach a 10-point score, let alone the 7 points available for such measures. Although the CMS topped-out policy is a perverse incentive since it rewards perceived differences in care rather than patient safety and efficiency, measures like monitoring intraoperative hypotension may provide groups with an opportunity to earn a higher score.

Anesthesiologists and their groups will need to determine how best to capture, report, and assess the Intraoperative Hypotension Quality Measure. For those participating in the Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (AQI NACOR), groups can collect the data throughout the year and then decide if they wish to report it to CMS for MIPS or if they prefer to use the measure as an internal quality improvement opportunity. In 2023, of the 54 measures AQI NACOR offers anesthesiologists and their groups to report, 27 of them could be reported either for non-MIPS quality improvement purposes or for MIPS. Intraoperative hypotension is one of those measures. As an aside, the other 27 measures are known as “Internal Improvement Measures” and can be reported just for benchmarking purposes only. The Intraoperative Hypotension Quality Measure was approved for use in the 2024 Anesthesia MIPS Value Pathway. Measures related to hemodynamic instability and intraoperative hypotension are also available for groups participating in the Multicenter Perioperative Outcomes Group (MPOG).

For some groups, just tracking the measure internally might be the best first step. The 2022 Anesthesia Patient Safety Foundation (APSF) Stoelting Conference recently produced recommendations around hemodynamic stability and emphasized the importance of revisiting how hemodynamic stability affects patient outcomes. Their recommendations call for preventing hemodynamic instability related to harm during all phases of care and encouraged further training on integrating blood pressure monitoring, communication, and data among anesthesia professionals and other health care workers. Such recommendations support further scrutiny on postanesthetic care coordination aimed at early detection, assessment, and action on patient data that may indicate possible poor patient outcomes, whether in the postanesthesia care unit or recovery floors.

Implementation of the measure can be challenging even if your group uses electronic health records and has information technology and vendor resources available. The measure itself encourages the monitoring of blood pressure and does not in and of itself directly measure patient outcomes beyond the postanesthesia care unit. But some anesthesia groups and facilities have used the measure to assess whether certain patient outcomes are influenced by the measure. At UCLA, the implementation of the Intraoperative Hypotension Quality Measure was paired with outcome measures.

Based on similar criteria as the Intraoperative Hypotension measure, the UCLA Department of Anesthesiology & Perioperative Medicine implemented a robust clinical decision support system and care pathway to notify personnel of the occurrence of hypotension during anesthesia care and to promote the treatment and prevention of intraoperative hypotension. Patients were assessed for the occurrence of acute kidney injury (AKI) as well as major adverse cardiovascular events (MACE). Data were collected on intraoperative hypotension as well as outcomes of AKI and MACE for 12 months prior to pathway implementation and for 34 months after implementation. A significant decrease in the incidence of intraoperative hypotension occurred, although the timing of the change actually occurred prior to the pathway implementation date and was sustained throughout the postimplementation period. No differences were seen in clinical outcomes before and after pathway implementation. Collecting and reporting data related to this pathway, and similar to reporting the Intraoperative Hypotension measure, are greatly aided by a robust information technology infrastructure. UCLA Health manages a departmental data warehouse with data exported directly from the electronic health record system.

As noted in the measure rationale, several studies within the last decade have indicated that a “MAP below 60-70 mmHg among adults having noncardiac surgery is associated with increased risk of AKI, myocardial injury, and mortality, and the risk is a function of both hypotension severity and duration.” Yet the UCLA observation that treating or preventing intraoperative hypotension did not improve clinical outcomes is consistent with other recent findings. Results of the POISE-3 (PeriOperative ISchemic Evaluation-3) Trial published this year showed that in patients having noncardiac surgery, a hypotension-avoidance strategy targeting intraoperative MAP ≥ 80 mmHg and hypertension-avoidance strategy targeting intraoperative MAP ≥ 60 mmHg resulted in a similar incidence of major vascular complications (Ann Intern Med 2023;176:605-14). Although it remains unclear to what extent treatment or prevention of intraoperative hypotension may influence important patient outcomes, the Intraoperative Hypotension measure allows anesthesiologists to report performance in this fundamental aspect of anesthesia care: intraoperative blood pressure management.

CMS has included the Intraoperative Hypotension measure in the 2024 Anesthesia MIPS Value Pathway, indicating its desire to give anesthesiologists additional options for choosing quality measures. For those groups not reporting MIPS, we encourage you to review the quality measure and consider collecting and reporting data via AQI NACOR for benchmarking purposes.

Additional information on the Anesthesia Internal Improvement Measures can be found at and Anesthesia MIPS and Qualified Clinical Data Registry Measures at