Quality Committee Meeting Minutes 1.28.2019

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, January 28, 2019

Agarwala, Aalok (MGH)

Lins, Steve (Bronson Battle Creek)

Applefield, Daniel (St. Joseph Oakland)

Louzon, Kathryn (Beaumont Royal Oak/Troy)

Angel, Alan (Bronson Battle Creek)

Lucier, Michelle (Henry Ford)

Aziz, Mike (Oregon)

Mathis, Mike (Michigan)

Biggs, Dan (Oklahoma)

Malenfant, Tiffany (Beaumont Trenton/Wayne)

Bledsoe, Amber (Utah)

McKinney, Mary (Beaumont Dearborn/Taylor)

Buehler, Katie (MPOG)

Milliken, Chris (Sparrow)

Clark, David (MPOG)

Quinn, Cheryl (St. Joseph Oakland)

Coffman, Traci (St. Joseph Ann Arbor)

Pardo, Nichole (Beaumont Grosse Pointe)

Collins, Kathleen (St. Mary)

Poindexter, Amy (Holland)

Coons, Denise (Bronson)

Poterek, Carol (Beaumont)

Cuff, Germaine (NYU Langone)

Pywell, Carol (Beaumont)

Harwood, Tim (Wake Forest)

Rensch, Robert (Beaumont Kalamazoo)

Johnson, Ray (Beaumont Wayne)

Saager, Leif (MPOG)

Heiter, Jerri (St. Joseph A2)

Schmidt, Carol (Beaumont)

Hitti, Nicole (Weill Cornell)

Schonberger, Rob (Yale)

Kheterpal, Sachin (MPOG)

Shah, Nirav (MPOG)

Lacca, Tory (Michigan)

Silvasi, Daniel (Beaumont Troy)

LaGorio, John (Mercy Muskegon)

Tyler, Pam (Beaumont Farmington Hills)

Agenda & Notes

1. Minutes from November 26, 2018 meeting approved- posted on the website for review.

Recording available as well.

2. Roll Call: Will contact QI Champions and ACQRs directly to inquire about participation status

if missing. Other participants can review meeting minutes and contact Coordinating Center if

missing from attendance record.

3. Upcoming Events:

a. April 5, 2019 – MSQC/ASPIRE Collaborative Meeting

i. Schoolcraft VistaTech Center- Livonia

ii. Keynote Speaker: Dr. Rob Schonberger (Yale)

iii. Dr. Sachin Kheterpal giving an update on PROSPER

b. July 26, 2019 – ASPIRE Collaborative Meeting

i. Lansing, MI

c. October 18, 2019 – MPOG Retreat

i. Orlando, Florida

d. Mark your calendars! Total of 6 Quality Committee meetings in 2019:

i. Monday, February 25, 2019 at 10:00 a.m. Eastern

ii. Monday, April 22, 2019 at 10:00 a.m. Eastern

iii. Monday, June 24, 2019 at 10:00 a.m. Eastern

iv. Monday, September 23, 2019 at 10:00 a.m. Eastern

v. Monday, November 25, 2019 at 10:00 a.m. Eastern

4. 2019 Plans

a. QI Initiative: Reducing Perioperative Infections

i. Measure Bundle (Temperature Management- TEMP 01, 02, 03, Glycemic

Management- GLU 01 and O2, Transfusion Management- TRAN 01 and 02) + new

Measures as identified (abx?)

ii. Toolkit Development

iii. Coordinating Center Support- work with other CQIs to obtain SSI outcome data

and feed back to anesthesia quality champions via the dashboard

b. Work with selected sites to improve data quality for research and quality projects (data

cleaning!)

i. Cleaning to ensure all sites are contributing minimum data set.

ii. MPOG selected sites have already been contacted by Coordinating Center and

work is under way!

iii. Contact Katie Buehler (kjbucrek@med.umich.edu

) if interested in data cleaning

assistance from Coordinating Center.

c. Measure Plans:

i. Incidence of PONV in PACU

ii. Glycemic Management- expand GLU 01 and 02 to preop/PACU

iii. Respiratory Complications in PACU

iv. SUS 01

v. CARD 03

vi. PUL 03/PUL 04 – Pulmonary bundle (PEEP and low tidal volume measure)

d. Continue work with CQIs for data integration: there are about 20 other collaboratives

within the state of Michigan and about 8 of those are surgical collaboratives. ASPIRE will

be working with these sites to modify data use agreements to allow for data integration

with other CQIs. Goal: Build shared measures across surgical CQIs with ASPIRE. Bridges a

gap in ASPIRE data: procedural outcomes data (mortality, postop cardiac complications,

SSIs). Michigan sites will hear from ASPIRE Coordinating Center to get this paperwork

updated. Contact Tory Lacca with any questions (lacca@med.umich.edu)

e. Convert sites to IM: Benefits sites in being able to get Preop/PACU data and allows local

IT teams to more easily conduct troubleshooting of technical issues that arise.

f. Contact Coordinating Center with any other ideas for initiatives.

5. 2019 BCBS VBR Program

a. Performance Period: October 1, 2017-September 30, 2018

b. To be eligible:

i. Member of a PO for at least 1 year

ii. Have at least 2 years of data in ASPIRE

iii. Aggregate PO performance >/= 90% for 3 out of 4 measures (PUL 01, TEMP 03,

TOC 02, NMB 02)

c. 3% applied starting March 1, 2019 to anesthesiologist provider payments for cases that

were personally performed or supervising resident

6. 2020 BCBS VBR Program

a. Performance Period: December 1, 2018-November 30, 2019

b. To be eligible:

i. Member of a PO for at least 1 year

ii. Have at least 2 years of data in ASPIRE

iii. Aggregate hospital performance >/= threshold for 2 out of 3 measures (PUL 02-

70%, TEMP 03- 90%, TOC 02-90%)

1. Physicians are assigned to hospital where they have performed the most

cases

2. Cumulative average over the 12 month period will be used to determine

if threshold was met

7. P4P Update

a. 2019 scorecards are available on the website

i. One scorecard for Cohort 4 (80% based on participation; 20% on performance)

ii. One scorecard for Cohort 1-3 (60% for performance; 40% for participation)

b. 2018 scorecard performance is being calculated now and sites will be contacted by the

end of the month regarding these scores

8. Subspecialty Subgroups: Contact if interested

a. Pediatrics: Wake Up Safe initiative started by Society of Anesthesia- Pediatrics (SOAP) has

several pediatric hospitals participating. If there are any anesthesiologists who

participate in this initiative and would like MPOG to translate these measures for data

capture through MPOG- please contact the Coordinating Center.

b. OB: If interested in joining the OB Subcommittee and would like to create other OB-

specific ASPIRE measures, please contact the Coordinating Center. ASPIRE/MPOG is

willing to re-convene this group and devote resources to measure development in this

area, if participants are interested.

9. Measure Updates

a. PONV 02 (MIPS 467)

i. Inhalational agents used for maintenance (as opposed to induction) counted as a

risk factor

ii. We use Procedure Start as the time marker to start the maintenance period.

Some sites do not document Procedure Start for MRI cases, resulting in several

false failures.

iii. Measure Modification: if Procedure Start not available, we will now use

Induction End to start the maintenance period.

b. TRAN 02

i. Transfusion Measure Meeting 12/05/2018

ii. Extend the measure period to 18 hours after surgery to take the lowest hgb/hct

in that time period

iii. Evaluate the hgb/hct at the time of transfusion (within 90 minutes before

transfusion)- if less than or equal to 8/24, will pass measure

c. TEMP 02: New Core Monitoring Device

i. Zero heat flux thermometry sensor

ii. Equivalent to other core temperature locations

iii. Will count as core temperature method

iv. Both 3M and Drager have devices that measure core temperature in this way

d. CARD 03

i. Description: Percentage of high cardiac risk cases with significantly elevated

postoperative troponin levels (Troponin I ≥ .60 mcg/L)

ii. “Cards 02” for high risk patients

iii. Inclusions

1. All high-risk surgeries

a. High-risk surgeries include intraperitoneal, intrathoracic, or

suprainguinal vascular procedures, as adapted from the Revised

Cardiac Risk Index (RCRI) and identified by Anesthesia CPT codes:

2. All anesthetic cases performed on patients with history of ischemic heart

disease, congestive heart failure, cerebrovascular disease, diabetes

requiring preoperative insulin, or chronic kidney disease (baseline Cr >

2.0 mg/dL)

a. Comorbidities posing high cardiac risk are adapted from the

Revised Cardiac Risk Index (RCRI) and are identified by Elixhauser

Comorbidity Index variables (congestive heart failure, diabetes),

preoperative lab values (baseline serum creatinine), or

comorbidity-specific ICD-9/10 codes (ischemic heart disease,

cerebrovascular disease):

i. Congestive heart failure - Elixhauser Comorbidity

Phenotype

ii. Diabetes - Elixhauser Comorbidity – Diabetes

(uncomplicated), Elixhauser Comorbidity – Diabetes

(complicated)

iii. Ischemic Heart Disease - MPOG Phenotype – Coronary

Artery Disease

iv. Cerebrovascular Disease - MPOG Phenotype –

Cerebrovascular Disease

v. Chronic Kidney Disease - Most recent serum creatinine

within 60 days > 2.0 mg/dL

iv. Exclusions

1. ASA 5 and 6 cases.

2. Troponin I > 0.01 within 42 days prior to anesthesia start.***

3. Pacemaker insertions (CPT: 00530)

4. Cardiac Ablation (CPT: 00537)

5. Cardiac surgery without pump (CPT: 00560)

6. Cardiac surgery with pump < 1 year old (CPT: 00561)

7. Cardiac surgery with pump and 1 year old (CPT: 005622)

8. Cardiac surgery with hypothermic arrest (CPT: 00563)

9. CABG without pump (CPT: 00566)

10. CABG with pump (CPT: 00567)

11. Heart Transplant (CPT: 00580)

12. Testing of cardioversion or defibrillator functions (CPT: 00534)

v. Release in March

e. AKI 01

i. Adding filter for high risk patients

ii. Patients at high risk for progressing to CRF

10. CPT Prediction

a. Finally… adding the ability to use this tool for all measures

b. Will supplement, but not replace pro fee billing data

c. Tool predicts top 3 anesthesia codes for each case

d. If one of those codes is on the exclusion list, then the case will be excluded.

e. Actual CPT code will then be used to compare result and change “status” of case as

necessary

11. NMB 02- C

a. Current exclusion criteria allows for cases to pass if there was 3 hours or greater since

last dose of NMB, no need to administer reversal

b. Dr. Glenn Murphy released new literature 4-5 months ago, both groups 0.9

acceleromyography measured at 4 hours after NMB dose, gave small dose of reversal to

one group and no reversal to the other group, group with reversal did much better in

terms of outcomes. Downsides of reversal unlikely to outweigh the benefit outlined in

this article. Will circulate article to ASPIRE and see what the group perceives as the best

next steps with modifications to NMB 02.

c. ASPIRE will review data to see how many cases passed due to the current 3 hour post-

NMB criterion vs. shifting to last dose of NMB 4-8 hours before not requiring reversal

Meeting concluded at 10:54am