Quality Committee
Meeting
March 22, 2021
Agenda
• Announcements
• VBR Update
• PONV 03 Threshold
• GLU Measure Attribution
• Subcommittee Updates
• Measure Review and Vote
– CARD 02/03 – Drs. Reidy & Andrawes
Meeting Minutes
January 2021
Roll Call – via Zoom or
contact us
Upcoming Events
Friday, April 23, 2021, MSQC / ASPIRE Collaborative Meeting - Virtual
Friday, July 16, 2021, ASPIRE Collaborative Meeting - probably virtual
Friday, October 8, 2021, MPOG Retreat - hopefully in person and also probably virtual
VBR Updates
Kate Buehler
2021 BCBSM VBR Program
● Performance Period: January 1, 2020-November 30, 2020
● Measures Included:
○ PUL 02 ≥ 85%
○ TEMP 03 ≤ 5%
○ PONV 01 ≥ 85%
● To be eligible:
○ Member of a PO for at least 1 year
○ Have at least 2 years of data in ASPIRE
○ Aggregate hospital performance
■ Met target for 2 out of 3 measures: 3% uplift
■ Met target for 3/3 measures: additional 2% uplift (NEW)
● Letters will be sent to Provider Organizations to inform providers of uplift amount
● Reminder: VBR is applied only to BCBSM Commercial PPO claims
2022 BCBSM VBR Program
● Performance Period: December 1, 2020-November 30, 2021
● Measures Included:
○ GLU 03 ≥70%
○ BP 03 ≥85%
○ SUS 01 ≥85%
● To be eligible:
○ Member of a PO for at least 1 year
○ Have at least 2 years of data in ASPIRE
○ Aggregate hospital performance
■ Meet target for 2 out of 3 measures: 3% uplift
■ Meet target for 3/3 measures: additional 2% uplift
PONV Threshold Changes
Nirav
PONV 03 - Request to change threshold from 5% to 10%
PONV 03: Percentage of patients, regardless of age, who undergo a procedure and have a
documented nausea/emesis occurrence OR receive a rescue antiemetic in the immediate
postoperative period
PONV 03b: Percentage of patients, regardless of age who undergo a procedure and have a
documented nausea/emesis occurrence with or without receiving an antiemetic in the
immediate postoperative period
Modify threshold to 10% to balance more closely with national rates/ good care
Glucose Measure
Attribution
GLU 03/04/05 Measure Description
• GLU 03 - The percentage of cases with perioperative high glucose (>200mg/dL)
appropriately treated or rechecked
• GLU 04 - The percentage of cases with perioperative low glucose (<60mg/dL)
appropriately treated or rechecked
• GLU 05 - Percentage of cases with a perioperative blood glucose >200 mg/dL with
documentation of insulin treatment
Provider Attribution
• There have been multiple requests from sites to add these measures to provider
feedback emails
• These measures do not currently include provider attribution, which will need to be
added before they can be included in feedback emails
• GLU 03/04/05 span from preoperative holding through PACU
• Should provider attribution be added to these measures?
• Who should be the ‘responsible provider’ for blood glucoses taken in preop? In PACU?
Our recommendation:
1. Add attribution
2. For blood glucose in preop, attribute to first providers signed into case
3. For blood glucose in PACU, attribute to last providers signed into case
OB Subcommittee
Updates
Brooke Szymanski Bogart
OB Subcommittee Update
• Next Meeting May 5th at 1pm EST
• The ‘Obstetric Anesthesia Type Phenotype’ is completed and will soon be used in
all measures for including/excluding labor epidural and cesarean delivery cases
• Two new measures released:
– BP 04 - OB
– GA 01-OB
– These are available via the ‘All Measures’ dashboard or through the
‘Obstetrics’ dashboard
Hypotension During Cesarean Delivery (BP 04- OB)
• Description: Percentage of cases with systolic blood pressure <90mmHg for less than or equal to 5 minutes
during the time from spinal placement to delivery.
• Measure Time Period: Spinal placement to neonate delivery
• Inclusions: All cesarean deliveries with neuraxial anesthesia only
• Exclusions
– Cesarean delivery patients undergoing general anesthesia- determined using Anesthesia
Technique-Neuraxial MPOG phenotype
– Patients undergoing cesarean section with hysterectomy (CPT: 01969)
– Emergency cesarean delivery with diagnosis of placental abruption (ICD-10: O45*)
– Rupture of uterus (spontaneous) before onset of labor (ICD-10: O71.0)
– Newborn affected by intrauterine blood loss from ruptured cord (ICD-10: P50.1)
– Abnormal uterine or vaginal bleeding, unspecified (ICD-10: N93.9)
– Placenta previa with hemorrhage, third trimester (ICD-10: O44.13)
– Hemorrhage from placenta previa, antepartum condition or complication (ICD-10: 641.13)
– Hemorrhage from placenta previa, delivered, with or without mention of antepartum condition (ICD-10:
641.11)
– ICD-10 Codes associated with the case and documented from 7 days before to 30 days after the case are
considered
Hypotension During Cesarean Delivery (BP 04- OB)
• Success: SBP <90mmHg for less than or equal to 5 minutes during the time period of spinal placement to
delivery
• Measure End Time:
1. Delivery of Neonate 2 (50189), if not available
2. Delivery of Neonate (50358), if not available,
3. Oxytocin (10343) Administration Start Time (bolus or infusion), if not available,
4. Obstetrics - Uterine Incision (50357), if not available,
5. AACD Anesthesia End Date/Time (50009)
• Other Measure Build Details:
– Multiple blood pressures: Instances where there are two blood pressure monitoring methods, the
higher MAP will be used to determine measure compliance.
– Artifact: Artifact readings will be identified and removed from final measurement calculation. Artifact
processing: if systolic and diastolic blood pressures are present, the values must be at least 5 mmHg
apart; otherwise the values will be excluded. MAP values less than 10 are excluded.
– Each incidence of hypotension will count for a max of 5 minutes or until ‘Measure End’ (whichever is
sooner) if there is a gap in blood pressure measurement
–
Hypotension During Cesarean Delivery (BP 04- OB)
Full measure specification details available at:
https://spec.mpog.org/Spec/Public/45
General Anesthesia used during Cesarean Delivery (GA 01- OB)
• Description: Percentage of cesarean delivery cases where general anesthesia was used
• Measure Time Period: Anesthesia Start to Anesthesia End
• Inclusions: All cesarean deliveries
• Exclusions
– Cesarean Hysterectomies as determined by the “Obstetric Anesthesia Type” Phenotype
– Non-cesarean delivery cases
• Success: Cesarean delivery completed without use of general anesthesia
• Other Measure Build Details:
• Use of general anesthesia is determined by the ‘Anesthesia Technique: General’ phenotype
General Anesthesia used during Cesarean Delivery (GA 01- OB)
Full measure specification details available at:
https://spec.mpog.org/Spec/Public/46
OB Subcommittee Updates
• Questions related to the ASPIRE OB Subcommittee can be sent to Brooke
Szymanski-Bogart, bmiszy@med.umich.edu
Pediatric Subcommittee
Updates
Meridith Bailey
Peds Subcommittee Update
• February 2021 Meeting Recap:
– Reviewed PAIN-01 performance across MPOG peds institutions
– Discussed PONV-02 measure revisions based on new 2020
consensus guidelines
Inclusion/Exclusion Criteria
OLD (2018)
Inclusion
• Patients ages 3-17 years old
• Received an inhalational general anesthetic
• Has ≥ 2 risk factors for POV
Exclusion
• Patients < 3 or > 17 years old.
• Patients transferred directly → ICU
• Liver or Lung Transplants
• Procedures on the Neck
• Intrathoracic Procedures
• Procedures on the Lower Abdomen
• Obstetric Procedures & Labor Epidurals
• Endoscopy
• Obturator neurectomy
• Shoulder cast application
UPDATE (2021)
Inclusion
• Patients ages 3-17 years old
Exclusion
• Patients < 3 or > 17 years old.
• Patients transferred directly → ICU
• ASA 5 or 6
• Labor Epidural cases
Gan et al, 2020
PONV Risk Factors
OLD (2018)
• Hx of PONV
– personal or first-degree relative
• At Risk Surgery
– Strabismus
• Procedure ≥ 30 minutes
UPDATE (2021)
• Post-pubertal females (≥ 12y)
• Inhaled anesthetic duration ≥ 30 minutes
– halogenated and/or nitrous
• Hx of PONV
– personal or first-degree relative
• At Risk Surgery
– Strabismus
– Adenotonsillectomy
– Tympanoplasty/Otoplasty
• Postoperative long-acting opioids
– Administered intraop
Gan et al, 2020
Success Criteria
OLD (2018)
Patient receives at least two prophylactic
pharmacologic antiemetic agents of
different classes preoperatively or
intraoperatively
UPDATE (2021)
Low (0 risk factors)
• Patient receives at least one prophylactic
pharmacologic antiemetic.
Medium (1-2 risk factors)
• Patient receive combination therapy consisting of at
least two prophylactic pharmacologic antiemetics from
different classes.
High (>2 risk factors)
• Patient receives three prophylactic pharmacologic
antiemetics.
Gan et al, 2020
Antiemetics Considered (no change)
Peds Subcommittee Update
• Next Meeting May 19th at 1pm EST
• Questions related to the Peds Subcommittee can be sent to
Meridith Bailey, meridith@med.umich.edu
Cardiac Subcommittee
Updates
Allison Janda
Cardiac Subcommittee Update
• Next Meeting will be in May/June
• The ‘Cardiac Anesthesia Type Phenotype’ is being revised to add more
granularity to bin EP/cath cases, for example
• Measure under development:
– Post-bypass hypothermia avoidance
• Measures to be addressed:
– Hyperthermia avoidance
– Glucose management
Cardiac Subcommittee Update
• Post-bypass hypothermia avoidance:
Cardiac Subcommittee Update
• Post-bypass hypothermia avoidance:
– Threshold: ≥ 35.5 C
– Timing: Last non-artifact temperature measure prior to anesthesia end, prioritizing
core temperature measurements
– Exclusions: EP, cath lab, and transcatheter procedures (focus on open cardiac cases)
– Attribution: Any provider signed in for ≥40 minutes from bypass end until
anesthesia end. If bypass was not used, the window would be expanded to any
provider signed in for ≥40 minutes for the entire case
CARD 02/03 Measure
Review & Vote
Voting
• Continue as is / modify / retire CARD 02 and 03
• If modify then:
• Should we change the marker of myocardial injury to the URL (99th percentile)
troponin level?
• Should we change CARD 02 and 03 to informational measures (ie remove the 5%
threshold)
• Should we add in the additional exclusions (via surgical CPTs) discussed during the
measure review?
Thank You
