Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, February 28, 2022

-Attendance:

Abess, Alex (Dartmouth)

Malenfant, Tiffany (MPOG)

Andrae, Michael (Utah)

Mango, Scott (MyMichigan - Midland)

Applefield, Daniel (St. Joseph Oakland)

Mathis, Mike (MPOG)

Bailey, Meridith (MPOG)

McKinney, Mary (Beaumont Dearborn / Taylor)

Balfanz, Greg (UNC)

Mentz, Graciela (MPOG)

Berndt, Brad (Borgess)

Milliken, Christopher (Sparrow)

Biggs, Dan (Oklahoma)

Moody, Rebecca (Beaumont)

Bollini, Mara (WUSTL)

Nurani, Shafeena (Beaumont Troy)

Boutin, Jimmy (Henry Ford Wyandotte)

Pace, Nathan (Utah)

Buehler, Kate (MPOG)

Pardo, Nichole (Beaumont)

Chiao, Sunny (Virginia)

Payne, Gloria (Beaumont Dearborn)

Ciardi, Federico (MGH)

Perkaj, Megan (Beaumont)

Clark, David (MPOG)

Pimental, Marc Phillip (Brigham and Women's Hospital)

Coleman, Rob (MPOG)

Ping Yu, Shao (Weill Cornell)

Colquhoun, Douglas (MPOG)

Poindexter, Amy (Holland)

Cohen, Bryan (Henry Ford - West Bloomfield)

Quinn, Cheryl (St. Joseph Oakland)

Corpus, Charity (Beaumont Royal Oak)

Riggar, Ronnie (MPOG)

Cuff, Germaine (NYU Langone)

Rozek, Sandy (MPOG)

Cywinski, Jacek (Cleveland Clinic)

Ruiz, Joseph (MD Anderson)

Davies, Eric (Henry Ford Allegiance)

Saad, Manal (MPOG)

Dewhirst, Bill (Dartmouth)

Saffary, Roya (Stanford)

Dillon, Jack (Spectrum)

Schonberger, Rob (Yale)

Domino, Karen (University of Washington)

Schultz, Kelly (St. Joseph Ann Arbor)

Doney, Allison (MGH)

Schwerin, Denise (Bronson)

Drennan, Emily (Utah)

Scranton, Kathy (Mercy St. Mary)

Eagle, Mary (Henry Ford Allegiance Health)

Shah, Nirav (MPOG)

Everett, Lucy (MGH)

Shannon, Lori (Beaumont)

Finch, Kim (Henry Ford Detroit)

Sherman, Jodi (Yale)

Gall, Glenn (St. Mary Mercy Livonia)

Smith, Susan (St. Joseph A2)

Goatley, Jackie (Michigan Medicine)

Taicher, Brad (Duke)

Gutman, Elena (Yale)

Tao, Jing (MSKCC)

Hall, Meredith (Bronson)

Trummel, John (Dartmouth)

Heiter, Jerri (St. Joseph A2)

Tyler, Pam (Beaumont Farmington Hills)

Horton, Brandy (A4)

Vaughn, Shelley (MPOG)

Janda, Allison (MPOG)

Vishneski, Susan (Wake Forest)

Johnson, Rebecca (Spectrum & Metro)

Wren, Jessica (Henry Ford Wyandotte/Macomb)

Khan, Meraj (Henry Ford Macomb)

Zittleman, Andrew (MPOG)

Kaper, Jon (Beaumont Trenton)

Kertai, Miklos (Cleveland Clinic)

Kumar, Vikram (MGH)

Lacca, Tory (MPOG)

LaGorio, John (Mercy Muskegon)

Lewandowski, Kristyn (Beaumont)

Lins, Steve (Bronson)

Lopacki, Kayla (Mercy Health - Muskegon)

Loyd, Gary (Henry Ford)

Lu-Boettcher, Eva (Wisconsin)

Agenda & Notes

1) Roll Call: Will contact QI Champions and ACQRs directly to inquire about participation status if

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

are missing from the attendance record.

2) Minutes from January 24, 2022 meeting approved- minutes and recording posted on the website

for review

3) Upcoming Events

a) Quality Committee Meetings via Zoom: 2022 calendar is posted on website

i) Monday, February 28, 2022

ii) ASPIRE/MSQC meeting: Friday, April 8, 2022

4) Announcements & Updates

a) New Cardiac Procedure Type Phenotype

b) New Categories:

i) Open Cardiac

ii) Transcatheter/Endovascular

iii) EP/Cardiac catheterization

iv) Other Cardiac

v) No/Non-cardiac

vi) Missing/unknown/unable to determine

c) Data Elements Utilized:

i) Surgical CPTs (if present)

ii) Anesthesia CPTs

iii) Procedural Service IDs

iv) CPB documentation concepts and phenotypes

v) Procedure text phrases

5) Precision Feedback Study Update - Aim 1

a) Plan to conduct interviews over the next couple of months to determine preferences in feedback

emails

b) Have reached to Quality Champions to refer potential interviewees

c) Criteria included:

i) Hospitals both within MI (BCBSM) and outside MI as well

ii) Hospitals with and without residents

iii) Community and med school affiliated hospitals

iv) Range of hospital sizes

d) If you are interested in participating in this phase of the project, please reach out to Allison

Janda (ajanda@med.umich.edu)

e) More detailed information about future phases (trial where we randomize regular emails vs

“precision feedback” emails) coming soon!

6) Subcommittee Updates

a) Pediatric Anesthesia Subcommittee

i) Met on February 16th: 28 attendees

ii) Finalized Measure Build for 2022

(1) NMB-03: Neuromuscular blockade dosing in patients < 1mo.

(2) ABX-02: Antibiotic Timing, Pediatrics

(3) FLUID-02: Minimizing Colloid Use, Pediatrics

(4) TRAN-03/04: Pediatric Transfusion metrics (mirror TRAN-01/02)

iii) Formation of Workgroups

(1) Pediatric Mortality (30 day in-hospital)

(2) Surgical Site Infection

(3) Normothermia

(4) PONV

(5) Pain Management

(6) Peds Cardiac

iv) Next Meeting, May 18th - Unblinded data review

b) Obstetric Anesthesia Subcommittee

i) Last meeting held on February 2022: 28 attendees

ii) Introduced unblinded performance review

iii) GA 01/02 & PONV measures

iv) Recommends PONV 05 include all cesarean delivery cases regardless of age

v) Modified hyperglycemia measures to exclude cesarean deliveries

vi) Subcommittee members recently completed survey to determine future measure focus

areas

vii) Next Meeting: August 3rd, 1pm EST

c) Cardiac Anesthesia Subcommittee

i) December meeting minutes & slides available

ii) New post-bypass hypothermia avoidance measure is has been released to the ‘All Measures’

and ‘Cardiac’ Dashboards

(1) TEMP 06-C is the percentage of adult patients who undergo open cardiac surgical

procedures for whom the last non-artifact body temperature prior to anesthesia end

was greater than or equal to 35.5 degrees Celsius. Additional measure specification

details available here.

iii) A countermeasure for on-bypass hyperthermia avoidance is also being developed and we’re

requesting perfusionist input

(1) Please reach out to ajanda@med.umich.edu if you have any perfusionists who would

like to join a subgroup to help develop this measure!

iv) Additional future measure topics include glucose management and AKI

v) Next meeting: Scheduling poll sent - likely April, 2022

7) ASPIRE Data and Joint Commission Visit

a) Email Request

i) ”As you may recall, one of the findings […] related to (moderate) sedation providers and Dr.

Y was found not to have privileges to provide sedation.”

ii) “I am not surprised a CRNA was pulled (in this light) and I would anticipate that more APPs

will be pulled over time. I am guessing that quality info was pulled to show compliance with

OPPE/FPPE requirements?”

iii) JC Ask - “Provide quality data for a CRNA over a period of a few months.”

iv) JC Standard: Ongoing Professional Practice Evaluation (OPPE)

(1) Your credentialing committee must have a process to evaluate professional practice.

What that process is, is up to you.

(2) What data is collected to make an assessment is also up to the department.

(3) This info can be used to continue, limit, or revoke privileges.

b) Takeaways

i) JC more interested that we maintain a process and track it, but do not care what the

specifics are

ii) MPOG provider dashboard is well equipped to fulfill these requirements

iii) Be familiar with your institutional credentialing FPPE/OPPE standard

iv) What will your credentialing committee do with ASPIRE data?

c) Where do we go from here?

i) Initiating feedback…

(1) Low-hanging fruit for metrics (process vs outcomes? Things you already do well?)

(2) Allow staff to become accustomed to this process

(3) Incentivize anesthesiologists with MOCA Part 2 credit

ii) What to do with underperformers?

(1) Mandatory QI/PBLI?

(2) Tied with performance bonus?

(3) Discussion at annual review?

(4) Triggered FPPE?

8) New Measure: BP-05 (informational)

a) Feedback from Quality Champions, individual providers, and sites, Coordinating Center,

Subcommittees, Research projects…

b) Prevalent Propofol Dosing Practices at MPOG Institutions: Dr. Rob Schonberger (Yale University)

i) The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent

propofol induction dose exceeded the upper bound of what has been described as the

typical geriatric dose requirement across every age category examined. The percent of

patients receiving propofol induction doses above the described typical geriatric range was

64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among

patients aged 80 and older.

ii) Induction medications and dosing are both attributable and modifiable

(1) Among 320,585 total patients, 22.6% experienced the outcome of pre-incision severe

hypotension (MAP≤55mmHg).

(2) 20.7% with non-invasive blood pressure measurements

(3) 35.0% with invasive blood pressure measurements had the outcome.

(4) Propofol induction dose (considered both as a continuous variable and as yes/no

>1.5mg/kg) was associated with pre-incision hypotension (MAP<55mmHg)

(5) However, a multitude of other factors both captured and not captured within MPOG

may mediate this relationship.

c) Percent of patients age >65 without preoperative hypotension undergoing GA who had an

episode of MAP<55mmHg within 15 minutes of induction and prior to surgical incision. (see slide

deck)

d) Percentage of cases where severe hypotension during anesthesia induction (defined as MAP <

55 mmHg) was avoided

e) Measure Time Period: Induction Start through Surgery Start

f) Inclusions: All patients requiring general anesthesia

g) Exclusions:

i) Patients <18 years old

ii) ASA 6 cases/ Organ Harvest

iii) Baseline MAP <60 mmHG

iv) Labor Epidurals / Obstetric Non-Operative Procedures

v) Anesthesia Procedures

h) Success Criteria: MAP > 55 mmHG throughout induction time period

i) Discussion:

i) Jing Tao (Memorial Sloan Kettering): Data shows that MAP<65mmHg is the cutoff associated

with bad outcomes. Is this threshold set too low for this measure? Also, it’s sustained low

MAP that is associated with bad outcomes not a single instance of low MAP.

(1) Rob Schonberger (Yale): Cleveland Clinic found in their dataset that one minute of low

MAP<55 was associated with bad outcomes. Though the threshold could be modified

ii) Eric Davies (Henry Ford Allegiance): Will this measure be reported differently? Perhaps

reported as AUC with mean and standard deviation.

(1) Nirav Shah (MPOG Coordinating Center): Great point! The new dashboard now allows us

to show different visualizations in addition to pass/flag results. Will check back with the

programmer team to see if this is possible for this new measure.

iii) Mike Mathis (MPOG Coordinating Center/Michigan Medicine): Most of our references are

observational studies, less evidence around treating this hypotension and the result in terms

of outcomes. Good focus area for researchers moving forward.

iv) Shafeena Nurani (Beaumont Troy): Is there any evidence that the outcomes are different

than the BP 03 measure?

(1) Rob Schonberger (Yale): This measure specifically focuses on attribution during the

induction time period and we should definitely consider a countermeasure to avoid

hypertension, which also is not associated with better outcomes.

v) Karen Domino (U. Washington): Induction time period can vary between case types - could

be 3 minutes for a short outpatient case but for a neurosurgery case, could be an hour and a

half. Would argue that one minute of hypotension may be too sensitive. Also, should

consider adjusting for comorbidities.

j) Next Steps: MPOG Coordinating Center to code and validate this measure to be released to the

dashboard in the next month.

9) PONV-05 Update

a) New Adult PONV prophylaxis measure released last month

b) Site Champions and ACQRs actively reviewing cases

c) Please continue to submit feedback to the Coordinating Center

d) Will vote on proposed changes at the May Quality Committee meeting:

i) Add midazolam as a potential antiemetic

ii) Add exclusion for endoscopy procedures (regardless of GA)

iii) Remove CPT prediction from procedure type risk factor (rely on actual codes only)

iv) Trigger ERCP as cholecystectomy risk factor (or only ‘true’ cholecystectomy)

v) Adjust fentanyl as ‘trigger’ for the opioid administration risk factor

vi) Include all cesarean delivery cases, regardless of age

10) New Measure: SUS-02 -TABLED for future discussion

a) Will convene a smaller group in a separate meeting to gain initial feedback and then will bring it

back to the Quality Committee to get a vote on the final version of the specification.

Zoom Chat Discussion:

Shafeena Nurani: Is there any evidence that the outcomes are different

than the BP03 measure?

Eric Davies: A very interesting study and data. Exciting to be

incorporating findings quickly into a MPOG measure.

Michael Mathis: Agreed. Great work Rob

Michael Mathis: Love the idea of counter-measures to capture any

unintended consequences

Michael Mathis: Agree

Michael Mathis: Rob et al - I recognize there is a challenge to

developing a measure that is simple to follow/understand, versus fully

appreciating all of the nuances / 'edge cases' that might make the measure

more or less relevant... but my n= 1 opinion, I think you are doing great

job

Sunny Chiao: sorry

Sunny Chiao: trying to log in on phone too

Sunny Chiao: dd everyone cut out

Sunny Chiao: or just me

Lucy Everett: Just you

Sunny Chiao: Thanks everyone! Have to run. I'm at

ssc4r@hscmail.mcc.virginia.edu if anyone wants to discuss further.

Kayla Lopacki: Thank you!!

Meeting concluded at 1101 EST