Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Notes – Monday, October 23, 2023

Attendance:

Abess, Alex (Dartmouth)

Liwo, Amandiy (UAB)

Abou Nafeh, Nancy (AUB)

Lauer, Kathryn (Froedtert)

Addo, Henrietta (MPOG)

Lalonde, Heather (Trinity Health)

Agerson, Ashley (Spectrum)

Lewandowski, Kristyn (Corewell)

Aouad, Marie (AUB)

Lopacki, Kayla (Mercy Health - Muskegon)

Barrios, Nicole (MPOG)

Lu-Boettcher, Eva (Wisconsin)

Bauza, Diego (Weill Cornell)

Mathis, Mike (MPOG)

Benitez, Julio (MyMichigan)

Madoff, Lauren (Boston Children’s)

Berndt, Brad (Bronson)

Malenfant, Tiffany (MPOG)

Biggs, Dan (Oklahoma)

McEwan, Dana (Trinity Ann Arbor)

Bollini, Mara (WUSTL)

McKinney, Mary (Corewell Dearborn / Taylor)

Bourget, Marlene, (Corewell)

McFarland, P (Tennessee)

Boutin, Jim (Henry Ford - Wyandotte)

Mentz, Graciela (MPOG)

Bowman-Young, Cathlin (ASA)

Nanamori, Masakatsu (Henry Ford Detroit)

Brennan, Alison (Maryland)

O’Conor, Katie (Johns Hopkins)

Buehler, Kate (MPOG)

O’Dell, Diana (MPOG)

Cain, James (University of Florida)

Ostarello, Claire (ASA)

Charette, Kristin (Dartmouth)

Owens, Wendy (MyMichigan - Midland)

Clark, David (MPOG)

Pantis, Rebecca (MPOG)

Cohen, Bryan (Henry Ford - West Bloomfield)

Pardo, Nichole (Corewell)

Coleman, Rob (MPOG)

Parks, Dale (UAB)

Collins, Kathleen (St. Mary Mercy)

Paul, Jonathan (Columbia)

Colquhoun, Douglas (MPOG)

Payne, Patrick (UVM)

Corpus, Charity (Corewell Royal Oak)

Pennington, Bethany (WUSTL)

Cywinski, Jacek (Cleveland Clinic)

Perkaj, Megan (Corewell)

Dewhirst, Bill (Dartmouth)

Poindexter, Amy (Holland)

Edelman, Tony (MPOG)

Rozek, Sandy (MPOG)

Esmail, Tariq (Toronto)

Schartel, Scott (Temple)

Finch, Kim (Henry Ford Detroit)

Schroeck, Hedi (Dartmouth)

Goldblatt, Josh (Henry Ford Allegiance)

Schwerin, Denise (Bronson)

Hall, Meredith (Bronson Battle Creek)

Scranton, Kathy (Trinity Health St. Mary’s)

Harrison, Kelly (UAMS)

Shah, Nirav (MPOG)

Harwood, Tim (Wake Forest)

Smiatacz, Frances Guida (MPOG)

Heiter, Jerri (St. Joseph A2)

Smith, Susan (Trinity Health St. Joseph)

Janda, Allison (MPOG)

Stewart, Alvin (UAMS)

Jiang, Silis (Weill Cornell)

Taicher, Brad (Duke)

Johnson, Rebecca (Spectrum & UMHS West)

Tyler, Pam (Corewell Farmington Hills)

Kaper, Jon (Corewell Trenton)

Vaughn, Shelley (MPOG)

Karamchandani, Kunal (UT Southwestern)

Vitale, Katherine (Trinity Health)

Khan, Meraj (Henry Ford)

Wade, Meredith (MPOG)

Kheterpal, Sachin (MPOG)

Walters, Andrew (UW)

Lacca, Tory (MPOG)

Wissler, Richard (University of Rochester)

Liu, Linda (UCSF)

Zittleman, Andrew (MPOG)

Meeting Start: 1002

Agenda & Notes

1) Roll Call: Via Zoom or contact us

2) Minutes from July 24

, 2023

3) Announcements

a) Featured Members– September and October

i) Sharon Reale, MD – Brigham & Women’s Hospital

b) Welcome Temple University

i) Chair: Dr. Gordon Morewood

ii) Quality Champion: Dr. Joseph McComb

iii) PI: Dr. Ellen Hauck

iv) IT Champion: Dr. Scott Schartel

c) Welcome Johns Hopkins University

i) Chair: Dr. Danny Muehlschlegel

ii) Quality Champion: Dr. Nadia Hensley

iii) PI: Dr. Tracey Stierer

iv) IT Champion: Dr. Katie O’Connor

4) Upcoming Events

a) Friday, April 5, 2024: Virtual ACQR Retreat

b) Friday, April 12, 2024: MSQC/ASPIRE Collaborative Meeting, Schoolcraft College Vistatech

Center, Livonia, MI

c) Friday, July 12, 2024: ASPIRE Collaborative Meeting, Henry Executive Center, Lansing, MI

d) Friday, September 13, 2024: ACQR Retreat, Location TBD

e) Friday, October 18, 2024: MPOG Retreat, Philadelphia, Pennsylvania

5) ACQR Annual Retreat – September 15, 2023 – Thank you to all ACQRs for participating!

6) MPOG Application Suite Upgrade: Now Available!

a) Upgrade package sent to each site’s IT contact (if you do not know who this is for your site,

contact support@mpog.zendesk.com)

b) Sites Using Desktop Virtualization (e.g. Citrix)

i) Your site’s IT team will upgrade App Suite

c) Users using App Suite installed on their PC

i) Your site’s IT team will distribute the installer to all individuals at their site after the

database upgrade has been applied

d) Release Notes

7) Michigan Sites Only: 2025 Standard VBR

a) Measures:

i) TEMP-02: Core Temperature Monitoring – Target: > 80%

ii) PONV-05: PONV Prophylaxis, Adults – Target: > 50%

iii) SUS-02: Global Warming Footprint, Maintenance – Target: > 40%

b) 3% - aggregate hospital performance met for 2/3 measures

c) 5% - aggregate hospital performance met for 2/3 measures

d) Participating specialist is eligible if they meet the following criteria:

i) Contracted with BCBSM’s PPO prior to the VBR effective date of 3/1/2025

ii) Have at least 2-years of data in MPOG

e) Performance calculated at hospital level – providers practicing at more than one hospital are

assigned the hospital where they performed the most cases. Increase in fee schedule:

f) See MPOG website for full VBR details

8) Michigan Sites Only: 2025 Smoking Cessation VBR

a) Measures:

i) SMOK-01: Smoking Tobacco Status Documentation – Target: > 70% (12-month average)

ii) SMOK-02: Smoking Tobacco Cessation Intervention – Target: > 10% (12-month average)

b) Performance Period: 10/1/2023 - 9/30/2024

c) Standard VBR rules apply (see previous slide)

d) Additional 2% for meeting threshold on both measures

9) Michigan Sites Only: 2024 P4P

a) Measures:

i) SUS-02: Global Warming Footprint, Maintenance – Target: > 45%

ii) PONV-05: PONV Prophylaxis, Adults – Target: >70%

iii) Site Selected Measure: Please submit form to lacca@med.umich.edu

b) See P4P Scorecard for details.

c) One scorecard for all cohorts for 2024

10) Subcommittee Updates

a) Obstetric Subcommittee

i) Next meeting: Wednesday, November 8th, 1pm ET

(1) Call for interest: OB Subcommittee Co-Chair – For next 3 years starting in January. Link

in Base camp

(2) Measure review BP-04

(3) Measure performance stratified by BMI

(4) Breakdown of administration of Uterotonic Agents

b) Cardiac Subcommittee

i) Last Meeting: September 20, 2023

ii) Minutes posted on the website

iii) Glycemic management measures for open cardiac procedures reviewed – GLU-07 & GLU-08

now available on Cardiac and All Measure dashboards!

iv) Next meeting: December 8, 2023, from 1-2pm ET

(1) Next measure focus area – Antibiotic selection, timing, re-dosing

(2) Unblinded review of GLU-06-CARD, GLU-07-CARD & GLU-08-CARD

c) Pediatric Subcommittee

i) Next meeting: Monday, December 4

, 2023, 3pm ET

(1) PAIN-01-Peds Measure Review

(a) Dr. Lisa Einhorn (Duke University)

(2) MPOG Peds Research Update

(3) Gestational Age at Birth

(a) Best practice documentation and phenotype discussion

11) Measure Review: FLUID-01-NC – Dr. Brad Taicher, Duke University

a) Brad Taicher (Duke): Measure performance suggests an overall avoidance of routine use of

colloids. There is some value in retiring a measure if site performance is at 100%. Some sites

may decide to keep metric available on dashboard if performance < 100%.

b) Vote: 1 vote/ site

i) Continue as is

ii) Modify

iii) Retire: Need > 50% to retire measure

c) Discussion:

i) Kunal Karamchandani via chat (UT Southwestern): Do we exclude liver transplant as well? A

lot of centers use albumin for these cases?

ii) Brad Taicher (Duke): Exclusion for 4 units of RBC or 2L of EBL; no exclusion for liver

transplants explicitly

iii) Nirav Shah (MPOG Quality Director): We do have a phenotype to identify Liver Transplant

cases if we want to exclude those procedures

iv) Sachin Kheterpal (MPOG Executive Director): Liver transplant CPT codes works well too –

these cases should be excluded

v) Jonathan Paul via chat (Columbia): Hi everyone this is Jonathan from Columbia, excited to

join the team! On this topic, agree with excluding liver transplants for this measure – we use

albumin routinely for these patients if they have significant ascitic losses on incision.

vi) Kunal Karamchandani via chat (UT Southwestern): And what about differentiating 5% vs

25% albumin

vii) Mike Mathis (MPOG Research Director): Should exclude cases with hypoalbuminemia – will

check code to make sure it excludes those cases

(1) Nirav Shah (MPOG Quality Director): Yes, initial goal with this measure was to exclude

those cases with low preop albumin but need to confirm the measure is doing so.

viii) Brad Taicher (Duke): You are all correct – liver transplant and hypoalbuminemia cases are

not listed in exclusions - ascites is all that is listed.

ix) Mike Mathis (MPOG Research Director): What should be the cut off if hypoalbuminemia is

excluded?

x) Julio Benitez via chat (MyMichigan-Midland): Looks like ascites is listed as an exclusion that

should exclude most liver transplants candidates. I agree on excluding liver transplant

procedures.

xi) Next steps:

(1) Modify measure:

(a) Add hypoalbuminemia as an exclusion

(b) Add liver transplants as an exclusion

12) New Measures

a) Brain Health/Geriatric Workgroup

i) BRAIN-01: Percentage of patients > 70 years old who did not receive any benzodiazepine

perioperatively. Informational only – No threshold

(1) Measure Time Period: Pre-op Start – PACU End

(2) Exclusions:

(a) Age < 70 years

(b) ASA 5 & 6 including Organ Harvest (CPT: 01990)

(d) ICU transfer postoperatively

(3) Success: Avoiding administration of benzodiazepines for patients > 70 years old

(4) Draft specification also shared with Dr. Vilma Joseph & the ASA committee on

Performance and Outcomes Measurement (CPOM)

(5) Any further questions – please reach out to the coordinating center

(addo@med.umich.edu)

(6) Discussion:

(a) Xan Abess (Dartmouth): No objection. Lack of evidence-based literature

(b) Josh Goldblatt via chat (Henry Ford Health System): Interested in doing stratification

with this measure – categorize doses – moderate vs high doses – to look at variation

in dose effect

possible research project related to midazolam

(d) Kathleen Collins via chat (Trinity Health Livonia): Also, IV midazolam for sedation vs.

po diazepam for spine surgery

b) NMB-04: Variation in Sugammadex Dosing

i) Description: Percentage of Cases with sugammadex administration where cumulative

sugammadex dose < 200mg OR < 3mg/kg.

ii) Measure Time Period: Anesthesia Start to Earliest Extubation (if non, PACU End)

iii) Exclusions:

(1) Age < 2 years

(2) ASA 5 & 6 including Organ Harvest (CPT: 01990)

(3) Cases < 30 min

(4) Patients that were not extubated in the immediate postoperative period (as defined by

the Postoperative Destination Phenotype). This excludes patient transported to ICU,

patient transported to another destination and intraoperative mortality (phenotype

values 0, 2 and 3)

iv) Success: Cases where cumulative sugammadex dose was < 200mg OR < 3mg/kg

v) Will be published to ‘All Measures’ dashboard this week.

vi) Limitations:

(1) Pediatric dosing (Allows high dosing for peds)

(2) Measure may become obsolete when sugammadex comes off patent (Jan 2026)

(3) May incentivize underdosing

(4) Focus on vial vs. mg/kg dosing

(5) Need feedback

vii) Threshold: 90%

viii) Discussion:

(1) Xan Abess (Dartmouth): Thanks for this measure – will help us with our pharmacy dosing

dialogues regarding sugammadex

(2) Nirav Shah (MPOG Quality Director): Curious if we anyone knows more about the patent

release? I had heard January 2026 but nothing more.

(3) Douglas Colquhoun (MPOG Associate Research Director): Yes, there is FDA approval for

a generic already, but held until Jan 2026. Can find the decision letter to disseminate.

c) Measure Updates

i) ABX-O1 has been updated to use Emergency Status phenotype - will include Emergency

cases for ABX timing

ii) BP-02 measure excludes Block only procedures

iii) CARD-02 and CARD-03 measures excludes patients < 18 years

iv) FLUID-01-NC/FLUID-01-C exclude patients < 3 years

v) NMB- 01/02/03/04 exclude Organ Harvest (CPT: 01990) if ASA=6

vi) PAIN-02 exclude cases with diagnostic imaging (no additional procedure performed) using

the Procedure Type: Diagnostic Imaging Phenotype

vii) PONV-04 exclude Mac cases using the Anesthesia Technique: Sedation phenotype

viii) PONV-05 exclude bronchs using the new Procedure Type: Bronchoscopy phenotype,

updated exclusion to use Diagnostic Imaging phenotype rather than excluding only MRIs

ix) SMOK-01/02 measures excludes Organ Harvest (CPT: 01990) if ASA=6 and Block Only

procedures

x) TEMP-03 exclude Mac cases using Anesthesia Technique: Sedation phenotype

xi) TRAN-01/02 - Hematocrit values < 1 reported in L/L (liters of blood cells per liter of blood

volume) are multiplied by 100 to convert from decimal to percentage)

13) QI Reporting Tool Updates

a) Benchmark Graph

i) Each hospital displayed as separate blue bar. Hovering shows hospital name and measure

score

ii) New info icon with graph description

b) Location Filter

i) Alert if time period includes more than one database instance (i.e., Legacy Data Alert)

ii) Duplicate locations removed

iii) Tree structure display

c) Case List

i) Faster Load Time!

ii) Default view is Flagged cases only

iii) Passed/Flagged/Excluded Filters

(1) Locked until case loads

(2) Remain when switching between measures

d) Find a Provider Filter

i) Duplicate provider names (legacy/IM) fixed

ii) Hospital entity added next to provider name

iii) Spinning wheel added to search bar to indicate loading

14) Data Direct Updates

a) New Filter Options

i) Starting population

(1) Added option for the Standardized Data File – filter updated annually as SDF is updated

(2) Added surgery type presets

(3) Auto-adds filters to narrow the starting population to the selected surgery type

ii) Cases

(1) Added Surgical Services

iii) Procedures

(1) Added Diagnostic Imaging filter

(2) Group Procedure Type phenotypes in sub-category

iv) *NEW* Medications Filter

b) Outputs

i) Reorganized output options a bit, hopefully more intuitive now!

ii) Removed Case Types category

c) Bug Fixes

i) Corrected Institution count error when creating a new query

ii) Date/time results now export in date/time format to Excel (downloads only)

Meeting Adjourned: 1100