MPOG Pediatric
Subcommittee Meeting
December 4, 2023
Agenda
Announcements
Dr. Brad Taicher, MPOG Pediatric Subcommittee Chair
Measure Review: Multimodal Analgesia (PAIN-01-Peds)
Dr. Lisa Einhorn, Duke University
Provider Feedback: Using MPOG for Pediatric QI
Dr. Lauren Madoff, Boston Children’s
MPOG Peds Research: Current Projects & Process
Dr. Vikas O'Reilly-Shah, Seattle Children’s
Dr. Michael Mathis, MPOG Research Director
2024 Meetings
• Pediatric Subcommittee Meetings
- March
- July
- December
• MPOG Updates at SPA Q&S
- April & October
• MPOG Annual Retreat 2024
- October (Philadelphia, PA)
Pediatric Subcommittee Leadership
Chair
Vice Chair
MPOG is pleased to announce Drs. Vikas O’Reilly-Shah (Seattle Children’s) and Morgan
Brown (Boston Children’s) as the new pediatric subcommittee leadership team.
Membership Update
• 28 Pediatric Hospitals
• Welcome to our newest site - Johns Hopkins!
• Onboarding In Progress
– Indiana University Health, Riley Children’s Hospital
– Lucile Packard Children’s
Measure Updates
NMB-04: Variation in Sugammadex Dosing
Description: Percentage of cases with sugammadex administration that had a
cumulative dose ≤ 200mg OR ≤ 3mg/kg.
Background:
● Measure proposed by Dr. Megan Anders (Univ. Maryland). Strategies for
cost-containment are an area of interest.
● A timely measure – groups may be engaging in discussion of loosening
formulary restrictions given ASA guideline
Limitations:
● Pediatric dosing (allows high dosing for peds)
● Measure may become obsolete when sugammadex comes off patent
(January 2026)
● May incentivize underdosing
● Focus on vial vs mg/kg dosing
Measure Details
Rationale
● Fixed cost of 200mg vial
● Acknowledges dose rounding given small injection volumes
● Encourages judicious use of NMBD to end with at least TOF = 2
● Compliant with FDA approved dosing and ASA 2023 guideline
Exclusions
● Age ≤ 2yrs
● ASA 5 and 6 cases including Organ Procurement (CPT: 01990)
● Cases <30 min
● Patients that were not extubated in the immediate postoperative period
Threshold – 90%
● Acknowledges CICV, unexpected discontinuation of surgery, safety margin for
individualized dosing
Sugammadex Dosing ≤ 200mg or ≤ 3mg/kg
NMB-05: Quantitative NMB Monitoring Coming Soon!
Description: Percentage of cases with documentation of train-of-four
count or ratio provided by a quantitative monitor
● Acceleromyography
● Electromyography
● Kinemyography
● Mechanomyography
Success Criteria: Documentation of train-of-four count or ratio provided by
a quantitative monitor between patient in room and patient out of room.
All MPOG institutions contributing subjective data while only half of
contribute data from quantitative monitoring.
Concept
ID
New MPOG Concept Name Example Values
#
institutions
# of
occurrences
3330 Train-of-four Qualitative (Subjective, Clinician Reported) Count TOF Count: (0,1,2,3,4, ST) 65
62,052,001
3485 Train-of-four Quantitative (Objective) Ratio
TOF Ratio: decimals or %
Values between 4 - 100
35
11,318,093
3033 Train-of-four Quantitative (Objective, From Device) Count TOF Count (0, 1, 2, 3, 4) 24
7,167,485
3486 Train-of-four Quantitative (Objective) Count and Ratio combined TOF Count + ratio: 4/4 55% 8
3,032,509
3487
Subjective Clinical Neuromuscular Monitoring Assessment (head
lift, hand grasp)
0-4 and sustained tetany 3
183
3488 Train-of-four Post Tetanic Count (PTC) 0
-
QI Dashboard Updates
*New* Demographics filter with multiselect options
Provider tab links directly to provider specific case list
Easily navigates to MPOG case viewer with measure details
Coming Soon!
Improved Provider
Dashboard
*Mock Up*
Peds Cardiac Workgroup
Peds Cardiac Workgroup
Background:
● MPOG formed an adult cardiac subcommittee and has built a number of cardiac
specific QI measures.
● Current cardiac procedure phenotype does not accurately categorize all peds
cases
Proposal: Form a pediatric cardiac workgroup to
● Define a cardiac phenotype specific to congenital cardiac procedures
● Build QI process and outcome measures
● Increase multicenter research with MPOG platform
● Future CCAS-STS/MPOG data merge
First Interest Meeting: Early February 2024
MPOG Pediatric Subcommittee
PAIN-01 PEDS Measure Review
Lisa Einhorn, MD, FAAP
Duke University
• Multimodal pain management in children during the perioperative period can decrease postoperative
pain, improve clinical outcomes, and increase patient satisfaction after surgery.
• Opioids remain an important analgesic strategy in acute pain management yet carry significant risk of
perioperative complications including postoperative nausea and vomiting (PONV) and
dose-dependent respiratory depression.
• The American Society of Anesthesiologists (ASA) and Society for Pediatric Anesthesia (SPA) have
published guidelines and recommendations which endorse the routine use of multimodal analgesia
when appropriate to reduce opioid exposure and opioid-related side effects.
• Current evidence supports the use of opioid sparing analgesics in pediatric surgical populations that
act through different mechanisms. This list includes (but is not limited to) acetaminophen, NSAIDs,
dexamethasone, ketamine, clonidine, and dexmedetomidine.
Rationale
Rationale Evaluation
• Rationale is appropriate and based on Clinical Practice Guidelines from ASA and SPA.
• No new CPGs have been published for pediatrics in the time period since the last review.
• Changes: Multiple modifications in language in the rationale for clarity and flow.
• Suggest removing the words indicating that opioids carry a significant perioperative risk of “increased
recovery time after surgery.” This remains controversial in the literature and is not supported by a
recent article published in JAMA Surgery in adult patients (PMID: 37314800) which concludes that
“reduced opioid administration during surgery may have the unintended outcome of increasing
postoperative pain and opioid consumption.”
Review of New Literature
• PMID: 37300350. Paediatr Anaesth. 2023 Sep;33(9):699-709. doi: 10.1111/pan.14705.
Recent report of a single-center QI project reviewing 41260 patients who underwent intraoperative opioid
free anesthesia using multimodal analgesia and regional anesthesia. Showed decreased opioid rescue
rates and PONV treatment in PACU and stable in-hospital pain scores and length of stay.
• Supports Rationale of PAIN-01 PEDS measure
Current Inclusion/Exclusion Criteria
• Inclusions:
• Pediatric patients requiring anesthesia
• Exclusions:
• Patients ≥ 18 years of age
• ASA 5 and 6
• Procedure Types
• TEE/Cardioversions
• Endoscopy
• Bronchoscopy
• Obstetric Procedures
• ECT
• Diagnostic Imaging Procedures
• Open Cardiac and 'other' cardiac procedures as determined by Procedure Type: Cardiac Surgery
• Intubation Only cases
• Block Only cases - Proposed addition
• Myringotomy and Tube cases - Proposed addition
• Otoscopy (00124)
• Central Line Placement (00532)
• Lumbar Puncture (00635)
• Other (01990, 01991, 01992, 01999)
• Rooms tagged as ‘Other - offsite anesthesia’
• Cases with procedure text ‘ABR Testing’ (without any additional procedures listed)
• Patients who remained intubated postoperatively (see ‘other measure build details’)
• Cases with a Spinal, Combined Spinal/Epidural or Unknown Anesthesia Technique: Neuraxial
Evaluation of Inclusion/Exclusion Criteria
• Inclusion criteria: Propose the addition of open cardiac cases that are extubated in the operating
room.
• Exclusion criteria: Propose the addition of Block Only cases and Myringotomy and PE tubes.
Continue to exclude cases with spinal/CSE/Epidural or Unknown Anesthesia Neuraxial Technique
due to high likelihood of misclassification following a review of a large sample of these cases.
• Will discuss patients who receive no analgesic medications in the next slide
Evaluation of Definition of Success or Flagged
Cases
• There were a total of 201,667 cases in the PAIN-01 (PEDS) measure. 34 institutions included. Of
100,000 pulled in the data extraction, 11,217 were flagged (11.2%).
• Of the flagged cases, 5,507 (49%) received no analgesic medications (no opioids, no
multimodal). Common procedures in this category are listed below:
– BAER with Sedation; ABR testing; Biopsy (kidney, liver, skin etc); Radiotherapy treatment;
Bilateral Myringotomy/Tympanostomy Tubes; Lumbar Puncture/Bone Marrow Aspiration; Botox
Injection; Arthrocentesis; Eye exam under anesthesia; EGD/Colonoscopy; CT/MRI needle biopsy;
Cystocosopy removal of stent/Cystogram; Dental restorations/extractions; Laser tx; Echo; Spica
Cast change
• Some of these procedures are already listed in the exclusion criteria (ie: ABR, LP) but require
improved logic beyond CPT codes to increase accuracy.
• Other common procedures on this list may be appropriate to add to the exclusion criteria.
• As the goal of this measure is to reduce opioid exposure using non-opioid analgesics, it may
be worth considering whether it is appropriate to exclude all patients who received no
analgesics during a procedure (no opioids and no multimodal therapies).
Additional Discussion Points
• Threshold: currently none set. Would recommend setting to 90%, this seems imminently feasible
and appropriate based on current numbers
• Responsible Provider: Continue any provider signed into the case? Other options include: provider
who has signed in longest, provider at the end of the case.
• Success Criteria: Discrepancy between MIPS measure definition which requires 2 multimodal
analgesics excluding opioids vs PAIN-01-PEDS which currently requires 1 multimodal analgesic.
– Adding the requirement for a second multi-modal will likely result in significantly more flagged cases and may/may
not be feasible for all included procedures.
• Exclusion Criteria: Exclude those who received no analgesia?
• Questions or other concerns?
PAIN-01 Performance by Age Group
Summary of Recommended Modifications
PAIN-01-Peds
● Add threshold of 90%
● Include Cardiac procedures that were extubated intraop
● Exclude Block Only cases
● Exclude Myringotomy & Tube cases
● Exclude cases that receive no analgesia
● Improve accuracy of ABR and Lumbar Puncture exclusions
● Modify language in Rationale
PAIN-01-Peds
1 vote per site
Continue as is / modify / retire
Need > 50% to retire measure
Coordinating center will review all votes after meeting to
ensure no duplication
Using MPOG for
Pediatric QI
Dr. Lauren Madoff
Boston Children’s
Goals
Individual
• Review personal metrics
• Compare to others within the department
Institutional
• Target department-wide areas for improvement
• QI measures at multi-institutional level
Timeline
June 2023: Announced the initiation of MPOG dashboard at
department-wide staff meeting
August 2023: Second announcement about individual MPOG dashboards
September 2023: Individual MPOG dashboards go live
Staff encouraged to review dashboards
Departmental MPOG QI Committee
• Volunteer committee
– 10 volunteers
• Monthly meetings
– 1 metric reviewed at each meeting
– Is the information being recorded correct?
– Mapping errors?
– Is the data relevant to our practice?
– Can the data be improved?
Future Directions
• Provide feedback on existing metrics
• Develop new metrics
– Cardiac
– Pain
– Blocks
– Multi-modal analgesia
• Email Lauren.Madoff@childrens.harvard.edu
Research
Update
Pediatric Research Update
Two multicenter pediatric research proposals recently accepted by the MPOG
Perioperative Clinical Research Committee (PCRC)
• PCRC 0145: Prophylaxis Practice in Pediatric PONV: A Retrospective
Observational Study
• PCRC 0180: The Association of Guideline Directed Prophylaxis with the
Incidence of Postoperative Nausea and Vomiting in Pediatric Patients.
Primary Collaborators: Lucy Everett, Ben Andrew, Wes Templeton, Vikas O’Reilly-Shah,
Lisa Vitale, Brad Taicher, Meridith Wade
Recent MPOG Peds Publications
Congratulations to Dr. Wes Templeton
and team on their publication in
Anesthesiology!
Congratulations to Dr. Sydney Brown and
team on their publication in BJA!
Other Projects
PCRC-0128 03/14/2022 Weill Cornell Pryor/Tangel Accepted
PCRC-0127 08/09/2021 Washington Lele Accepted
PCRC-0092 03/09/2020 Mass General Rosenbloom Accepted
Pediatric Phenotypes In Progress - PCRC 241/Nasr
Gestational Age at Birth
Current State
• AIMS data sites have mapped to MPOG
concepts is very limited and highly
variable.
• MPOG Concepts Available
– Pediatrics-Premature Birth
Pediatrics-Gestational Age at Birth
Some value examples include:
Text
● 28 - 31 weeks (2)
● < 28 weeks (3)
● 24.57142857
● Twin at 32 weeks EGA
● Premature newborn (BW … lb … oz: NICU x
100 days)
● 22 5/7 wks
● Less than 37 weeks
● Yes
Numeric
● 0.156
● 1
● 0
Gestational Age Phenotype
Description: determines if a case was performed
on a patient that was born prematurely.
Limitation: Results dependent on submission and
accuracy of ICD codes
Future Goal: Refine phenotype with additional data
submitted to increase accuracy and fill rates for
projects on neonates
• Encourage sites to review/update their
current variable mappings
• Share current and best documentation
practices.
Value Code Definition
Extremely Preterm 1 Gestational age < 28 weeks
Preterm, Unspecified 2 Unspecified weeks of gestation
Very Preterm 3 Gestational age 28 - 31 6/7 weeks
Moderately Preterm 4 Gestational age 32 - 33 6/7 weeks
Late Preterm 5 Gestational age 34 - 36 6/7 weeks
PCRC proposals and “rightsizing” the paper
• Typically, one “proposal” -> one manuscript
• Diffuse proposals and hypotheses lead to unfocused
manuscripts
• Paper must be “big” enough to warrant reading it, the
“energy of activation”
• More messages, more complexity increase the energy of
activation
• Novelty, focus, and “buzz” decrease energy of activation
• Paper must be “small” enough to be consumable and
have a clear message (or two)
Reporting
• Pick an EQUATOR checklist
– https://www.equator-network.org/ & https://www.goodreports.org/
– Use it when designing the protocol
• If there is a better checklist for a novel methodology (machine learning, etc), use it
– https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.120.006556
• STROBE is not enough anymore
– RECORD, SQUIRE, etc
MPOG-specific guidance
• When reporting a paper, sample size is your enemy, not your friend
• Do *NOT* highlight how many cases are in MPOG that you “started” with
– readers question generalizability after excluding so many cases
• Statistical significance is a burden that must be explained
• Effect sizes are the key
• Consider a priori minimal clinically important difference in protocol
• MPOG data is no longer restricted to “academic medical centers”
• Model parsimony builds upon hypothesis focus
• Use supplemental digital content freely for model reporting
Thank You!
