MPOG QUALITY COMMITTEE
Quality Committee
Meeting
September 28, 2026
10:00–11:00 a.m. Eastern Time
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PREVIOUS MEETING
Meeting Minutes
July 27, 2026
Roll call — via Zoom
or contact MPOG
01
UPCOMING EVENTS
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02
ANNOUNCEMENTS
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MPOG-ASPIRE Quality Committee
September 28
th
, 2026
Jonathan Paul, DO
BP-01, BP-03, BP-06 Review
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MEASURE
DEFINITIONS
Three measures flag hypotension according to severity/duration
BP-03
MAP <65 mmHg
Success: <15 min cumulative
Performance threshold: 90%
Broader hypotension signal
BP-01
MAP <55 mmHg
Success: <20 min cumulative
Performance threshold: 90%
Severe, prolonged hypotension
BP-06
MAP <55 mmHg
Success: <10 min cumulative
Performance threshold: 90%
Severe hypotension, shorter
exposure
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MEASURE
DEFINITIONS
The measures share a common framework
Population
Adult patients requiring anesthesia.
Common exclusions include age <18, ASA 5–6, baseline
MAP <60 mmHg, labor epidurals, liver/lung transplant, and
specified cardiac procedures.
Measurement period
Anesthesia start to patient out of room, with detailed rules
for start/end times and cesarean conversions.
Blood-pressure handling
MPOG Blood Pressure Observations phenotype handles artifact. When two monitoring methods exist, the higher MAP is used;
gaps may carry the last MAP forward for up to 5 minutes.
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BP-03 REVIEW
BP-03: 65 mmHg remains a reasonable threshold for most patients
Why retain the threshold
Recent trials and consensus statements do not establish a clearly
superior lower threshold. POQI recommended an intraoperative
goal of MAP 60 mmHg, but acknowledges uncertainty regarding
the ideal lower limit.
Why there is not an imperative to lower BP-03 target to 60
Trials comparing higher vs lower MAP targets have not shown
clear benefit from higher targets, but the available evidence is not
sufficient to justify changing the existing 65-mmHg measure
threshold.
Dose–response signal
Large observational data continue to associate intraoperative
hypotension with MACE and cerebrovascular events, with
increasing risk at lower MAP thresholds (<75, <65, <55 mmHg).
Duration
The original evidence linked ~13 minutes at MAP <65 mmHg
with adverse outcomes; the 15-minute cumulative criterion
remains reasonable.
Review conclusion: rationale and success definition remain appropriate.
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BP-03 | LITERATURE ANALYSIS
BP-03 evidence review: why retain MAP >65 mmHg as our target?
Source(s) Key review interpretation Implication for measure
Salmasi et al.
Anesthesiology 2017
Prolonged MAP <65 mmHg and ≥20% reduction from
baseline were similarly associated with myocardial and
acute kidney injury.
Supports an absolute MAP threshold;
individualized targets related to baseline were not
clearly superior.
POQI XI
BJA 2024
Consensus recommended MAP 60 mmHg as an
intraoperative goal, while acknowledging uncertainty about
the ideal lower limit for avoiding organ injury.
A 60-mmHg target is defensible clinically, but does
not by itself establish that BP-03 should be
changed from 65.
Wanner 2021 +
POISE-3 2023
Trials comparing higher versus lower intraoperative BP
targets did not demonstrate improvement in composite
cardiovascular / renal outcomes with higher targets.
Evidence does not show clear benefit from
aggressively targeting substantially higher MAPs.
Gregory et al.
Anesth Analg 2021
In >300,000 noncardiac surgeries, hypotension was
associated with MACE and cerebrovascular events in a
dose-dependent pattern at <75, <65, and <55 mmHg.
Supports continued vigilance and highlights
increasing risk with greater hypotension severity.
Selected references
Salmasi V et al. Anesthesiology. 2017;126:47–65. | Saugel B et al. Br J Anaesth. 2024;133:264–276. | Wanner PM et al. JACC. 2021;78:1753–1764. | Marcucci M et al. Ann Intern Med. 2023;176:605–614. |
Gregory A et al. Anesth Analg. 2021;132:1654–65.
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BP-03 | LITERATURE ANALYSIS
BP-03 evidence review: the 15-minute duration remains reasonable
Source(s) Key finding from review Implication for measure
Salmasi et al.
Anesthesiology 2017
The study contributing to BP-03 development identified
approximately 13 minutes of MAP <65 mmHg as associated
with adverse outcomes.
The current 15-minute cumulative threshold closely
reflects the evidence used to construct the
measure.
Penev et al.
Am J Surg 2024
Systematic review: in 13 of 19 studies, MAP <65 mmHg for
>5 minutes was most commonly associated with
postoperative AKI in a dose-dependent manner.
Reinforces that duration below 65 matters; does
not provide a compelling argument to liberalize the
existing 15-minute threshold.
Interpretation
No new evidence identified in the review supports changing BP-03's success definition. The
existing MAP <65 mmHg / 15-minute construct remains a reasonable quality signal.
Selected references
Salmasi V et al. Anesthesiology. 2017;126:47–65. | Penev Y et al. Am J Surg. 2024;232:45–53.
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BP-03 | LITERATURE ANALYSIS
BP-03: potential pragmatic exclusions for controlled hypotension
Source(s) Key finding from review Implication for measure
D'Amico et al.
BJA 2023
Meta-analysis of 10 randomized trials (9,359 patients): a
MAP target of 60 mmHg was not associated with increased
mortality; some secondary outcomes favored the lower-
target group.
Suggests mild controlled hypotension can be
tolerated in selected populations, but does not
establish universal safety.
Dauterman et al.
BJA 2024
Meta-analysis of 48 RCTs: controlled hypotension reduced
blood loss, but trials were not adequately powered to
evaluate MI, AKI, or other major safety outcomes.
As above, demonstrated efficacy for surgical
benefits without evidence (positive or negative) re:
safety.
Orthopedic / OMFS /
ENT literature
Studies report reduced blood loss, improved visualization,
shorter operating time or LOS in selected procedures;
samples are generally too small and heterogeneous to
establish impact on safety outcomes.
Many clinicians target a MAP in the 60-65 range for
patients without risk factors, which BP-03 classifies
as noncompliant despite a deliberate protocol.
Trauma literature
In selected hemorrhagic trauma without TBI, early
hypotensive resuscitation has shown benefit in randomized
data.
Illustrates evidence-based benefit rather than
quality metric failure.
Selected references
D'Amico F et al. Br J Anaesth. 2023;131:823–831. | Dauterman L et al. Br J Anaesth. 2024;133:940–954. | Zhang QY et al. Orthop Surg. 2022;14:555–565. | Ji J et al. BMC Surg. 2026;26:509. | Carrick MM et al. J Trauma Acute
Care Surg. 2016;80:886–896.
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BP-03
REVIEW
BP-03: should we add select procedures to exclusion list?
Controlled or permissive hypotension is sometimes requested to reduce blood loss &/or improve the
surgical field. Evidence suggests efficacy, but safety data are limited and heterogeneous.
Orthopedics
Total knee and total hip
replacement; low-normal targets are
commonly used, and some studies
report less blood loss / shorter LOS.
OMFS / ENT
Le Fort osteotomy, maxillary
orthognathic surgery, and sinus
surgery may use deliberate
hypotension to improve
visualization.
Trauma
Early hypotensive resuscitation can
be appropriate in hemorrhagic
trauma without TBI.
Discussion point: consider excluding THR/TKA? Select OMFS/ENT Cases? It may be difficult to filter
out hemorrhagic trauma in “early resuscitative phase”.
Source: MPOG measure specifications and 2026 reviewer documents provided for this presentation.
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BP-03 Vote
Consider excluding the following case types in the absence of
contraindications (cerebrovascular, cardiovascular, renal
disease): total knee replacement, total hip replacement, Le Fort
osteotomy, and maxillary orthognathic surgery.
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BP-01
REVIEW
BP-01: the 20-minute allowance at MAP <55 mmHg may be too lenient
Severity matters
Risk is related to both duration and depth of hypotension.
Published studies associate MAP <55 mmHg with AKI,
MACE, cerebrovascular events, and mortality.
Duration matters
In patients <60 years old, >10 minutes at MAP <55 mmHg
was associated with increased AKI risk; >20 minutes was
associated with a markedly higher reported odds ratio.
Discrimination
The institutional performance plot in the review shows most
institutions above the 90% threshold, suggesting the
measure may provide limited discrimination.
Overlap with BP-06
BP-06 captures the same severe MAP threshold at a
shorter 10-minute exposure, aligning more closely with
evidence that shorter periods of severe hypotension may be
harmful.
Source: MPOG measure specifications and 2026 reviewer documents provided for this presentation.
Because BP-06 flags the same MAP <55 threshold after 10 cumulative minutes, BP-01's 20-
minute version may be too permissive and less useful as a discriminating quality measure.
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BP-01 | LITERATURE ANALYSIS
BP-01: severe hypotension has a depth–duration relationship
Source(s) Key finding from review Implication for measure
Tang et al.
Kidney Blood Press Res 2019
In relatively young patients (<60 years), MAP <55 mmHg for
>10 minutes was associated with postoperative AKI; >20
minutes was associated with an AKI odds ratio of 14.11
(95% CI 5.02–39.69).
Evidence of harm begins before BP-01's 20-minute
flagging threshold; the current measure may
tolerate too much severe hypotension.
Gregory et al.
Anesth Analg 2021
Multicenter analysis of >300,000 patients found the greatest
risk of MACE and cerebrovascular events with MAP <55
mmHg.
Supports treating MAP <55 as a particularly
important severity threshold.
Ristovic et al.
J Clin Med 2020
In cardiac surgery, prolonged intraoperative MAP <55
mmHg was associated with postoperative mortality.
Additional evidence that we should not tolerate a
significant duration of severe hypotension.
Selected references
Tang Y et al. Kidney Blood Press Res. 2019;44:211–21. | Gregory A et al. Anesth Analg. 2021;132:1654–65. | Ristovic V et al. J Clin Med. 2020;9:2057.
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BP-06
REVIEW
BP-06: remains important to promote minimal exposure to MAP<55
Clinical premise
BP-06 flags cumulative MAP <55 mmHg beyond 10
minutes. The measure reflects the concept that more
severe hypotension may cause harm over a shorter
exposure window.
Supporting evidence
A cohort study in abdominal surgery found that, at MAP <55
mmHg, a narrower exposure window was associated with
complications compared with higher MAP cutoffs.
Rationale
The review supports continued vigilance against
prolonged, significant hypotension and regards the severe
MAP threshold as clinically important.
Current specification
MAP <55 mmHg for no more than 10 cumulative minutes;
90% performance threshold.
Source: MPOG measure specifications and 2026 reviewer documents provided for this presentation.
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BP-06 | LITERATURE ANALYSIS
BP-06 : severe hypotension warrants a shorter exposure window
Study / source Key finding from review Implication for measure
Putowski et al.
J Clin Med 2021
Cohort study of 500 abdominal surgery patients: compared
with higher MAP cutoffs, MAP <55 mmHg was associated
with complications over a narrower time window.
Supports the premise that deeper hypotension may
become clinically relevant after a shorter
cumulative exposure.
Joosten et al.
Intensive Care Med 2026
Narrative review of intraoperative blood-pressure
management highlights importance of maintaining a MAP
above 60-65 due to potential for harm with even brief
exposure to BP below that threshold.
Provides contemporary context for retaining a
measure focused on avoiding sustained severe
hypotension.
Interpretation
There is no rationale to liberalize BP-06. Its MAP <55 mmHg / 10-minute construct complements
BP-03 by focusing specifically on a shorter exposure to more severe hypotension.
Selected references
Putowski Z, Czajka S, Krzych ŁJ. J Clin Med. 2021;10:5010. | Joosten A et al. Intensive Care Med. 2026;52:500–511.
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BP-01 and BP-06 Votes
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SYNTHESIS
Recommended disposition of the three blood-pressure measures
Measure Current definition 2026 recommendation Primary rationale
BP-03 MAP <65; <15 min MODIFY Retain threshold/duration; consider select procedure exclusions.
BP-01 MAP <55; <20 min RETIRE Likely too lenient; limited discrimination; BP-06 still captures
severe hypotension.
BP-06 MAP <55; <10 min KEEP AS IS Clinically meaningful severe-hypotension signal with shorter
exposure.
Overall theme: preserve a broad MAP <65 measure, emphasize earlier intervention for severe
hypotension (MAP<55), and reduce a redundant/less discriminating measure.
Source: MPOG measure specifications and 2026 reviewer documents provided for this presentation.
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DISCUSSION
Summary of Questions for Quality Committee discussion
• Should BP-03 exclude selected procedures in which controlled/permissive hypotension is
intentionally used?
• If so, should exclusions be procedure-based, diagnosis/risk-based, or require both?
• Does BP-01 add meaningful information beyond BP-06, given its longer 20-minute exposure
window?
• Are any changes needed to BP-06 inclusion/exclusion criteria or success definition before
continuation?
Proposed dispositions: BP-03 modify | BP-01 retire | BP-06 keep as is
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References
• Salmasi V, Maheshwari K, Yang D, et al. Anesthesiology. 2017;126:47–65.
• Saugel B, Fletcher N, Gan TJ, et al. Br J Anaesth. 2024;133:264–276.
• Wanner PM, Wulff DU, Djurdjevic M, et al. J Am Coll Cardiol. 2021;78:1753–1764.
• Marcucci M, Painter TW, Conen D, et al. Ann Intern Med. 2023;176:605–614.
• Gregory A, Stapelfeldt WH, Khanna AK, et al. Anesth Analg. 2021;132:1654–65.
• Penev Y, Ruppert MM, Bilgili A, et al. Am J Surg. 2024;232:45–53.
• D'Amico F, Fominskiy EV, Turi S, et al. Br J Anaesth. 2023;131:823–831.
• Dauterman L, Khan N, Tebbe C, et al. Br J Anaesth. 2024;133:940–954.
• Tang Y, Zhu C, Liu J, et al. Kidney Blood Press Res. 2019;44:211–21.
• Ristovic V, de Roock S, Mesana TG, et al. J Clin Med. 2020;9:2057.
• Putowski Z, Czajka S, Krzych ŁJ. J Clin Med. 2021;10:5010.
• Joosten A, Chew MS, Futier E, et al. Intensive Care Med. 2026;52:500–511.
https://www.apsf.org/article/perioperative-hypotension/
BP-03 Performance Benchmark - All Cases
MEASURE REVIEW
MONTHLY TREND
HOSPITAL DISTRIBUTION
BP-03 Performance Benchmark - Knee
MEASURE REVIEW
MONTHLY TREND
HOSPITAL DISTRIBUTION
BP-03 Performance Benchmark - Hip
MEASURE REVIEW
MONTHLY TREND
HOSPITAL DISTRIBUTION
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Thank you
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COMMITTEE VOTE
BP-03: Revisions
One vote per site
01 Modify: Update BP-03 to exclude hip replacements in
patients without significant comorbidities?
02 Modify: Update BP-03 to exclude knee replacements in
patients without significant comorbidities?
03 Modify: Update BP-03 to exclude Le Fort osteotomies or
maxillary orthognathic surgery in patients without
significant comorbidities?
04 The Coordinating Center will review submissions for
duplicate votes.
PONV-03 Measure
Review
Dr. Tariq Esmail · University Health Network
MPOG QUALITY COMMITTEE — SEPTEMBER 28, 2026
Recommendation:
Modify
Postoperative Nausea or Vomiting
Outcome
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Why this measure is being revisited
The Fifth Consensus Guidelines for PONV (2026) supersede the 2020 guidance PONV-03 was last reviewed against.
New evidence
• Rescue must use a different drug class than
prophylaxis — now a guideline recommendation, not
just a suggestion
• Pediatric PONV uses its own validated risk tools
(VPOP, POVOC), not the adult Apfel score
• Antiemetic evidence has shifted — several agents
strengthened, several weakened
Rationale refinement
• Procedure type is now a stronger risk signal than the
Apfel score alone
• Apfel score is a population-level tool with moderate
discrimination (c-statistic ≈ 0.7)
• Counterintuitive finding: higher BMI and lower ASA
class both associate with lower measured PONV risk
Gan TJ, Jin Z, Ayad S, et al. Fifth Consensus Guidelines for the Management of PONV. Anesth Analg. 2026;143(3):497-513.
PART 1 OF 2 — NO VOTE NEEDED
Coordinating Center will action directly
1
Replace the "direct-to-ICU" exclusion with the existing Airway:
Remained Intubated phenotype
2
Retain obstetric cases as currently specified — captures post-
cesarean PONV
3
Add a PONV-03 PONV-05 cohort-matching visualization to
the dashboard
4
Add a case-detail column: different antiemetic class than
prophylaxis (Yes / No / NA)
5
Future: explore case-mix/Apfel- or procedure-type-based risk
adjustment
6
Future: discuss a more data-driven success threshold
7
Keep dolasetron — supported by pediatric-guideline evidence;
refer to Peds Subcommittee
8
Case duration: prefer an existing validated phenotype over a
custom fallback order
PART 2 OF 2 — VOTE REQUIRED
Proposed specification changes
1
Change the measure window: PACU Start→Anesthesia End+6h becomes PACU Start→PACU Start+6h
2
Add olanzapine and transdermal scopolamine to the antiemetic list
3
Add ramosetron and tropisetron (available in parts of Asia and Europe)
4
Remove diphenhydramine from the antiemetic list
5
Remove prochlorperazine from the antiemetic list
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COMMITTEE VOTE
PONV-03: Revisions
One vote per site
01 Modify: Change measure window from PACU Start to Anesthesia End +
6 hours to PACU Start to PACU Start + 6 hours?
02 Modify: Add olanzapine and transdermal scopolamine to the Antiemetics
List?
03 Modify: Add ramosetron and tropisetron to the Antiemetics List?
04 Modify: Remove diphenhydramine from the Antiemetics List?
05 Modify: Update PONV-03 to remove prochlorperazine from the
Antiemetics List?
06 The Coordinating Center will review submissions for duplicate votes.
Thank you
Questions & discussion
MPOG Quality Committee
