Quality Committee Meeting Minutes 9.28.26

Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE)

Quality Committee Meeting Minutes – September 28, 2026

Attendance:

Atcheson, Carrie (UAB)

Gereboff, Avner (Avi) (Cedar Sinai)

Mendez, Nicholas (UCSF)

Balfanz, Greg (North Carolina)

Glanding, Kimberly (UAB)

Milliken, Christopher (Sparrow)

Berndt, Brad (Bronson)

Goatley, Jackie (Michigan)

Mirizzi, Kam (MPOG)

Berger, Jack (MGH)

Grewal, Ashanpreet (Maryland)

Nguyen-Buckley, Christine (UCLA)

Bollini, Mara (WUSTL)

Hall, Meredith (Bronson Battle Creek)

Ohlendorf, Brian (Duke)

Booker, Cheyenne (Henry Ford)

Heiter, Jerri (Trinity Health)

Pantis, Rebecca (MPOG)

Boville, Miranda (Wisconsin)

Herren, Melanie (MPOG)

Pardo, Nichole (Corewell Grosse Pointe)

Bowman-Young, Cathlin (ASA)

Huntington, Michelle (Corewell West)

Paul, Jonathan (Columbia)

Brennan, Alison (Maryland)

Jewell, Elizabeth (MPOG)

Poindexter, Amy (Holland)

Brown, Morgan (Boston Children’s)

Johnson, Rebecca (UMHS West)

Rolfzen, Megan (Michigan)

Buehler, Kate (MPOG)

Kaper, Jon (Corewell Trenton)

Roselinsky, Howard (Yale)

Calabio, Mei (MPOG)

Karamchandani, Kunal (UT Southwestern)

Sarwar, Aqsa (MPOG)

Cassidy, Ruth (MPOG)

Khan, Meraj (Henry Ford)

Segurado, Arthur (Wisconsin)

Charette, Kristin (Dartmouth)

Kirke, Sarah (Nebraska)

Schwerin, Denise (Bronson)

Charette, Megan (MPOG)

Krauss, Kristin (Temple)

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

Chopra, Ketan (Henry Ford - Detroit)

Krauss, Ruby (Wisconsin)

Shah, Nirav (MPOG)

Clark, David (MPOG)

Kunkler, Bryan (Corewell West)

Shettar, Shashank (OUHSC)

Claybaugh, Deborah (MyMichigan)

Lacca, Tory (MPOG)

Shu, Zhu (Columbia)

Cohen, Bryan (Henry Ford)

LaGorio, John (Trinity Health)

Smiatacz, Frances Guida (MPOG)

Coleman, Rob (MPOG)

Lalonde, Heather (Trinity Health)

Stewart, Alvin (UAMS)

Colquhoun, Douglas (MPOG)

Lewandowski, Kristyn (Corewell Troy)

Stierer, Tracey (Johns Hopkins)

Corpus, Charity (Corewell Royal Oak)

Liu, Bin (Michigan Medicine)

Stumpf, Rachel (MPOG)

Cusick, Jordan (OHSU)

Liu, Linda (UCSF)

Szymanski-Bogart, Brooke (MPOG)

Cywinski, Jacek (Cleveland Clinic)

Lopacki, Kayla (Mercy Health - Muskegon)

Tyler, Pam (Corewell Farmington Hills)

Delhey, Leanna (MPOG)

Lozon, Tim (Henry Ford - Wyandotte)

Vaughn, Shelley (MPOG)

Esmail, Tariq (UHN)

Lu-Boettcher, Eva (Wisconsin)

Wedeven, Chris (Holland)

Fayed, Mohamed (MyMichigan)

Malenfant, Tiffany (MPOG)

Weinberg, Aaron (Weill Cornell)

Finch, Kim (Henry Ford Detroit)

Mathis, Mike (MPOG)

Whittle, Jacob (Utah)

Foster, Julie (MyMichigan)

McCaughan, Michael (Sparrow)

Yuan, Yuan (MPOG)

Gedela, Radhika (Vermont)

McKinney, Emily (Trinity Health)

Zittleman, Andrew (MPOG)

Georgiadis, Paige (University of Vermont)

McKinney, Mary (Corewell Health)

Start: 1002 EST

Announcements & General Updates

Minutes from July 2026 Quality Committee Meeting approved – minutes, slides and recording posted on the

MPOG website for review

Roll call

• Roll call taken via the Zoom attendance list. Participants who joined by phone, or who were present but not

listed on Zoom, were asked to contact the Coordinating Center (support@mpog.zendesk.com) so

attendance credit could be recorded.

2026 Meetings & Events

• MPOG Annual Retreat: Friday, October 16, 2026, San Diego, CA — held the day before the ASA annual

meeting. Both in-person and virtual attendance will be available.

o Registration for the MPOG Retreat is now open.

• Next Quality Committee meeting: Monday, November 23, 2026

Featured Member – September & October

• Joseph Cravero, MD, FAAP (Boston Children’s Hospital)

Measure Review – BP-03

Reviewer: Jonathan Paul, MD (Columbia University Medical Center)

Review document: BP-03 - Jonathan Paul Review 9.28.26

Background

• BP03 measures avoidance of intraoperative hypotension defined as MAP < 65 mmHg for > 15 minutes. The intent is to

capture signals of broad intraoperative hypotension.

• Exclusions common to BP03, BP01, and BP06: pediatric patients, ASA 5–6, baseline MAP < 60, labor epidurals, liver

and lung transplant, and select cardiac procedures. Measurement window: anesthesia start to patient out of room.

• A growing body of evidence links intraoperative hypotension to adverse postoperative outcomes including

cerebrovascular events, MACE, and AKI. No large randomized trials have established causality, but the association is

well-supported.

Discussion

• Is MAP 65 still the right target? The POQI published a 2024 consensus statement recommending a MAP target above

60. Two large trials (one single-center comparing MAP 75 vs. 60; POISE-3 comparing MAP 80 vs. 60) found no

difference in composite outcomes. The POQI guidelines acknowledge the absence of high-quality evidence for a

specific lower threshold; 65 remains a reasonable goal.

• Should total hip and knee arthroplasty be excluded? At some centers, a MAP of 60–65 mmHg is deliberately targeted

for orthopedic cases to improve surgical visualization and reduce blood loss. Two BJA meta-analyses (Damoco and

Doderman) and the Jang systematic review showed surgical benefit but insufficient data to confirm or exclude safety

risk. MPOG benchmarking confirmed that BP03 performance drops from the mid-80s overall to the mid-70s for total

knees and the mid-60s for total hips.

• Discussion highlighted the tension between central measure design and site-level control. Options discussed: (1) add

procedure-type context to flagged case reports rather than changing the denominator; (2) add a QI Reporting Tool

visualization of BP03 performance excluding hips and knees; (3) stratify cases by risk level, referencing the CARD04

precedent (Low / Intermediate / High Risk).

• Kunal Karamchandani [UT Southwestern] noted his site does not practice permissive hypotension for the proposed

exclusion cases. Tariq Esmail [UHN] raised the possibility that hypotension in hip cases may reflect regional anesthetic

physiology rather than deliberate targeting. Carrie Atcheson [UAB] noted trauma exclusion would improve faculty

engagement but cautioned that TBI patients require higher MAP targets.

Reviewer Recommendations

• Keep BP03 as-is — do not add hip/knee exclusions to the denominator.

• Add procedure-type context (hip, knee, trauma) to the flagged case detail reports to support site-level interpretation.

• Add a QI Reporting Tool visualization of BP03 performance excluding total hip and knee cases.

Vote

QC 9.28.26 BP-03 Overall Vote — 33 of 86 participants (38%) responded.

Measure Review – BP-01

Reviewer: Jonathan Paul, MD (Columbia University Medical Center)

Review document: BP-01 - Jonathan Paul Review 9.28.26

Background

• BP01 measures avoidance of severe intraoperative hypotension defined as MAP < 55 mmHg for > 20 minutes. It is one

of the original MPOG measures, introduced circa 2014–2015 as a demonstration that blood pressure data could be

converted into a quality metric.

• Nearly all MPOG institutions currently exceed the threshold; flagged cases are rare.

Discussion

• Evidence indicates that even 5 minutes at MAP < 55 mmHg can be associated with AKI and major adverse cardiac

events. The 20-minute threshold is too lenient and may create a false sense of security.

• BP01 is functionally superseded by BP06 (MAP < 55 for > 10 minutes), which is better aligned with current evidence.

• Kunal Karamchandani [UT Southwestern] asked about the original rationale. Nirav Shah [MPOG Coordinating Center]

explained it represented the minimum quality floor that all nine original MPOG sites could agree upon at the

measure’s inception.

• Michael Mathis [MPOG] suggested BP03 flagged cases could be stratified as Low Risk (orthopedic, no cardiovascular

comorbidities per CARD04), High Risk (cases that would also have flagged BP01), and Intermediate Risk.

Reviewer Recommendations

• Retire BP01. The 20-minute threshold is too lenient, nearly all sites exceed it, and it is superseded by BP06.

Vote

QC 9.28.26 BP-01 Overall Vote — 33 of 86 participants (38%) responded.

Measure Review – BP-06

Reviewer: Jonathan Paul, MD (Columbia University Medical Center)

Review document: BP-06 - Jonathan Paul Review 9.28.26

Background

• BP06 measures avoidance of severe intraoperative hypotension defined as MAP < 55 mmHg for > 10 minutes.

• Evidence supports that even brief periods below MAP 55 mmHg are associated with AKI and adverse cardiac events.

Discussion

• BP06 complements BP03 by demonstrating to stakeholders that significant hypotension is avoided even in cases

where low-normal blood pressure is deliberately targeted.

• Kunal Karamchandani [UT Southwestern] raised interest in pre-incision hypotension. Nirav Shah noted that BP05

(from Rob Schoenberger’s NIA-funded AIM-3 study) already captures induction hypotension and will be reviewed on a

separate cycle.

Reviewer Recommendations

• Keep BP06 as-is.

Vote

QC 9.28.26 BP-06 Overall Vote — Vote result: Keep as is — confirmed verbally; no poll image captured.

Measure Review – PONV-03

Reviewer: Tariq Esmail, MD (University Health Network)

Review document: PONV-03- Tariq Esmail Review 09.28.26

Background

• PONV03 measures the percentage of patients (all ages) who experience documented nausea or emesis, or receive a

rescue antiemetic in the immediate postoperative period. PONV03B captures the same population regardless of

antiemetic receipt.

• A new PONV consensus guideline was published in print in September 2026 (accepted August 2025; literature through

September–October 2024). Dr. Esmail reviewed the 2024–2026 literature and found no evidence rising above the

guideline threshold. All proposed changes reference this guideline.

Discussion

• New guideline updates: (1) Guideline 4 now explicitly recommends using a different drug class for rescue than for

prophylaxis. (2) Greater emphasis on procedure-based risk factors in addition to the APFEL score. (3) Several agents

added or downgraded in evidence level.

• Coordinating Center updates (informational, no vote required): (1) Replace direct-to-ICU exclusion with the ‘airway

remained intubated’ phenotype, aligning with PONV05. (2) Retain obstetric cases as currently specified; labor epidural

exclusion retained due to data limitations. (3) Add a matching cohort visualization (PONV03B prophylaxis rate vs.

actual PONV incidence). (4) Add a drug class indicator to case detail. (5) Future items: procedure-type risk adjustment

(pending since 2019), data-driven success threshold, unified case duration phenotype. (6) Retain dolasetron for

pediatric cases.

• Proposed modifications requiring a vote: (1) Change the measure window to a defined 6-hour window starting at

PACU start (fallback: patient out of room), replacing the current PACU start to anesthesia end +6 hours definition. (2)

Add olanzapine (as in PONV05). (3) Add transdermal scopolamine (referenced in measure specs but absent from drug

list). (4) Add ramosetron and tropisetron (Grade A evidence in updated guidelines). (5) Remove diphenhydramine as a

standalone agent (only A3-grade evidence in combination with ondansetron). (6) Remove

prochlorperazine/Compazine (no evidence grade assigned in guidelines).

• Discussion on diphenhydramine and prochlorperazine: Kunal Karamchandani [UT Southwestern], Ketan Chopra [Henry

Ford – Detroit], and Kristin Krauss [Temple] requested retention of both agents, citing drug shortages and clinical use

as rescue antiemetics. Nirav Shah noted the concern that these agents may be given for non-antiemetic indications,

creating ambiguity in data capture. Tariq Esmail suggested that if both are retained, haloperidol should also be added

for consistency. Michael Mathis [MPOG] suggested improved QI Reporting Tool filtering. Kunal Karamchandani noted

droperidol and haloperidol are the same pharmacological class, making prochlorperazine the only remaining option

for a second rescue in some scenarios. Kate Buehler [MPOG Coordinating Center] confirmed the PACU Start

phenotype supports the proposed measure window update.

Reviewer Recommendations

• Modify the measure window: unify to a 6-hour window starting at PACU start (fallback: patient out of room).

• Add olanzapine and transdermal scopolamine to the antiemetics list.

• Add ramosetron and tropisetron to the antiemetics list.

• Retain diphenhydramine (committee voted against removal).

• Retain prochlorperazine/Compazine (committee voted against removal).

• Coordinating Center to add a drug class indicator column to PACU case detail reports.

Vote

QC 9.28.26 PONV-03 Overall Vote — 29 of 75 participants (38%) responded.

Vote

QC 9.28.26 PONV-03 Revisions Vote — 32 of 71 participants (45%) responded.

Adjourned: 1105 EST

Next Meeting: Monday, November 23, 2026 (10 – 11am EST)

Appendix A — Full Transcript

ASPIRE Quality Committee – September 28, 2026

Original wording preserved; filler, false starts, and speech-to-text artifacts corrected for readability. Chat comments are inserted at

the chronologically correct point and marked “via chat.”

Announcements

Nirav Shah [MPOG]

Good morning, everyone. It is 10 o'clock Eastern. Let's give folks just another minute or two to join.

All right, it's 10:02 — we should probably get started. I know we have a very busy agenda. I think we're at

quorum. Hope everyone is doing well. Happy Monday, everyone.

The weather is as nice where you are as it is here. We finally have fall in Ann Arbor, which is super fun.

We have a packed agenda today, so I am just going to dive in.

Just a couple of announcements. We have two really important measure reviews. Dr. Esmail and Dr. Paul are

with us today, reviewing PONV and the blood pressure measures, respectively. I think that is probably all we will

have time for, but if for some reason we have a little bit of time at the end, we will share some other updates —

some small measure updates that we have made, as well as an overview of all the changes we are making to the

glycemic management measures based on feedback from the glycemic management workgroup. We will also

share a couple of web updates. We may share some of that through the forum as well.

Regarding minutes: our last meeting was in July, a couple of months ago. Those are posted on the website. If

anyone has any corrections, please let us know; otherwise we will consider those approved.

We have just one upcoming event to share. The MPOG Retreat is on October 16th in San Diego — that is the day

before the ASA starts. We know many of you are coming. Between virtual and in-person, we have about 170

registrants. We are super excited to see many of you there. We know some of you will be unable to attend, and

we will miss you. If you are planning on coming either virtually or in person, please register to help us manage

the day. Looking forward to it.

Finally, our featured member for September and October is Dr. Joe Cravero from Boston Children's. As many of

you know, Dr. Cravero is the chair of anesthesiology at Boston Children's, a longtime MPOG supporter, and a

member of our board. If you have a moment, please go to our website and check out what he has to say.

With that, I am going to turn the mic over to Dr. Paul. Dr. Paul is going to review BP03, BP01, and BP06. With

that, JP?

[Via Chat] Mei Calabio [MPOG] 14:33

• MPOG Retreat: https://appsuite.mpog.org/retreat

• MPOG Retreat - MPOG: https://mpog.org/events/mpog-retreat-10-16-2026

• Featured Members - MPOG: https://mpog.org/featuredmembers/

Blood Pressure Measure Review — BP03, BP01, BP06

Presenter: Dr. Jonathan Paul

Jonathan Paul [Columbia]

Thank you, Nirav. In terms of the order of review, we are going to start with BP03 first, because I think it is our

primary metric focused on prevention of intraoperative hypotension. We will pause for some discussion about

potential modification, and then move on to BP01 and BP06 in tandem.

BP03 — Intraoperative Hypotension (MAP < 65 for > 15 min)

Jonathan Paul [Columbia]

BP03 involves avoiding intraoperative hypotension defined by a MAP of less than 65. The success definition is

avoiding a period of greater than 15 minutes below that number. The intent is to capture signals of broad

hypotension.

Contrast that with BP01 and BP06, which are both focused on preventing severe hypotension intraoperatively at

a MAP defined as less than 55. For BP01, success is defined as avoiding more than 20 minutes below 55; for

BP06, more than 10 minutes.

Exclusions common to all three measures include: children, ASA 5–6, baseline MAP less than 60, labor epidurals,

liver and lung transplant, and some cardiac procedures. The time period defined is from anesthesia start to

patient out of room.

The imperative to prevent significant intraoperative hypotension remains. Our analysis of recent literature since

the last measure review has not changed that. There is a growing body of evidence that intraoperative

hypotension is associated with significant postoperative outcomes, including cerebrovascular events, MACE, and

AKI, among others. Even though there have not been large trials demonstrating a causal association, the

association is there, and the importance of these hypotension measures has not changed.

Two considerations came up in my literature review. The first: is 65 the right target for intraoperative blood

pressure? The Perioperative Quality Initiative (POQI) met in Europe and in 2024 published a consensus

statement suggesting that the intraoperative goal for anesthesiologists should be a MAP above 60. The question

is: should we change our target from 65 to 60?

Part of their rationale was that several trials published in recent years compared higher targets to a lower target

of 60. One large single-center trial found no difference in composite outcomes — including acute MI, AKI, and

MACE — whether the intraoperative target was MAP 75 or 60. The POISE-3 trial similarly compared MAP targets

of 80 and 60 and found no difference in similar outcomes.

When you read through the POQI recommendations, they acknowledge there is not really high-quality evidence

to specify the exact lower number for an intraoperative target. In the absence of compelling evidence, 65 still

remains a reasonable goal, and I am not sure there is enough signal from the literature to lower it further.

In the ICU literature, the '65 Trial' looked at patients with septic shock comparing MAP targets of 65 versus 60

and did not find a difference in mortality. However, there was substantial non-adherence — patients

randomized to the 60 arm ended up practically at a higher MAP — so I do not think there is enough evidence

from that to shift to a lower number either.

Taken together: there is still a growing body of evidence that intraoperative hypotension is associated with

adverse outcomes. There are some signals and recommendations that 60 might be a reasonable target, but

probably not enough to change the metric. The 15-minute threshold also remains valid — a 2017 trial suggested

that adverse outcomes were associated with approximately 13 minutes at a MAP less than 65, so 15 minutes as

a round number remains reasonable.

The second consideration: should we add additional procedures to the exclusions for BP03? I raise this because

at my institution, our regional team had received some complaints — for certain orthopedic procedures like

total hips and knees, we often target a low-normal blood pressure to improve visualization and surgical

technique. For patients without risk factors such as cerebrovascular, cardiac, or renal disease, we might target a

MAP in the 60–65 range, and these patients get flagged as failing the metric when the approach was deliberate.

Looking at the literature: two meta-analyses from BJA (Damoco and Doderman) demonstrated efficacy and

benefit from lower MAP targets in terms of surgical technique — reduced blood loss, reduced transfusion

requirements, decreased surgical time, and in some cases decreased hospital length of stay. However, neither

was able to demonstrate a positive or negative association with adverse postoperative outcomes. Zhang et al.

did a retrospective cohort study of about 200 patients and found that TXA combined with a MAP of 70–80 was

associated with decreased surgical duration and blood loss without demonstrating adverse safety outcomes.

The Jang systematic review and meta-analysis also demonstrated surgical benefit but was underpowered, and

studies were too heterogeneous to evaluate the impact on safety outcomes. Similar findings come from the

OMFS and ENT literature. In the trauma literature, there is substantial evidence that during the early

resuscitative phase for hemorrhagic trauma, targeting a lower blood pressure actually has a mortality benefit.

The question for the Quality Committee: should we add select procedures to the exclusion list for BP03 — such

as total hips and knees? Acknowledging the lack of data confirming safety for mild controlled hypotension, the

reality is that some centers are doing this pragmatically. Should we remove these cases to reduce noise in the

quality metric signal? I would like to pause here for feedback from the group.

[Via Chat] Mei Calabio [MPOG]

• MPOG Measure Spec - BP-03: https://datalibrary.mpog.org/Measures/Public/34

Nirav Shah [MPOG]

I was able to pull some benchmarking information looking at all cases, and then specifically the knees and hips. If

you want, I can quickly show that and then come back to the slide.

Jonathan Paul [Columbia]

Yes, that would be great.

Nirav Shah [MPOG]

This is performance across all of MPOG — 160-plus hospitals across the U.S. and beyond, including Canadian

sites and UAB. Overall performance is pretty high, and there is some variation. There is definitely a cluster of

sites performing above the threshold for most measures, but there is also some variation in care.

When I filter by total knees, performance drops from the mid-80s to the mid-70s. JP, this corroborates your

perspective that some sites — probably intentionally — have lower overall performance in BP03 for knee cases.

When you look at hips, performance drops further, from the mid-70s for knees to perhaps the mid-60s, with a

fair amount of variation across sites. There is a clear signal that performance is different for hips and knees

compared to everything else. Whether or not we want it to be is the feedback we need from the Quality

Committee.

Mike, I see your hand is up — feel free to unmute.

Michael Mathis [MPOG]

These are really good points. One thought: I wonder whether the right approach is refining the exclusion criteria

as proposed, or whether it is better to parse the flagged cases to provide more context. For example, there

might be a difference between a flagged case in a patient having major vascular surgery where hypotension was

genuinely important, versus a flagged case in an ASA 2 patient with no cardiovascular risk factors getting a hip or

knee replacement.

Practically speaking, from a quality measure design perspective — is it easier to have separate quality measures

for those case types, or is it feasible to provide more granular detail on why specific cases were flagged? It might

be that quality standards should be universal across all MPOG sites, and we coalesce around a consistent set of

inclusion criteria. Or it might be that this determination is best made at the site level, where the QI director

knows their local practice patterns and can decide which flagged cases are meaningful. Giving some site-level

control might be valuable.

We do have precedent — CARD04 carves out a definition of a high-risk patient for troponin ordering. A similar

approach could be used here: flagging whether the hypotension occurred in a high-risk patient, high-risk

surgery, or low-risk surgery like these orthopedic cases. The question is whether to refine the exclusion criteria

or refine the information provided to sites about their flagged cases.

[Via Chat] Carrie Atcheson [UAB]

For our institution (high complexity, Level 1 trauma center), exclusion of trauma cases would improve

uptake/trust among faculty, but we have to be careful to include patients who have TBI because targets

for hypotension are higher in that population.

[Via Chat] Kunal Karamchandani [UT Southwestern]

I would say it should be site-specific. We do not do permissive hypotension for the cases that are being

proposed to be excluded.

Nirav Shah [MPOG]

Good point. Tariq?

Tariq Esmail [UHN]

I don't have a solution, but along the same lines as what Mike was saying — looking at that data is interesting.

Kunal mentioned that they would prefer it to be site-specific because they don't permit hypotension in the cases

being proposed for exclusion. My thought is also this: is it really that many places are targeting lower pressures

in hip surgeries, or is it that the majority of these surgeries are done under regional anesthetic with a higher or

higher-spread dose, and so patients are more hypotensive — and we are not actually managing that

deliberately? We don't have a blanket statement permitting hypotension in our orthopedic practice. I don't

know whether exclusion is the answer, but if there were a site-specific way to handle it, that might be the

approach our site would look to as well.

Kunal Karamchandani [UT Southwestern]

In an ideal world, if we had an Epic or EMR field where you click 'permissive hypotension' with the indication,

and that click excluded the case, that would work. But going through Epic, there isn't really an option for that. If

we asked providers to document 'permissive hypotension' in a note for MPOG to find and exclude, I don't think

that would work reliably across all sites either. But intentional documentation of permissive hypotension would

be a good way to do it.

[Via Chat] Alvin F Stewart [UAMS]

You could create an anesthesia event.

Nirav Shah [MPOG]

You're right — creating an anesthesia event is probably how you would do it. And Carrie's point is well taken:

parsing out specific scenarios like trauma with TBI becomes very difficult. For example, even for hips —

excluding patients without cerebrovascular or cardiac disease who had intentional permissive hypotension —

starts to get complicated.

Since filters exist for some of these cases, she would vote for sites to be able to use site-specific exclusion

criteria when analyzing their data, and suggests adding more filters. That is an interesting option — providing

more information within the QI Reporting Tool rather than changing the measure denominator. For example, we

could add a visualization for BP03 cases without hips and knees so that sites can use that as their primary view

without needing to manually select filters. We could also add additional columns to the measure case reports

flagging whether a case is a hip, knee, or trauma case, so that quality champions reviewing flagged cases have

that context before following up with faculty.

[Via Chat] Ashanpreet Grewal [Maryland]

Since filters exist for some of these cases, I would vote for sites to be able to use site-specific exclusions

when they analyze their data. Maybe more filters could be added?

[Via Chat] Tariq Esmail [UHN]

But the filters are good for the champion — is it available at the individual level?

Michael Mathis [MPOG]

I like the idea of shared responsibility between the MPOG central design of the quality measures and the QI

director at each site determining the site-specific interpretation of the data. There is only so far we can go in

designing the measure centrally in a way that is both useful and not overly prescriptive. It is up to the QI director

to have some control over the filters and decide, based on the nuances of their site, whether care should be

modified or not.

Nirav Shah [MPOG]

Exactly. We need to enable a certain level of local control over these measures to account for local practice

patterns, while also maintaining consistency across all sites so that benchmarking works. That balance can be

challenging.

JP, your thoughts on building in a specific exclusion versus adding additional details to the measure summary

page or measure case reports — so sites have more information about the types of failures, whether they are

emergency, trauma, or orthopedic cases — to help determine whether a case actually needs follow-up?

Jonathan Paul [Columbia]

My initial impression was to add exclusions, but based on the discussion and feedback, I think keeping the

measure as-is with modifications to add more granularity to the flagged case reports is the better approach.

When quality champions click through to do their case review, they would see what proportion of failures fall

under which case types and can interpret accordingly.

That said, I want to echo some of the chat comments: most of our end users see the email summary and stop

there. That leads to jaded perspectives — 'This metric isn't for me because I'm a regionalist and our surgeons

insist on this blood pressure, so I'm just not going to pay attention.' Even if we apply filters, until they click

through to the dashboard, they won't see the difference. The downside of not adding these to the exclusion list

is that we don't address that known engagement issue. But that is my feeling.

Tariq Esmail [UHN]

I would echo that, JP. I was thinking about how much this would actually encourage engagement with the

people we want to engage. I wonder if it would be better to drop the number to 60 and keep them in, rather

than exclude them.

Jonathan Paul [Columbia]

I am not sure about that. There is a slippery slope — when we move the benchmark, everyone who has been

using it as a target for their QI initiatives has to make an adjustment and can no longer easily compare historical

performance. I think it is good that we are having this conversation because there is clearly some equipoise

here.

Nirav Shah [MPOG]

Any other comments before we move to the next slide?

Jonathan Paul [Columbia]

My recommendation is to modify the measure — not to add exclusions, but to add more granularity to the

flagged case reports in the individual dashboards.

[Via Chat] Carrie Atcheson [UAB]

One vote for keep >65 and add filters. Agree it will improve engagement.

Nirav Shah [MPOG]

That sounds very reasonable. We would need to do some work at the Coordinating Center to determine how

best to fit it in, but I think we can accommodate that.

I thought we would do all the voting at once, if that is okay.

BP01 and BP06 — Severe Intraoperative Hypotension (MAP < 55)

Jonathan Paul [Columbia]

Both BP01 and BP06 focus on avoiding severe hypotension defined as a MAP less than 55 mmHg. This remains

important: there is evidence that significant drops in blood pressure, even for shorter durations, have a greater

association with adverse postoperative outcomes including AKI and major adverse cardiac events.

BP01 is the more lenient of the two — success is defined as avoiding MAP less than 55 for at least 20 minutes.

The concern with BP01 is that evidence shows even 5 minutes at a MAP less than 55 can be associated with

adverse outcomes, so the 20-minute threshold may give providers a false sense of security. My impression is

that we should retire this measure, both because of redundancy with BP06 and because it sends a misleading

signal about what success should look like. Additionally, nearly all institutions are already exceeding the

threshold, and the incidence of flagged cases is rare. That is another case for retiring BP01.

For BP06 — also focused on avoiding intraoperative hypotension below a MAP of 55, but with a success

threshold of greater than 10 minutes — the evidence that even brief periods below this number are associated

with AKI and other adverse outcomes supports keeping the 10-minute threshold. In the context of our earlier

discussion about permissive hypotension in orthopedic cases, this metric serves an important purpose: it

demonstrates to our stakeholders that we are avoiding significant hypotension in all cases, including those

where we might target low-normal blood pressure.

My recommendation: keep BP06 as-is, and retire BP01 — because the 20-minute threshold is too lenient and

most institutions are already exceeding it.

[Via Chat] Mei Calabio [MPOG]

• MPOG Measure Spec - BP-01: https://datalibrary.mpog.org/Measures/Public/11

• MPOG Measure Spec - BP-06: https://datalibrary.mpog.org/Measures/Public/83

Nirav Shah [MPOG]

That makes a lot of sense. BP01 was one of the original MPOG measures — it helped get us launched — but it

has since been supplanted by BP06. Kunal?

Kunal Karamchandani [UT Southwestern]

What was the original rationale for the 20-minute threshold? Is there something we might be missing before we

retire it?

Nirav Shah [MPOG]

In the early days of MPOG — around 2014 or 2015 — this was literally one of the first two or three measures. It

was partly a demonstration project: could we actually take individual blood pressure measurements and turn

them into a quality measure? And could we find a minimum threshold that all nine MPOG centers at the time

could agree on as a floor for quality? The 20-minute threshold at MAP less than 55 was essentially that floor. It

really just shows where we were and how far we have come. We can now have nuanced discussions about MAP

65 targets and blood glucose at 180 — which is a testament to the growth of MPOG over 12 years.

[Via Chat] Michael Mathis [MPOG]

It might be that BP-03 flagged cases are parsed into 'Low Risk' (specific procedure types, in absence of

specific cardiovascular comorbidities as defined in the CARD-04 measure) and 'High Risk' (those which

would have flagged the BP-01 measure), and 'Intermediate Risk' (everything else in between).

Kunal Karamchandani [UT Southwestern]

That makes sense. One additional thought: since we are discussing blood pressure and JP has done a

comprehensive literature review, is there any interest in looking specifically at pre-incision hypotension? It is

more directly attributable to anesthesia drugs and what we do before incision. I know Kamal did a study looking

at the relationship between pre-incision hypotension and AKI.

Nirav Shah [MPOG]

That is essentially what BP05 captures. BP05 came out of Rob Schoenberger's NIA-funded study looking at the

incidence of hypotension with propofol. As part of his AIM-3 project, we developed BP05, which looks at

induction hypotension — directly attributable to the anesthesiologist. Not many sites are actively using it, and

there is some variability due to documentation differences around what that time period looks like across MPOG

sites. We have built in algorithms to minimize that variation. Rob is the permanent designated measure reviewer

for it as part of his study, so we will review it on a different cycle.

[Via Chat] Mei Calabio [MPOG]

MPOG Measure Spec - BP-05: https://datalibrary.mpog.org/Measures/Public/60

Vote — Blood Pressure Measures

Nirav Shah [MPOG]

In the interest of time, any other comments on any of these measures before we move to a vote?

For BP03: because the proposed modification is to add additional filters and visualizations — rather than

excluding hips and knees from the denominator — I would vote to record that as 'Keep as Is.' A vote to 'Modify'

would mean actually removing hips and knees from the denominator. I will launch the poll now.

Results: 79% voted Keep as Is. We will add the visualizations JP suggested and will not modify the denominator.

For BP01 — MAP less than 55 for 20 minutes — JP's recommendation was to retire this measure. Results: 91%

voted to retire BP01.

For BP06 — MAP less than 55 for 10 minutes — JP's recommendation was to keep as is. Results: Keep as Is

confirmed.

JP, thank you so much. This was a phenomenal amount of work. Thank you for the great discussion. We need to

move on — Tariq, the floor is yours.

PONV Measure Review — PONV03

Presenter: Dr. Tariq Esmail

Tariq Esmail [UHN]

Thank you, and thank you, Dr. Paul — your literature search review was far more extensive than mine. I was

fortunate that a new consensus guideline was published very recently, which encompasses a lot of the relevant

evidence and serves as the focus of today's discussion.

PONV03 measures the percentage of patients, regardless of age, who are undergoing a procedure and have

documented nausea or emesis occurrence, or received a rescue antiemetic in the immediate postoperative

period. Together with PONV03B, which captures the same outcome with or without receiving an antiemetic, this

is particularly useful for institutions that have a practice of delivering antiemetics routinely, whether or not

patients are nauseated.

The new consensus guidelines were published in print in September 2026. They were accepted for publication in

August 2025 and contain literature up to approximately September–October 2024. I did review the literature

from 2024 to the present, and while there is a considerable amount in PONV, nothing rises to the level of

evidence summarized in these guidelines. For our measures — which are intended to reflect definitive, non-

disputed evidence rather than emerging evidence — I have made all proposed changes with reference to this

guideline.

Background and New Evidence

Tariq Esmail [UHN]

Why is this being revisited? The rationale remains very appropriate, and several things are new according to the

updated guidelines. First, Guideline 4 now explicitly states that a different drug class should be used for rescue

than what was used for prophylaxis — this is now a recommendation, not just a suggestion. Second, the

guidelines discuss pediatric PONV in more detail, which is relevant since PONV03 includes all ages. Third, there is

an increased focus on procedure-based risk factors in addition to the APFEL score. Fourth, there are a few new

antiemetic agents, and several agents have been downgraded in evidence level.

Coordinating Center Updates (No Vote Required)

Tariq Esmail [UHN]

The following are groupings of changes that I believe are informational and do not require a committee vote:

1. Replace direct-to-ICU exclusion with the existing 'airway remained intubated' phenotype. Previously there

was variability in cases that were extubated and went to ICU. PONV05 has already adopted this update;

PONV03 should align.

2. Retain obstetric cases as currently specified to capture post-cesarean PONV. PONV05 has removed all

obstetric cases, and a separate PONV06 with an obstetric focus is planned, but I recommend retaining

obstetric cases in PONV03 for now. The existing labor epidural exclusion remains due to data availability

limitations in MPOG — it is not that we do not care about nausea in the laboring patient, it is that the data

are not clean enough for that purpose.

3. Add a matching cohort visualization. PONV03 and PONV05 are not apples-to-apples populations because

PONV03 includes all ages. A suggested addition would be a matching cohort so sites could compare their

PONV03B prophylaxis rate with the corresponding actual nausea and vomiting incidence. The Coordinating

Center believes this is feasible.

4. Add a drug class indicator to the case detail. The guidelines recommend using a different drug class for

rescue than for prophylaxis. It would be helpful if the case detail could show — when a rescue drug was

given after prophylaxis — whether it was actually a different class. This is actionable information for quality

champions.

Items for future discussion include: procedure type-based risk adjustment (pending since the measure's

inception in 2019), a more data-driven success threshold (currently 10%), and a unified case duration phenotype

— the Coordinating Center will review case duration definitions for consistency across measures. One pediatric-

specific antiemetic, dolasetron, is supported by pediatric guideline evidence and should remain in the drug list

even though it is not evidence-based for adults.

Nirav Shah [MPOG]

All of those items fall into the bucket of either things we need to do at the Coordinating Center or items to

investigate for future discussion. I do not think we need to vote on them. If anyone has a strong feeling

otherwise, please reach out and we will bring it up for a future vote. Many of these just make sense to do.

[Via Chat] Mei Calabio [MPOG]

MPOG Measure Spec - PONV-03: https://datalibrary.mpog.org/Measures/Public/33

Proposed Modifications (Requiring Vote)

Tariq Esmail [UHN]

The proposed changes requiring a vote are:

1. Change the measure window. Currently, the measure window is defined as PACU start to anesthesia end

plus 6 hours. The issue is that 'anesthesia end' is variable — at our institution, anesthesia end is tied to

billing time, so it may occur after PACU start. I would propose unifying this to PACU start (with fallback to

patient out of room if PACU start is unavailable) to define a consistent 6-hour window. The evidence

supports measuring PONV out to 24 hours, but MPOG does not currently have that data capability.

2. Add olanzapine to the drug list. As in PONV05, olanzapine was introduced as a drug class and should be

added.

3. Add transdermal scopolamine. It is mentioned in the measure specifications but is not actually in the drug

list. It should be added.

4. Add ramosetron and tropisetron. These are specifically called out in the updated guidelines with Grade A

evidence. They are not commonly used in the U.S. or Canada, but as MPOG grows internationally, they

should be included.

5. Remove diphenhydramine as a standalone antiemetic. The updated guidelines only include

diphenhydramine in combination with ondansetron, with A3 grade evidence. There is no standalone

evidence.

6. Remove prochlorperazine (Compazine). There is even less support for this agent — it was never assigned an

evidence grade in the guidelines.

[Via Chat] Kunal Karamchandani [UT Southwestern]

With drug shortages so common, could we please not exclude diphenhydramine and prochlorperazine?

[Via Chat] Ketan Chopra [Henry Ford - Detroit]

Agree, I use Compazine as a rescue.

[Via Chat] Kristin Krauss [Temple]

Agree with above. Also agree with the trouble of filtering cases where patients get diphenhydramine for

other reasons.

Nirav Shah [MPOG]

Regarding diphenhydramine and prochlorperazine — we want to cast as wide a net as possible for what we call

a rescue antiemetic. The question is not whether these medications should be given as antiemetics, but rather:

if they were given, can we assume they were given for antiemetic reasons? If someone gave Benadryl in the

PACU, were they treating nausea or an allergic reaction? That ambiguity is the concern.

Tariq Esmail [UHN]

That is a good point, and it connects to the ambiguity around haloperidol — we did not include it previously

because it is also used for delirium, but I use it as a rescue antiemetic before any of these agents. If we want to

cast a wide net, perhaps we should include haloperidol as well. Dexamethasone, on the other hand, is never

really used as a rescue — it is given early and takes a couple of hours to work — so it should remain excluded.

But if we are keeping diphenhydramine and prochlorperazine for pragmatic reasons, I would suggest adding

haloperidol as an inclusion for the same reason.

Nirav Shah [MPOG]

Interesting. I see comments from Kunal requesting that we not exclude diphenhydramine and prochlorperazine,

and from Ketan agreeing on Compazine as a rescue. And a note: we do not have a PACU start button in Epic, but

the MPOG extract does capture PACU start from nursing documentation in many cases — it is not as universal as

anesthesia end or patient out of room, but in many cases we can capture it.

Tariq Esmail [UHN]

Mike has his hand up.

Michael Mathis [MPOG]

I would revisit what we discussed for BP03 — perhaps improved filtering ability, similar to the site-specific

control concept. Having filtering ability based on which rescue antiemetic was given might be useful, so the site

can judge whether it was a valid flag or not.

Tariq Esmail [UHN]

I will remind everyone that this is only relevant for PONV03. For PONV03B, none of these drugs matter — it is

whether nausea or vomiting occurred, regardless of drug administration. And Kunal, your hand is up.

[Via Chat] Kate Buehler [MPOG]

PACU Start phenotype: https://datalibrary.mpog.org/Phenotypes/Public/PACU%20Start%20Time

Kunal Karamchandani [UT Southwestern]

There should be a way to discriminate between prophylactic and rescue use. For example, if someone gives

ondansetron in the OR for prophylaxis and then orders ondansetron in the PACU for rescue — which we are

trying to discourage — filtering that out would be very helpful. Additionally, if you are using aprepitant,

dexamethasone, and ondansetron for prophylaxis and want to use a different class for rescue, droperidol and

haloperidol are actually the same class as each other. So prochlorperazine and similar agents may be the only

remaining option if you need a second rescue after haloperidol or droperidol.

Nirav Shah [MPOG]

That is true. Tariq did mention recommending that the Coordinating Center add a column indicating whether

the same or a different class of drug was used in the PACU, and I think that is a great idea — we should plan on

doing it. We are at time. I want to get the vote out before folks drop off.

Tariq Esmail [UHN]

Since we want to cast a wide net, are you going to leave the proposed removals out of the vote, or are people

voting on it as it stands and we revisit another time?

Nirav Shah [MPOG]

The modifications are individual items, so I am assuming we do want to add ramosetron, tropisetron, and

olanzapine. I will launch the poll now.

Tariq Esmail [UHN]

While people are voting — Kate, the PACU Start phenotype you posted is super helpful. It shows all the fallbacks

if PACU Start is unavailable, with several layers down to anesthesia end. That phenotype works really well for

this purpose.

Vote — PONV03 Modifications

Nirav Shah [MPOG]

Results:

• Modify the measure window: Yes — approved.

• Add olanzapine and transdermal scopolamine: Yes — approved.

• Add ramosetron and tropisetron: Yes — approved.

• Remove diphenhydramine: No — the committee voted to retain diphenhydramine.

• Remove prochlorperazine (Compazine): No — the committee voted to retain prochlorperazine.

These results reflect the discussion we had. We are 5 minutes over. Thank you all so much. Dr. Esmail, Dr. Paul

— really excellent reviews. Diving back into the literature, teasing out the guideline updates, and thinking

through how those need to reflect in the measures to keep them current and relevant, and how the QI

Reporting Tool can enable more local control — all of it is extremely helpful. Two top-notch reviews. Thank you

both.

Everyone, have a great Monday. Take care.