October 16, 2017 

When it comes to measuring the quality of anesthesia care—or the quality of care in any medical specialty, for that matter—why not compare apples to apples so that measures are reliable, straightforward, accurate and consistent?

That’s the direction the Centers for Medicare and Medicaid Services (CMS) has been heading in recent years with the development of quality measures for the Merit-Based Incentive Payment System (MIPS) of the Quality Payment Program (QPP) and other federal healthcare programs.  CMS’s Core Quality Measures Collaborative, for example, has worked with commercial plans, Medicare and Medicaid managed care plans, purchasers, physician and other care provider organizations and consumers to develop core measure sets that reduce variability in measure selection, collection burden and cost. 

It’s also the thinking behind the American Society of Anesthesiologists’ (ASA’s) QCDR Roundtable, a consortium that brings together the CMS-approved anesthesia Qualified Clinical Data Registries to discuss and work on common interests related to measure development and implementation that reflect the way anesthesia groups practice today.  (In June, ABC was approved for the second consecutive year as a QCDR.)  QCDRs offer one method—in ABC’s opinion, the most prudent and reliable method—through which anesthesia providers can report their MIPS quality data.  (See our May 1, 2017 eAlert, “QR Versus QCDR for MIPS:  Answers for Anesthesiologists and Nurse Anesthetists.”)

The QCDR Roundtable joins the Anesthesia Quality Institute (AQI) and vendors in working cooperatively to reach consensus and reduce variability among the quality measures submitted for CMS approval by each of the QCDRs; to ensure that those measures, such as cardiac arrest, actually reflect the same dimensions of care and clearly indicate what they are measuring; and to align the anesthesia specialty with CMS’s goals and requirements around quality measure harmonization.

“The ASA reached out to all of the QCDRs for anesthesia to create avenues of collaboration and discussion,” explains Bryan Sullivan, chief quality officer for ABC, who attended the Roundtable’s meeting in September.  “It’s an excellent framework for all of us to work together.”

If several QCDRs include measures of the incidence of cardiac arrest, for example, should those measures exclude emergent cases that come through the emergency department?  Isn’t the risk of cardiac arrest in this group much higher than that for patients who come in for a screening colonoscopy?  Or, should the measure cover all causes of cardiac arrest?  These are the types of issues that CMS wants the QCDRs to work out and that the QCDR Roundtable hopes to address.  The point of CMS’s focus on harmonization is to generate a much larger denominator (the total number of patients that fit into a measure) to facilitate a better comparison of data from the various registries and more accurately differentiate providers based on their performance.

The Roundtable agreed that harmonization of measures should be planned in advance and accomplished through an agreed-upon timeline (typically a year in advance).  Guidelines for harmonization requests and planning will be developed in future meetings and discussions.  (Because the deadline for QCDRs to submit their 2018 measures to CMS is less than a month away, most of the harmonization of measures that takes place will impact 2019 and beyond.) 

To facilitate measure-sharing among the QCDRs, the ASA plans to develop draft timelines for the QCDRs for reviewing measures and recommending changes.  Eventually, it’s expected that the QCDRs will develop a process for sharing measures with each other in a timely fashion to limit duplication of efforts.

With that collective mindset, the Roundtable also agreed on the following grounding principles and goals:

• Stability:  The Roundtable will work to develop stable measures that are sensitive to the costs/benefits of revising measures annually, and will consider developing standard definitions, data collection methods and timeframes to enhance this stability.
• Timeliness:  The Roundtable will aim to finalize measures in a timeframe that gives anesthesia providers ample time to learn, understand and implement them.
• Accommodation:  The Roundtable will provide education and outreach to enable vendors to update anesthesia quality measures, and will consider providing templates to simplify the process of measure development.
• Proactive approach:  The Roundtable will study differences in performance rates between objective and subjective mechanisms for capturing data to inform the development of future measures.

The Roundtable also discussed instances in which it would be best not to harmonize measures across QCDRs.  These include instances in which measures have different data sources and/or measurement timeframes, and measures that address similar topics but differ in significant ways.  To avoid confusion, these measures should have distinct names that clearly reflect their intent.  Also on the table is the question of whether to develop measures that go beyond what anesthesiologists directly observe, such as measures related to patient outcomes and patient-reported outcomes.

The Roundtable also plans to look into ways to:

• Develop common, informal guiding principles for the development of quality measures.
• Encourage early input and communication on new concepts to prevent downstream harmonization issues.
• Advocate for the flexibility needed to add other QCDRs’ measures to a QCDR following the self-nomination deadline (as is currently allowed for the MIPS measures).
• Set expectations for ownership, stewardship, intellectual property and branding at the beginning of the licensing or harmonization process.
• Develop a two-year timeline and deadlines for harmonization efforts.
• Create a system for the mutual labeling of harmonized measures that explicitly indicates the measure is used by multiple QCDRs.

As you might suspect, achieving harmony around quality measures is a multi-faceted process fraught with questions.  The Roundtable is working to answer them.  Who will be the steward of a measure? Who will own the changes and see the measure through to fruition?  For example, should the quality measure for pain control in the PACU exclude chronic pain patients, whose threshold for pain differs from that of other patients and whose pain medication dosage requirements will also vary?  It’s relatively easy for a QCDR to make that decision on its own.  Hashing out the details and reaching consensus as a group is inherently more complex.

But anesthesia providers and the specialty as a whole ultimately stand to benefit from this ongoing group exercise.  Despite the complexity, we anticipate that an effort to pool expertise and resources in the interests of developing quality measures that reflect the contemporary practice of anesthesia and fully meet CMS requirements will enhance quality reporting for the specialty.

In choosing a QCDR for reporting your MIPS data, we recommend asking potential vendors the following questions:

1. What is your strategy for continuing to meet our needs as CMS and MIPS requirements continue to evolve?
2. How much is your strategy going to cost me?
3. How involved have you been with the industry to help shape our future with MIPS?
4. What are the advantages and disadvantages of harmonization with QCDRs?

With best wishes,

Tony Mira
President and CEO