Measuring Quality of Care: A Call to Action

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February 1, 2014 Volume 78, Number 2
Measuring Quality of Care: A Call to Action Sheila R. Barnett, M.D.
Committee on Performance and Outcomes Measurement

Edward Pollak, M.D.
Committee on Performance and Outcomes Measurement



Physicians face a new reality: fewer healthcare dollars directed toward those who deliver the highest-quality care for the lowest price. The new system means that some physicians will receive proportionately more and some less of value-based payments. The Centers for Medicare & Medicaid Services (CMS) has already indicated that value is the new deliverable from physicians and hospitals, and soon other payers, including patients, will follow their lead. Thus, anesthesiologists cannot afford to ignore the current reality: prove your value with data. It may surprise anesthesiologists, often touted as leaders in patient safety, that our surgical colleagues are ahead of us on measurable quality. The American College of Surgeons (ACS) and Society for Thoracic Surgeons (STS) have already partnered with CMS to create pay-for-performance measures that have demonstrably improved patient care. By contrast, anesthesiologists have only three measures as of November 2013: antibiotic timing, normothermia, and the central line bundle. Many of us doubt that these three measures will even be meaningful in a world of bundled payments. Furthermore, future measures will need to reflect our impact on the continuum of care during the entire perioperative period. If anesthesiologists are defined only by the intraoperative management of their patients, anesthesiology, as we know it, will be in serious jeopardy.


As the health care landscape shifts, anesthesiologists also need to heed the changing demographics of our population. America is rapidly aging: in 2000 it was estimated that there were 35 million individuals 65 years and over; by 2030 this number is expected to reach 71 million. Thirty to 40 percent of surgeries occur in older patients, representing a significant fraction of our “customers.” With approximately 40 percent of tax dollars going toward Medicare and Social Security combined, seniors also have significant economic and political clout. Thus, providing high value care to America’s oldest patients is a must for the 21st century anesthesiologist.


It is well recognized that, compared to their younger counterparts, older patients have more medical problems, less hemodynamic reserve, and consequently higher rates of perioperative morbidity and mortality. A 2008 report1 details the aging health care problem and calls on leaders in medicine to “enhance the competence of all individuals in the delivery of geriatric care …” Anesthesiologists have a tremendous opportunity to provide value to patients, surgeons, and hospitals by embracing the perioperative management of complex and potentially frail geriatric patients. This includes ensuring older patients receive appropriate age-based care from the preoperative assessment through the postoperative recovery period. Following surgery, geriatric perioperative measures will need to be developed. For high risk surgery (e.g., cardiothoracic surgery), mortality and major morbidities are obvious and important outcomes measures, and this is not different for an older or younger patient. However, an assessment of the functional recovery and the discharge disposition (e.g., home versus a nursing home) of a geriatric patient might provide a more meaningful measure of the quality of the perioperative care experienced by the older patient.


Value-Based Purchasing

The business case for quality and safety has shifted to focus on patient-centered value: value equals quality plus patient experience divided by cost. The need for better outcomes measures has been underscored with the implementation of the 2013 CMS Value-Based Purchasing program. Under this program, CMS pays hospitals according to their ability to meet efficiency (cost), service and quality targets. This year, whether a hospital does or does not meet the CMS break-even point will determine whether they will receive a 1 percent positive payment of a 1 percent reduction in their Medicare payments. By 2017, the amount at risk will be 2 percent of all Medicare payments.


The literature suggests that if 2 percent is not a strong enough incentive to change behaviors, then CMS will continue increasing the percentage until it reaches an inflection point at which the additional payments or payment reductions will substantially matter to hospitals and physicians. At present, the payments matter less to the bottom line of physicians than to hospitals.2


The trend line is clear: high-value health systems and providers will be paid at higher rates. This is a zero-sum game, so the negative outliers performing below the set point will lose by an amount equal to that gained by those who are the positive outliers, i.e., perform better than the set point. As indicated in the table below, efficiency, which is risk adjusted expenditure per Medicare beneficiary, will become an increasingly important determinant for payment models. To report outcomes measures, anesthesiologists will need to adopt CMS-approved outcomes measures currently reported by surgeons and institutions. The ASA Committee on Performance and Outcomes Measurement (CPOM) is exploring shared accountability by asking CMS to support, and measure stewards to allow, anesthesia codes to be added to already approved outcome measures for which anesthesiologists also make significant contributions to patient outcomes. Over time, the National Anesthesiology Clinical Outcomes Registry (NACOR) will provide additional data to allow development of more specific anesthesiology outcome measures.



“Measure for Measure”

There are several types of measures that can be used to evaluate care; the most commonly adopted are process and outcomes measures. Process measures address how the care was delivered, such as the timely administration of antibiotics. This measure calculates the percentage of practitioners who followed the accepted guidelines for surgical prophylaxis against infection. By contrast, the incidence of surgical infection would be an outcomes measure. Outcomes measures quantitate the end result of the care delivery and are a better measure of value or quality of care. Meaningful outcomes measures require appropriate risk adjustment to discriminate between better and worse care as opposed to healthy and unhealthy patients. By contrast, process measures are typically not risk adjusted – they are all or none.


It has been challenging for anesthesiologists to capture good outcomes measures. Anesthesia-related complications are rare, and historically anesthesiologists have searched for outcomes measures solely attributable to better or worse anesthesia care. At a local level, some groups have addressed rates of complications; for example, individual rates of postoperative nausea or vomiting or dental injuries. But robust publicly reported outcomes measures do not currently exist for our specialty. It would be prohibitively expensive to capture data on rare anesthesia complications (e.g., neuropathy after peripheral nerve blockade) solely for the purpose of public reporting. Additionally the gap between prevailing current practice and best practice is narrow. Therefore, outcomes measures will require collaboration with other specialties that have already developed robust databases. As stated above, ASA leadership, including CPOM members, are working with the ACS, the STS, the National Quality Forum and CMS to allow anesthesiologists to participate in shared measures such as mortality after cardiac surgery.


As U.S. demographics shift, developing “gero-centric” measures will also be needed. An example that would reflect on the entire perioperative period of care of an elderly patient might be the percentage of surgical patients successfully discharged to home as opposed to a skilled nursing facility. This is a very meaningful outcome measure for older patients. Another example could address postoperative cognitive dysfunction, one of the most feared complications for older patients after surgery. However this is challenging, since many older patients present to the hospital with previously unrecognized cognitive dysfunction and a variable degree of vulnerability. At present, collecting detailed baseline cognitive information for all older patients would likely be expensive and impractical. However, for this example, a process measure – although intrinsically limited – may be more appropriate. Such a measure could include avoidance of medications that are associated with delirium or cognitive dysfunction, such as those with strong anticholinergic properties. These and other medications to avoid in the geriatric age group are well described in the Revised Beers criteria.3 While by no means a perfect measure, this would address a gap in care that is important to the patient and public, and therefore has the potential to enhance the value of our specialty.


Conclusion

Many in our specialty may worry that reporting the quality of anesthesia care may backfire and be used against us to drive down payments. Yet having no meaningful quality data to report is far more dangerous, as payers can use the absence of data to devalue the contributions of all anesthesia practices, not only those that are inferior. As anesthesiologists, we have an opportunity to become drivers of high-quality perioperative care, especially for vulnerable populations such as the elderly. The ASA leadership, through work with CPOM and others, is committed to developing meaningful measures that extend beyond the operating room and accurately reflect our expertise. This will reaffirm our role as leaders in patient safety and additionally establish our specialty as leaders in value-based perioperative care.


Value-Based Purchasing Structure
 Fiscal Year   Program Carveout    Clinical   HCAHPS   Outcomes of Care   Efficiency of Care 
 2013  1.00%  70%  30%  N/A  N/A
 2014  1.25%  45%  30%  25%  N/A
 2015*  1.50%  20%  30%  30%  20%
 2016  1.75%  10%  25%  40%  25%
 2017  2.00%  tbd tbd  tbd  tbd


Sheila R. Barnett, M.D. is Director of Remote Anesthesia, Medical Director of Quality for Interventional Procedures, Associate Professor of Anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston.

Edward Pollak, M.D. is Vice Chief, Department of Anesthesiology and Perioperative Medicine, and Patient Safety Officer, William Beaumont Hospital, Royal Oak, Michigan.


References:

1. Institute of Medicine Committee on the Future Health Care Workforce for Older Americans. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: The National Academies Press; 2008

2. Epstein AM. Will pay for performance improve quality of care? The answer is in the details. N Engl J Med. 2012; 367(19):1852-1853.

3. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631. http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012

Accessed December 10, 2013.