For more than 25 years, anesthesiologists have been at the forefront of quality improvement activities to enhance patient safety, implement best practices and execute quality initiatives at the practice level. Establishing the Anesthesia Patient Safety Foundation in 1985 marked a milestone in the ongoing efforts by anesthesiologists to increase quality and safety for patients receiving an anesthetic. However, in the last decade or so, the medical profession, as well as public and private payers, has increasingly emphasized how measurement can lead to improved patient outcomes, reduced costs and a more efficient delivery of care. Merging practice standards, guidelines and advisories with quality measurement has continued the tradition of improving quality and safety at the practice level.
Beginning with the Institute of Medicine report To Err Is Human, published in 1999, Congress and other government agencies began to make changes that would impact medicine in ways never before experienced by physicians. ASA leaders recognized the need for developing ways to demonstrate quality of care delivered by anesthesiologists (i.e., measures to benchmark locally and to compare across practices). The Committee on Performance and Outcomes Measurement (CPOM) was established and tasked with identifying gaps in practice, reviewing evidence-based literature and developing measures used to demonstrate improvement of care over time. CPOM has developed several process measures but faced significant challenges with the advancement of these measures. While many anesthesiologists believed in a more broad application of measures, others have argued that the measures should focus solely on the intraoperative and recovery room phases of the patients’ care. CPOM faced another formidable hurdle – lack of reliable and valid data, which is essential in developing meaningful quality outcomes measures. Large amounts of data are now being collected by the Anesthesia Quality Institute (AQI) through its National Anesthesia Clinical Outcomes Registry (NACOR). These data impact CPOM’s contemplation of future anesthesiology-related measures.
The process measures developed by CPOM for use by anesthesiologists today present challenges for the specialty tomorrow. Both the National Quality Forum (NQF) and the Centers for Medicare & Medicaid Services (CMS) have expressed unequivocally that outcomes measures are the gold standard. As NQF and CMS de-emphasize and phase out many process measures, anesthesiologists will need to be more aggressive in developing outcomes measures. Evidence is accumulating that anesthesiologists contribute to patient outcomes for many types of surgery, including cardiac, thoracic, orthopedic, major abdominal and obstetric procedures. Neither anesthesiologists nor surgeons act in isolation; both influence patient outcomes.
Team-based outcomes measurement will emerge as the model leading to a higher level of patient care, patient experience and improved outcomes. Anticipating the shift in quality measurement, CPOM began to explore the concept of team-based measures with shared accountability. CPOM proactively engaged measure stewards, requesting that anesthesiology Current Procedural Terminology (CPT®) codes be added to selected NQF-endorsed and CMS-approved measures used in the Physician Quality Reporting System (PQRS). Once the stewards have agreed to add anesthesiology CPT codes to the measures, it is critical to determine the appropriate mechanism to allow the specialty to report these measures.
Anesthesiologists being fully invested in patient outcomes, sharing accountability and partnering with surgeons for these outcomes will raise the bar for improving patient care. At the same time, shared accountability measures will recognize anesthesiologists for their key role in impacting patient care. However, surgeons and anesthesiologists sharing accountability is not enough. This effort will require support from hospital and ambulatory center administrators and a favorable atmosphere for enhanced quality improvement activities. Anesthesiologists, at the very least, must be proactive team members who take leadership on shared accountability with surgeons and hospital administrators for patient outcomes.
During a recent a discussion with a measure developer, a question was asked, “Well, it’s surgery, so anesthesia is certainly used. Why should anesthesiologists be able to report on a foregone conclusion?” Although the question on its face seems flip, it nonetheless underscores the necessary actions that must take place to ensure that anesthesiologists are recognized for the care delivered. Anesthesiologists should move from the back side of the “blood brain barrier” and consider the concept that anesthesiologists contribute to patient outcomes beyond the confines of the operating room and the postanesthesia care unit. As a corollary, limiting attribution to one medical professional, as in the case of surgery, unfairly singles out the surgeon without requiring the anesthesiologist to assume responsibility for components of care he/she provides. Bridging those silos, working as a team, and sharing attribution and accountability for patient outcomes will lead to better patient care, better outcomes and more satisfied patients.
On November 27, 2013, CMS released its 2014 Physician Fee Schedule (PFS). This change has far-reaching implications for anesthesiologists both in measuring and reporting quality of care metrics. Future NEWSLETTER articles will detail provisions within the schedule, but suffice it to say that anesthesiologists must accept that medicine has changed and there is no going back. Anesthesiologists must report on meaningful outcomes measures as the way to enhance the specialty and to move forward.
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