QCDR 2017

ASPIRE Qualified Clinical Data Registry (QCDR)

The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) was designated as a Qualified Clinical Data Registry (QCDR) by the Centers of Medicare and Medicaid Services (CMS) in 2015. With this designation, ASPIRE was able to report approved quality measures to CMS on behalf of eligible professionals (EPs) for participation with Physician Quality Reporting System (PQRS). ASPIRE has continued to maintain QCDR designation and plans to report on behalf of more than 500 anesthesia professionals for 2016.

For more information about the ASPIRE QCDR program for 2017, please refer to the Participation Guide.

New Data Requirement for 2017: All participating sites are now required to submit insurance type. See Technical Specification for more details. For Epic sites: Clarity Insurance Query.

ASPIRE Measure Benchmark deciles as determined by CMS using 2015 data are available here: MIPS_ASPIRE Benchmark Results.

If interested in participating, please complete the Non-Binding Letter of Intent to begin the registration process.

QUALITY

Approved Measures for QCDR Reporting- 2017

QCDR Measure

ASPIRE Measure Abbreviation

Measure Description

Measure Domain

ASPIRE 2

NMB 01

Train of four monitor documented after last dose of non-depolarizing neuromuscular blocker

Effective Clinical Care

ASPIRE 3

NMB 02

Administration of Neostigmine before extubation for cases with nondepolarizing neuromuscular blockade

Effective Clinical Care

ASPIRE 4

GLU 01

Administration of insulin or glucose recheck for patients with hyperglycemia

Effective Clinical Care

ASPIRE 6*

PUL 01

Avoiding excessively high tidal volumes during positive pressure ventilation

Patient Safety

ASPIRE 8

TEMP 02

Core temperature measurement for all general anesthetics

Effective Clinical Care

ASPIRE 13*

TRAN 02

Transfusion goal of hematocrit less than 30

Efficiency and Cost Reduction

ASPIRE 16*

BP 01

Avoiding intraoperative hypotension

Patient Safety

ASPIRE 18*

CARD 01

Avoiding myocardial injury

Effective Clinical Care

ASPIRE 19*

AKI 01

Avoiding acute kidney injury

Effective Clinical Care

ASPIRE 22*

MED 01

Avoiding medication overdose

Patient Safety

MIPS 424*

TEMP 03

Perioperative temperature management

Patient Safety

MIPS 426*

TOC 02

Post-anesthetic transfer of care measure: procedure room to a PACU

Communication and Care Coordination

MIPS 430*

PONV 01

Prevention of postoperative nausea and vomiting (PONV)- combination therapy

Patient Safety

For complete measure specifications, please go to the ASPIRE Measures webpage: www.aspirecqi.org/aspire-measures

*Those measures with an (*) are considered High Priority measures per CMS.

Bold: Risk adjusted outcome measures. Risk adjustment methodology provided by the MPOG statistics team.

IMPROVEMENT ACTIVITIES

ASPIRE recommends that you review the list of improvement activities posted on the CMS website: https://qpp.cms.gov/mips/improvement-activities and select the activities most applicable to your providers.

Anesthesia providers are required to attest to 2 medium-weighted or 1 high-weighted activity for full participation in 2017.  There are 13 activities related to QCDR activity however, the five (5) activities listed below are most relevant to your participation in ASPIRE.  As we near the submission deadline, ASPIRE will send a form to each site to request information about the activities selected/performed.

1)      IA_BE_8: Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive (Medium)

2)      IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements (Medium)

3)      IA_PM_7: Use of QCDR for feedback reports that incorporate population health (High)

4)      IA_CC_6: Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination (Medium)

5)      IA_BE_2: Use of QCDR to support clinical decision making (Medium)

Contact Katie Buehler with any questions regarding ASPIRE QCDR: kjbucrek@med.umich.edu