Quality measurement lags in the outpatient surgery arena

Ambulatory surgery centers are scrambling to develop better quality measures for their care. 

With more surgeries now performed in outpatient settings than in hospitals, ambulatory surgery centers have few ways to demonstrate the quality of care they can offer patients. 

“We are probably 10 years behind in our ambulatory (quality measurement) journey than where we are in our inpatient journey,” said Dr. David Levine, senior vice president of advanced analytics and informatics at consultancy Vizient, which develops quality measures. 

About 60% of surgeries once performed in a hospital are now performed in an ambulatory setting and the number of measures officially sanctioned by the CMS is getting smaller instead of larger. The agency only required ASCs to report four measures this year as part of its Quality Reporting Program—or otherwise face a 2% Medicare payment penalty for 2021—which is actually half the number of measures ASCs had to report in 2017 for payment this year. 

The low number of measures leaves consumers seeking care in outpatient surgery centers largely in the dark about the quality of care they will receive. “People are entrusting their lives in these centers, someone is taking a knife to your body. You want to believe precautions are taken and quality matters and you don’t have that assurance right now,” said Leah Binder, CEO of the Leapfrog Group.

Given the dearth of measures and the rising complexity of cases moving to the outpatient setting, ASCs have initiated efforts to create more measures, focusing mostly on better outcome measures, and to go beyond CMS reporting requirements.

“We want to be able to show the quality of care we provide,” said Bill Prentice, CEO of the Ambulatory Surgery Center Association, which represents ASCs in the U.S. “We are very much interested in developing outcome measures. We have taken it upon ourselves to try and develop and pilot test measures that go through the same approval process as the measures developed by (contracted measure developers) Yale and RTI.”

As such, the association is a founding member of the ASC Quality Collaboration, an organization formed in 2006 to create measures in the setting. The collaboration, which includes roughly 1,600 ASCs, has developed measures specific to certain ASC specialties as well as measures that can be “broadly applied across all settings such as measures of patient safety,” said Donna Slosburg, executive director of the collaboration, in an email. 

The Medicare Payment Advisory Commission also advocated for this approach. “The commission believes CMS should continue to improve (the ASC Quality Reporting Program) and move toward more CMS-calculated claims-based outcome measures that apply to all ASCs,” MedPAC stated in a March 2018 report.

The ASC collaboration has developed a few measures that take this approach. For instance, it has a measure that tracks emergency department visits within one day of discharge from an ASC.

The CMS hasn’t included the measure in its quality reporting program, but Slosburg said the collaboration advocates for the measures it develops to eventually be adopted. Additionally, ASC members of the collaborative use the developed measures in their practice, including the ones not required by the CMS.

The CMS didn’t respond to a request for comment about the new measures it plans to include in the ASC reporting program going forward, but next year ASCs will have two new measures to report on: hospital visits after orthopedic procedures and hospital visits after urology procedures. 

The orthopedic measure appears to be recognition from the CMS that total hip and knee replacements performed at ASCs are on the rise even though they aren’t yet covered by Medicare.

Five measures are currently part of CMS’ ASC Quality Reporting Program, of which one is voluntary. ASCs’ performance on the measures is published on Hospital Compare.

Criticisms of one of the outcome measures reported on for 2017—all-cause hospital transfer or admission after an ASC—illustrates the difficulty of measure development. 

Prentice said a high hospital transfer rate at an ASC doesn’t necessarily equate to poor quality of care. A patient can arrive on the day of a procedure with poor vitals before the surgery even begins and the surgeon may transfer that person to a hospital as a precaution. “That is where we need to get to more granular information about what these measures mean. Are they really showing to our regulator or a patient that something good or bad happened?” 

The CMS removed the measure from the current reporting period. 

The agency also delayed indefinitely the implementation of the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems survey, known as OAS CAHPS, from the ASC Quality Reporting Program because of opposition from providers. “We are trying to convince the CMS that our mothers and fathers of Medicare age do know how to email and complete online surveys. We objected to both the length of the survey and that it didn’t have an electronic option,” Prentice said. 

The CMS plans to test a web-based format of the survey this spring, according to its website. ASCs can also still voluntarily participate in the survey. The CMS publicly posts the results.

Considering the scarcity of measures from the CMS, some in the ASC industry have taken it upon themselves to go beyond the agency’s public reporting requirements. 

For instance, the California Ambulatory Surgery Association, which represents 330 ASCs in the state, has its own benchmarking program. ASCs voluntarily submit their quality data, which is used for quality improvement work. The ASC Quality Collaboration has a similar program that includes data from its 1,600 members. 

“We ask ourselves how we are doing in comparison to our industry and how can we network to identify ways to do things better,” said Michelle George, incoming president of the California Ambulatory Surgery Association. 

California’s program is asking ASCs to submit data on measures not currently included in the CMS’ reporting program, like wound infections post surgery, medication errors and excessive bleeding that requires a patient’s return to the operating room. Some 136 ASCs participated in the program in 2017. 

Although the benchmarking programs are helpful to ASCs, George said it’s still challenging to get an “apples-to-apples” comparison of surgical outcomes across different settings because the reporting requirements are all different. “What we don’t have is the ability to compare outpatient procedures across all the provider settings where the procedure can be performed. A hospital can perform them, then hospital outpatient surgery departments and ASCs,” she said.

For health systems with outpatient surgery departments, keeping track of patients’ outcomes post-discharge is a bit easier than it is for independent ASCs, argues Georgia Fojtasek, CEO of Henry Ford Allegiance Health, who plans to retire this year. 

The Jackson, Mich.-based health system, which is part of Henry Ford Health System, announced late last month it’s opening a new outpatient surgery center. Fojtasek said Henry Ford has an integrated electronic health record system that allows its physicians to see when patients have an admission to the hospital post-surgery. “A hospital comes with a lot of that rigor,” she said. “We have invested in the infrastructure.”

Some ASCs have forged relationships with local hospitals to try to know when an admission happens, but it isn’t the same as using a common EHR system. The CMS proposed a rule last year to try to make it easier for ASCs to transfer patients to hospitals by removing the requirement that ASCs have a written transfer agreement with the hospital. The rule is still pending.

Fojtasek added that she finds it confusing that outpatient surgery centers aren’t required to report the same things as hospitals. “There has to be a requirement that we are all reporting the same measures so we can compare the same things, including the acuity of the patients and the anesthesia class,” she said.

Leapfrog is also working on improving transparency of quality information in the setting. The organization last month opened its longstanding voluntary hospital safety survey to hospitals’ outpatient surgery departments and ASCs. 

Because there aren’t a lot of measures in the space, Binder said Leapfrog started “from scratch” to determine what to include in the survey to assess quality and safety.

The survey will ask about volume of procedures, credentials of clinical staff, safety practices, patient experience and structural measures like ensuring there is a protocol to guarantee patient consent.

"We prefer outcome measures but there aren't very many," Binder said. "Because there is so little known about ASCs, structural measures will turn out to be very important. We don't have a good understanding of what procedures are performed where."

The information from the surveys will be publicly displayed next spring so consumers can compare safety and quality between facilities. Leapfrog doesn’t plan to assign grades to the facilities at this time as it currently does for hospitals.

In order to get valuable outcomes data, and instead of only relying on relationships with local hospitals, some ASCs are starting to ask patients how they are doing post-discharge. 

Proliance Surgeons, a surgical practice with 20 ASCs in Washington state, is currently evaluating patient engagement firms that will allow them to digitally connect with patients before, during and after surgery. 

Proliance plans to communicate with patients frequently in the hours, days and sometimes even weeks after a procedure to ensure they haven’t experienced an adverse outcome leading to a hospital readmission. The data collected will allow Proliance to better understand where there are areas to improve care and boast about their performance to patients and payers when the data merits it, said Dr. Charles Peterson, Proliance’s board chairman.

“What we are doing right now at Proliance, and I think most ASCs are doing if they’re thoughtful, is trying to figure out how do we develop the data collection platforms to measure outcomes objectively and demonstrate them to patients and payers who are thinking about joining us,” Peterson said. 

The future of quality measurement in the ASCs setting likely will be focused on asking patients to report their own outcomes, said Dr. Gerald Maccioli, chief quality officer of Envision Healthcare, which owns Amsurg, a large ASC operator. 

A well-developed understanding of patients’ outcomes will allow providers to understand if these surgeries, which are usually elective, actually improve quality of life. But there are challenges to getting there. 

“The biggest barrier to a system of patient-reported outcome measures is getting consensus among groups to agree on measures,” Maccioli said. “The next is risk adjustment because everyone you talk to has sicker patients.”