Levers of change for CMS quality measures
CMS 30-day quality measures present challenges, but they also present opportunities for anesthesiologists across all stages of the surgical setting.
The Centers for Medicare & Medicaid Services (CMS) 30-day quality measures are designed to enhance healthcare accountability and improve patient outcomes by tracking areas such as unplanned readmissions and mortality. The quality measures are part of CMS’s value-based purchasing and public reporting programs. Although they don’t evaluate anesthesiologists directly, they still present a challenge and an opportunity for them.
Those challenges and opportunities will be highlighted in the Tuesday session, “Navigating CMS 30-Day Quality Measures: Opportunities and Challenges for Anesthesiology.”
“Anesthesiologists manage many of the clinical needs that affect outcomes,” said Amanda Rhee, MD, MS, System Vice President of Perioperative and Procedural Services at Mount Sinai Health System in New York City. “This is often unknown to many, even patients, as the work is done in the OR, and outcomes are attributed to surgeons, not anesthesiologists. The way anesthesiologists show their work is through sharing metrics, results, and having a seat at the table, lending their expertise.”
Session presenter Miklos Kertai, MD, MMHC, PhD, Professor and Vice Chair of Perioperative Medicine at Vanderbilt University Medical Center in Nashville, Tennessee, agreed with Dr. Rhee’s assessment.
“Anesthesiologists sit at a unique point of leverage because they touch the patient across the entire perioperative continuum, not just the operating room,” he said.
Dr. Kertai pointed to four key areas, or levers, that anesthesiologists can use to help a hospital system come into alignment with CMS 30-day quality measures.
Perioperative optimization
Perioperative optimization, according to Dr. Kertai, includes using perioperative anesthesia clinics and Perioperative Surgical Home models to identify high-risk patients before surgery. High-risk categories include frailty, poor functional capacity, and uncontrolled comorbidities, such as diabetes or anemia.
“Identifying these before surgery allows time to optimize them using risk stratification tools such as the revised cardiac risk index (RCRI), frailty indices, and cardiopulmonary exercise testing to help match the anesthetic plan and postoperative care level to the patient risk level,” Dr. Kertai said. “Anemia correction, glycemic control, smoking cessation counseling, and medication reconciliation in this window measurably reduce complications.”
Intraoperative management
In the intraoperative setting, Dr. Kertai said that maintaining hemodynamic stability by avoiding intraoperative hypotension through goal-directed fluid and vasopressor management is associated with lower rates of acute kidney injury (AKI) and myocardial injury, both of which are drivers of unplanned readmission and 30-day mortality. Although randomized data have not consistently confirmed that these interventions reduce hard outcomes, he said hemodynamic optimization remains one of the modifiable levers within the anesthesiologist's control.
In cases such as AKI, the outcome metrics favored by CMS are sometimes more difficult for the anesthesiologist to report and require a great deal of interdepartmental cooperation, according to session presenter Lilibeth Fermin, MD, MBA, CPPS, Clinical Professor of Anesthesiology at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University in Weston, Florida.
“A correlation between the anesthesia management and the desired outcome is fundamental to creating a meaningful outcome measure,” she said. “Events like postoperative AKI are multifactorial and cannot be attributed solely to anesthesia management.”
Dr. Rhee echoed this sentiment, recommending a multidisciplinary approach to outcome metrics and shared accountability.
“The coordination of clinical planning is what ultimately leads to the best result for our patients,” she said. “Close communication between surgeons and anesthesiologists can best ensure that the optimal clinical management plan is determined and executed before, during, and after the surgery.”
According to Dr. Kertai, there are several other intraoperative areas anesthesiologists should focus on.
“Avoiding excessively deep anesthesia, guided by processed EEG monitoring, may help reduce postoperative delirium. Opioid-sparing multimodal analgesia lowers opioid-related adverse events like respiratory depression, nausea, and ileus,” he said. “Anesthesiology-led ERAS [Enhanced Recovery After Surgery] protocols also consistently shorten length of stay and lower complication rates, while the readmission and mortality benefits are less certain.”
Temperature management, glucose control, and lung-protective ventilation can help reduce surgical site infection and pulmonary complications, Dr. Kertai said.
Postoperative and transitional care
Postsurgery is a critical time for both patients and anesthesiologists, and there are numerous areas that can lead to mortality and unplanned readmissions. Postoperative cognitive dysfunction, or delirium, is one of the first pitfalls, Dr. Kertai said, especially with elderly patients.
“The general anesthetic agent itself doesn't appear to change delirium risk much, but avoiding deliriogenic medications such as benzodiazepines in older adults, along with depth-of-anesthesia monitoring and multimodal analgesia, reduces the likelihood of these conditions,” he said.
He also recommended PACU- and ICU-level anesthesiology involvement in the early recognition of hemodynamic instability, respiratory compromise, and pain crises.
“Acute pain service management reduces opioid-related complications and supports earlier mobilization,” he said.
When it comes time for the patient to leave the hospital, Dr. Kertai said anesthesiologists should be closely involved in discharge planning and handoff quality to avoid communication gaps that can drive readmissions.
“Anesthesiologists increasingly participate in Perioperative Surgical Home models that follow patients beyond discharge,” he said, noting that these models most consistently shorten length of stay and reduce opioid and ICU utilization, while their effect on readmission rates has been more modest.
System-level and quality roles
Dr. Kertai said anesthesiologists can play key roles in the hospital system by leading or coleading perioperative quality committees, morbidity and mortality reviews, and enhanced recovery pathway designs.
“[Anesthesiologists] are positioned to standardize protocols across surgical services, which is where a lot of variability and preventable harm lies,” he said.
Keeping track of requirements can be a challenge for both hospital systems and anesthesiologists. This is especially true as CMS is constantly changing the metrics by removing those who score highly. Dr. Fermin will discuss some of the proposed upcoming changes during the session.
“For the 2027 performance year, CMS has proposed to remove the prevention of postoperative nausea and vomiting metric from the Anesthesiology Merit-based Incentive Payment System (MIPS) Value Pathways,” she said. “The evolving landscape of Medicare quality payment programs becomes in itself a challenge for anesthesiologists who practice in very different settings, from tertiary hospitals to offices.”
Although CMS measures don’t directly evaluate anesthesiologists, they can still have an impact on the work they do.
“They create the financial and reputational incentive structure that can push anesthesiologists toward a perioperative medicine model, since the specialty controls many of the modifiable risk factors that ultimately determine whether those numbers improve,” Dr. Kertai said.
