Factors that Predict Failure to Meet Merit-Based Incentive Payment System Quality Measures for Asymptomatic Carotid Endarterectomy - Journal of Vascular Surgery

Hospital records of patients who underwent carotid endarterectomy (CEA) for asymptomatic stenosis were evaluated in the state of Florida between 2008 and 2012. A total of 34,235 patient records and 701 providers were identified. Significant negative predictors for Physician Quality Reporting System (PQRS) measure of discharge by postoperative day 2 included weekend admission, Medicaid, surgeon postoperative stroke rate >2.0%, African-American race, and female gender. Not surprisingly, the most significant negative predictor for PQRS measure of postoperative stroke or death was surgeon postoperative stroke rate >2.0%. Surgeons in this underperforming group had worse outcomes despite operating on patients with fewer risk factors. Surgeon specialty, board certification, and case volume did not impact either PQRS measure. Selected groups of asymptomatic patients and surgeons with a high rate of postoperative stroke following CEA are at risk of failing to meet PQRS pay for performance quality measures. Evaluation of surgeon underperformance could improve quality of care. The PQRS and Merit-based Incentive Payment System (MIPS) created by the Centers for Medicare and Medicaid Services (CMS) financially penalizes providers who fail to meet expected quality-of-care measures. Compliance in 2017 will impact payment starting in 2019. With regard to CEA in asymptomatic patients, MIPS standards call for the analysis of patients undergoing CEA without major complications, which is implied by discharge to home by postoperative day 2. This paper specifically analyzed CEA results for asymptomatic patients, explaining why surgeons with >2.0% postoperative stroke rate were considered “underperforming.” A similar analysis in CEA results for symptomatic patients would almost certainly yield a higher postoperative “underperforming” stroke rate. One surprising finding in this paper is that surgeon specialty, board certification, and case volume did not impact hospital length of stay or postoperative stroke or death. These findings contradict several other reports showing that vascular surgeons and high-volume surgeons have better results performing CEA compared to nonvascular surgeons or low-volume surgeons. In Florida during this time period, about half of CEAs in asymptomatic patients were performed by vascular surgeons, one-quarter by cardiothoracic surgeons, one-sixth by general surgeons, and the rest by neurosurgeons, otolaryngologists (hmmm), and others. Nonetheless, the findings in this paper will likely be repeated in future publications and show that if you don't get