Operationalizing Evidence: Aligning CPG Key Action Statements for Registry-trackable Measures

Saturday, October 17, 2026

9:42 AM - 9:48 AM PT

Location: 406A

Presenting Author(s)

JL

Jenel Lansang, MSN, RN, MEDSURG-BC

Senior Manager, Quality and Performance Measurement (Research & Quality/Reg-ent Registry)
American Academy of Otolaryngology - Head and Neck Surgery, United States

Co-Author(s)

JL

Jenel Lansang, MSN, RN, MEDSURG-BC

Senior Manager, Quality and Performance Measurement (Research & Quality/Reg-ent Registry)
American Academy of Otolaryngology - Head and Neck Surgery, United States
SP

Soniya Phatak, MPH

Senior Manager, Operations (Research & Quality, Regent Registry)
AAO-HNSF, United States
SK

Sam Kim, BS

Senior Data Scientist
AAO-HNSF
Chevy Chase, Maryland, United States
KT

Kaitlyn E. Tholen, BS

Senior Program Manager, Grants
American Academy of Otolaryngology
Alexandria, VA, United States
Michael J. Brenner, MD

Associate Professor
University of Michigan
Ann Arbor, MI, United States

Senior Author(s)

Jocelyn S. Meyer, MPH

Vice President, Research & Quality Executive Director, Reg-ent Registry
American Academy of Otolaryngology - Head and Neck Surgery Foundation
Alexandria, VA, United States
Margo K. McKenna, MD

Associate Professor of Otolaryngology and Pediatrics
University of Rochester Medical Center
Rochester, NY, United States

Disclosure(s):

Kaitlyn E. Tholen, BS:

faculty for this accredited education activity has no relationship(s) with ineligible companies to disclose.

Jocelyn S. Meyer, MPH:

faculty for this accredited education activity has no relationship(s) with ineligible companies to disclose.

Margo K. McKenna, MD:

faculty for this accredited education activity has no relationship(s) with ineligible companies to disclose.

Introduction: Clinical practice guidelines (CPGs) are critical to evidence-based care, and clinical data registries like Reg-ent have become increasingly used to support quality improvement and application of guideline-based recommendations. However, variability in the wording of CPG Key Action Statements (KASs) can limit their translation into actionable and trackable quality measures that Reg-ent can reliably capture.

Methods: The AAO-HNSF CPG: Bell’s Palsy Update KASs were evaluated using a codability rubric to assess the extent to which they could be translated into discrete, consistently implementable data elements without altering clinical intent. KASs were mapped to potential quality measures using Reg-ent data elements. For each KAS, we evaluated the feasibility of measuring adherence by comparing the original guideline wording to a “measure-enhanced” version that clarified key elements including patient population, timing, and clinical exceptions. We evaluated differences in the types of measures that could be supported within the Reg-ent registry under each version.

Results: 53% of the CPG’s KASs were either already codifiable or could be made codifiable with refinements. Original KAS wording supported a limited number of quality measures within Reg-ent, whereas the measure-enhanced versions enabled more precise registry-based measures that facilitated patient outcome tracking, which expands the range of quality improvement questions that could be addressed using the Reg-ent data.

Conclusions: This case study illustrates Reg-ent’s ability to translate CPGs into actionable quality measures and highlights how guideline specificity directly influences what measures and registries can track. Integrating measurability considerations into guideline development will enhance the value of Reg-ent for quality improvement and evidence-based care.