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Cesarean Birth

Compare Versions of: "Cesarean Birth"

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Measure Information 2023 Reporting Period 2024 Reporting Period 2025 Reporting Period
Title Cesarean Birth Cesarean Birth Cesarean Birth
CMS eCQM ID CMS334v4 CMS334v5 CMS334v6
Short Name

PC-02

PC-02

PC-02

CBE ID Not Applicable 0471e 0471e
Measure Steward The Joint Commission The Joint Commission The Joint Commission
Description

Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth

Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Outcome Outcome Outcome
Stratification *See CMS334v4.html

None

None

Risk Adjustment *See CMS334v4.html

None

None

Rationale *See CMS334v4.html

The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean birth (CB) rates. Some hospitals’ CB rates were over 50%. Hospitals with CB rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Symum et al., 2021). There is no data that higher rates improve any outcomes, yet the CB rates continue to rise. This measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in nulliparous women. This population segment accounts for the large majority of the variable portion of the CB rate and is the area most affected by subjectivity.

As compared to other CB measures, what is different about Nulliparous, Term, Singleton, Vertex (NTSV) CB rate is that there are clear cut quality improvement activities that can be done to address the differences. Main et al., 2012 found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Rosenstein et al., 2021 also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz et al.,1989; Goyert et al., 1989; Luthy et al., 2003; Symum et al., 2021). The dramatic variation in cesarean rates seen in all populations studied is striking. (Cesarean rates varied tenfold in US hospitals nationwide across hospitals, from 7.1% to 69.9% and there was a 15-fold variation among low-risk women, from 2.4% to 36.5% (Kozhimannil et al., 2013).

A reduction in the number of NTSV patients delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs. Successful quality improvement efforts incorporate audit and feedback strategies combined with provider and nurse education, guidelines and peer review.

The measure will assist health care organizations to track NTSV patients delivering by cesarean birth to reduce the occurrence. Nulliparous women have 4-6 times the cesarean birth rate than multiparous women thus the NTSV population is the largest driver of primary cesarean birth rate (Sakala et al., 2020). NTSV has a large variation among facilities, thus identifying an important population on which to focus quality improvement efforts.

In addition, a reduction in primary cesarean births will reduce the number of women having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth (CDC, 2020)). Thus, improvement in the rates of cesarean birth for the first birth will reduce the morbidity of all future births and avoid all the controversies with trial of labor after cesarean/elective repeat cesareans.

The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean birth (CB) rates. Some hospitals’ CB rates were over 50%. Hospitals with CB rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Symum & Zayas-Castro, 2023). There is no data that higher rates improve any outcomes, yet the CB rates continue to rise (Bailit, Garrett, Miller, McMahon, & Cefalo, 2002; Main, Bloomfield, & Hunt, 2004). This measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in nulliparous women. This population segment accounts for the large majority of the variable portion of the CB rate and is the area most affected by subjectivity.

As compared to other CB measures, what is different about Nulliparous, Term, Singleton, Vertex (NTSV) CB rate is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2012) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates (Main et al., 2006). The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Rosenstein et al. (2021) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, Fiarman, Mojica, Bauman, & de Regt, 1989; Goyert, Bottoms, Treadwell, & Nehra, 1989; Luthy, Malmgren, Zingheim, & Leininger, 2003; Symum & Zayas-Castro, 2023; Main et al., 2006). The dramatic variation in cesarean rates seen in all populations studied is striking. Cesarean rates varied tenfold in US hospitals nationwide across hospitals (Agency for Healthcare Research and Quality [AHRQ], 2002), from 7.1% to 69.9%, and there was a 15-fold variation among low-risk women, from 2.4% to 36.5% (Kozhimannil, Law, & Virnig, 2013).

A reduction in the number of NTSV patients delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs (Main et al., 2019). Successful quality improvement efforts incorporate audit and feedback strategies combined with provider and nurse education, guidelines and peer review.

The measure will assist health care organizations to track NTSV patients delivering by cesarean birth to reduce the occurrence. Nulliparous women have 4-6 times the cesarean birth rate than multiparous women thus the NTSV population is the largest driver of primary cesarean birth rate (Sakala, Belanoff, & Declercq, 2020). NTSV has a large variation among facilities, thus identifying an important population on which to focus quality improvement efforts.

In accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations (2020), cesarean delivery is indicated for patients with active genital lesions of genital herpes or prodromal symptoms (i.e., vulvar pain or burning at delivery) that may indicate viral shedding. Therefore, the measure will exclude encounters with a diagnosis of active genital herpes.

In addition, the accepted approach to treat placenta accreta spectrum, or the range of pathologic adherence of the placenta that includes placenta increta, placenta percreta, and placenta accreta, as well as placenta previa, is cesarean delivery (ACOG & Society for Maternal-Fetal Medicine (SMFM), 2018). Vasa previa is an indication for cesarean delivery (SMFM Publications Committee, Sinkey, Odibo, & Dashe, 2015). Accordingly, placenta previa, vasa previa, and placenta accreta spectrum are all qualifying conditions to also be excluded from the measure.

 

Ultimately, a reduction in primary cesarean births will reduce the number of women having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth (CDC, 2020)). Thus, improvement in the rates of cesarean birth for the first birth will reduce the morbidity of all future births and avoid all the controversies with trial of labor after cesarean/elective repeat cesareans.

Clinical Recommendation Statement *See CMS334v4.html

The American College of Obstetrics and Gynecology (ACOG) report, Evaluation of Cesarean Delivery, recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. A reduction in the number of nulliparous patients with live term singleton newborns in vertex position delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs.

The ACOG report, Evaluation of Cesarean Delivery (2000), recognizes the importance of the Nulliparous, Term Singleton Vertex (NTSV) population as the optimal focus for measurement and quality improvement action. A reduction in the number of nulliparous patients with live term singleton newborns in vertex position delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs.

Improvement Notation

Within Optimal Range. The Joint Commission does not want to encourage inappropriately low Cesarean rates that may be unsafe to patients. Acceptable PC-02 rates are 30% or lower, however there is not an established threshold for what rate may be too low. PC-06 serves as a balancing measure for PC-02 to guard against any unanticipated or unintended consequences and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for this measure. In order to identify areas for improvement, hospitals may want to review results based on specific ICD-10 codes or patient populations. Data could then be analyzed further determine specific patterns or trends to help reduce cesarean births.

Within Optimal Range. The Joint Commission does not want to encourage inappropriately low Cesarean rates that may be unsafe to patients. Acceptable PC-02 rates are 30% or lower, however there is not an established threshold for what rate may be too low. PC-06 serves as a balancing measure for PC-02 to guard against any unanticipated or unintended consequences and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for this measure. In order to identify areas for improvement, hospitals may want to review results based on specific ICD-10 codes or patient populations. Data could then be analyzed further determine specific patterns or trends to help reduce cesarean births.

Within Optimal Range. The Joint Commission does not want to encourage inappropriately low Cesarean rates that may be unsafe to patients. Acceptable PC-02 rates are 30% or lower (U.S. Department of Health and Human Services, n.d.), however there is not an established threshold for what rate may be too low. PC-06 serves as a balancing measure for PC-02 to guard against any unanticipated or unintended consequences and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for this measure. In order to identify areas for improvement, hospitals may want to review results based on specific ICD-10 codes or patient populations. Data could then be analyzed further determine specific patterns or trends to help reduce cesarean births.

Definition *See CMS334v4.html

Parity: The number of pregnancies reaching 20 weeks gestation regardless of the number of fetuses or outcomes

Gravidity: The number of pregnancies, current and past, regardless of the pregnancy outcome

Preterm Birth: The number of births >= 20 weeks and < 37 weeks gestation, regardless of outcome

Term Birth: The number of births >= 37 weeks gestation, regardless of outcome

Nulliparous: Parity = 0 or Gravidity = 1 or Preterm & Term Births both = 0

Parity: The number of pregnancies reaching 20 weeks gestation regardless of the number of fetuses or outcomes

Gravidity: The number of pregnancies, current and past, regardless of the pregnancy outcome

Preterm Birth: The number of births >= 20 weeks and < 37 weeks gestation, regardless of outcome

Term Birth: The number of births >= 37 weeks gestation, regardless of outcome

Nulliparous: Parity = 0 or Gravidity = 1 or Preterm & Term Births both = 0

Guidance

Vertex position is modeled implicitly, as the measure excludes deliveries with abnormal presentations.

Patients who do not receive prenatal care and have no documented gestational age or estimated due date are implicitly excluded from the measure, as gestational age is required to meet denominator criteria.

This measure allows for 2 approaches to determine estimated gestational age (EGA) in the following order of precedence:

1. The EGA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.*

2. The EGA is obtained from a discrete field in the electronic health record. This option is only used when the calculated EGA is not available.

Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.

 

*ACOG ReVITALize Guidelines for Calculating Gestational Age:

 

Gestational Age = (280-(EDD minus Reference Date))/7

--Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known lastmenstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (eg, assisted reproductive technology)

--Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery.

Note however the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

The timing relationship of relevantDatetime 42 weeks or less before TimeOfDelivery is applied to the data elements of parity, gravida, preterm/term live births for which prenatal records may include relevant information.

The denominator includes logic to determine if the patient is nulliparous. The patient is considered nulliparous when one of the following is true:

Parity equals zero

Gravida equals one

Preterm and Term births both equal zero

Parity, preterm and term live births may be updated by the electronic health record software or by clinicians during a delivery encounter. To capture the pre-delivery value, organizations may need to create a rule or calculation to capture the number prior to the delivery start time.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM

Vertex position is modeled implicitly, as the measure excludes deliveries with abnormal presentations.

Patients who do not receive prenatal care and have no documented gestational age or estimated due date are implicitly excluded from the measure, as gestational age is required to meet denominator criteria.

This measure allows for 3 approaches to determine gestational age (GA) in the following order of precedence:

1. The GA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.*

2. The GA is obtained from a discrete field in the electronic health record. This option is only used when the calculated GA is not available.

3. The GA is based on ICD10 or SNOMED codes indicative of weeks gestation. This option is only used when results from items #1 and #2 (see above) are not available.

Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.

 

*ACOG ReVITALize Guidelines for Calculating Gestational Age:

 

Gestational Age = (280-(EDD minus Reference Date))/7

--Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (e.g., assisted reproductive technology)

--Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery.

Note however the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

The timing relationship of relevantDatetime 42 weeks or less before TimeOfDelivery is applied to the data elements of parity, gravida, preterm/term live births for which prenatal records may include relevant information.

Note: The eCQM and chart-based measure slightly digress in the denominator and denominator exclusion logic. The chart-based measure excludes single stillbirth and patients with multiple gestations from the denominator. These concepts are mutually exclusive of the denominator requirement of live singleton newborn and therefore the logic does not address single stillbirth nor multiple gestation.

Parity, preterm and term live births may be updated by the electronic health record software or by clinicians during a delivery encounter. To capture the pre-delivery value, organizations may need to create a rule or calculation to capture the number prior to the delivery start time.

"Gravida", "PretermBirth", "TermBirth" and "Parity" results should be submitted via QRDA I as integer and not as number or quantity.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Vertex position is modeled implicitly, as the measure excludes deliveries with abnormal presentations.

Patients who do not receive prenatal care and have no documented gestational age or estimated due date are implicitly excluded from the measure, as gestational age is required to meet denominator criteria.

This measure allows for 3 approaches to determine gestational age (GA) in the following order of precedence:

1. The GA is calculated using the American College of Obstetricians and Gynecologists ReVITALize guidelines.*

2. The GA is obtained from a discrete field in the electronic health record. This option is only used when the calculated GA is not available.

3. The GA is based on ICD10 or SNOMED codes indicative of weeks gestation. This option is only used when results from items #1 and #2 (see above) are not available.

Wherever gestational age is mentioned, relative to the delivery, the intent is to capture the last estimated gestational age prior to or at the time of delivery.

 

*ACOG ReVITALize Guidelines for Calculating Gestational Age (ACOG, 2014):

 

Gestational Age = (280-(EDD minus Reference Date))/7

--Estimated Due Date (EDD): The best obstetrical Estimated Due Date is determined by last menstrual period if confirmed by early ultrasound or no ultrasound performed, or early ultrasound if no known last menstrual period or the ultrasound is not consistent with last menstrual period, or known date of fertilization (e.g., assisted reproductive technology)

--Reference Date is the date on which you are trying to determine gestational age. For purposes of this eCQM, Reference Date would be the Date of Delivery.

Note however the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.

The timing relationship of relevantDatetime 42 weeks or less before TimeOfDelivery is applied to the data elements of parity, gravida, preterm/term live births for which prenatal records may include relevant information.

Note: The eCQM and chart-based measure slightly digress in the denominator and denominator exclusion logic. The chart-based measure excludes single stillbirth and patients with multiple gestations from the denominator. These concepts are mutually exclusive of the denominator requirement of live singleton newborn and therefore the logic does not address single stillbirth nor multiple gestation.

Parity, preterm and term live births may be updated by the electronic health record software or by clinicians during a delivery encounter. To capture the pre-delivery value, organizations may need to create a rule or calculation to capture the number prior to the delivery start time.

"Gravida", "PretermBirth", "TermBirth" and "Parity" results should be submitted via QRDA I as integer and not as number or quantity.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Initial Population

Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure that ends during the measurement period

Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period

Inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period

Denominator

Inpatient hospitalizations for nulliparous patients delivered of a live term singleton newborn >= 37 weeks' gestation

Note: The eCQM and chart-based measure slightly digress in the denominator logic.

eCQM:

The measure description states "Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth". ACOG defines nulliparous as a woman with a parity of zero. The eCQM logic concludes that a patient is nulliparous when ONE of the following is true:

1. Parity equals zero

2. Gravidity equals one

3. Preterm and Term births both equal zero.

See Definition Section for more details.

Chart Based:

The chart based measure evaluates the data element "Previous Live Births". If the answer is "yes" the patient will be excluded from the denominator. If a patient had a previous stillbirth or fetal demise, the abstractor is instructed to answer "no" and the patient will remain in the denominator.

Inpatient hospitalizations for nulliparous patients who delivered a live term singleton newborn >= 37 weeks' gestation

See Guidance and Definition Sections for more details.

Inpatient hospitalizations for nulliparous patients who delivered a live term singleton newborn >= 37 weeks' gestation

See Guidance and Definition Sections for more details.

Denominator Exclusions

Inpatient hospitalizations for patients with abnormal presentation or placenta previa during the encounter.

Note that the chart-based measure excludes single stillbirth and patients with multiple gestations from the denominator. These concepts are mutually exclusive of the denominator requirement of live singleton newborn and therefore the logic does not address single stillbirth nor multiple gestation.

Inpatient hospitalizations for patients with abnormal presentation, placenta previa, placenta accreta or vasa previa during the encounter

Inpatient hospitalizations for patients with any of the following conditions during the encounter:

- abnormal presentation

- genital herpes

- placenta previa

- vasa previa

- placenta accreta spectrum

Numerator

Inpatient hospitalizations for patients who deliver by cesarean section.

Inpatient hospitalizations for patients who deliver by cesarean section

Inpatient hospitalizations for patients who deliver by cesarean section

Numerator Exclusions

None

None

Not Applicable

Denominator Exceptions

None

None

None

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CMS334v4-v2.zip 128.78 KB
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Last Updated: Mar 04, 2024