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Cesarean Birth

Measure Information 2023 Reporting Period
CMS eCQM ID CMS334v4
Short Name PC-02
NQF Number Not Applicable
Description

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

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

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.

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.

Numerator

Inpatient hospitalizations for patients who deliver by cesarean section.

Numerator Exclusions

None

Denominator Exceptions

None

Measure Steward The Joint Commission
Measure Scoring Proportion measure
Measure Type Outcome measure
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.

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

MIPS Quality ID
Meaningful Measure Safety
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Measure Information 2023 Reporting Period
Title Cesarean Birth
CMS eCQM ID CMS334v4
Short Name PC-02
NQF Number Not Applicable
Description

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

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

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.

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.
Numerator

Inpatient hospitalizations for patients who deliver by cesarean section.

Numerator Exclusions

None

Denominator Exceptions

None

Measure Steward The Joint Commission
Measure Scoring Proportion measure
Measure Type Outcome measure
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.

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

Meaningful Measure Safety
Next Version No Version Available
Previous Version No Version Available
Last Updated: Aug 29, 2022