Cesarean Birth
Compare Versions of: "Cesarean Birth"
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| Measure Information | 2023 Reporting Period | 2024 Reporting Period | 2025 Reporting Period | 2026 Reporting Period |
|---|---|---|---|---|
| Title | Cesarean Birth | Cesarean Birth | Cesarean Birth | Cesarean Birth |
| CMS eCQM ID | CMS334v4 | CMS334v5 | CMS334v6 | CMS334v7 |
| Short Name |
PC-02 |
PC-02 |
PC-02 |
PC-02 |
| CBE ID* | Not Applicable | 0471e | 0471e | 0471e |
| Measure Steward | The Joint Commission | 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 |
Nulliparous patients with a term, singleton baby in a vertex position delivered by cesarean birth |
| Measure Scoring | Proportion measure | Proportion measure | Proportion measure | Proportion measure |
| Measure Type | Outcome | Outcome | Outcome | Outcome |
| Stratification | *See CMS334v4.html |
None |
None |
None |
| Risk Adjustment | *See CMS334v4.html |
None |
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. Show more >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. Show less |
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. Show more >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. Show less |
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 patients. 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 patients have 4-6 times the cesarean birth rate than multiparous patients 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 patients having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth (Centers for Disease Control and Prevention, 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. Show more >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 patients. 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 patients have 4-6 times the cesarean birth rate than multiparous patients 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 patients having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth (Centers for Disease Control and Prevention, 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. Show less |
| 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. Show more >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. Show less |
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. Show more >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. Show less |
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. Show more >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. Show less |
| 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. Show more >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. Show less |
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. Show more >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. Show less |
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. Show more >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. Show less |
Decreased score indicates improvement - The Joint Commission does not 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 to determine specific patterns or trends to help reduce cesarean births. Show more >Decreased score indicates improvement - The Joint Commission does not 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 to determine specific patterns or trends to help reduce cesarean births. Show less |
| 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 outcomePreterm 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 Show more >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 Show less |
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 outcomePreterm 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 Show more >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 Show less |
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 outcomePreterm 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 Show more >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 Show less |
| 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 Show more >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 Show less |
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 de...nominator 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. Show more >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. Show less |
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. Show more >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. Show less |
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. When the calculated GA is not available, the GA is obtained from a discrete field in the electronic health record. The intent is to capture the last estimated GA in the interval starting 24 hours or less prior to delivery and ending before midnight on the same day of delivery. 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. *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. Show more >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. When the calculated GA is not available, the GA is obtained from a discrete field in the electronic health record. The intent is to capture the last estimated GA in the interval starting 24 hours or less prior to delivery and ending before midnight on the same day of delivery. 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. *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. Show less |
| 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 |
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. Show more >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. Show less |
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. |
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. Show more >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. Show less |
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 |
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 |
Inpatient hospitalizations for patients who deliver by cesarean section |
| Numerator Exclusions |
None |
None |
Not Applicable |
None |
| Denominator Exceptions |
None |
None |
None |
None |
| Next Version | No Version Available | |||
| Previous Version | No Version Available |
Additional Resources for CMS334v6
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Header
Updated the eCQM version number.
Measure Section:
eCQM Version Number
Source of Change:
Annual Update
Changed all references from NQF to CBE to identify the consensus-based entity role.
Measure Section:
CBE Number
Source of Change:
Annual Update
Updated copyright.
Measure Section:
Copyright
Source of Change:
Annual Update
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Updated references and measure header to reflect current evidence and new or updated literature.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Logic
Added 'herpes' to the Denominator Exclusions to provide clarity and align with measure intent.
Measure Section:
Denominator Exclusions
Source of Change:
Expert Work Group Review
Updated Encounter with Abnormal Presentation definition to better align with measure intent by specifying that the delivery encounter addressed includes the hospitalization with emergency department and/or obstetric triage encounters if each transition occurs within one hour or less.
Measure Section:
Denominator Exclusions
Source of Change:
ONC Project Tracking System (JIRA): CQM-6797
Updated value set used in Denominator Exclusions to include the 'full placenta accreta spectrum' based on recommendations of technical expert panel.
Measure Section:
Denominator Exclusions
Source of Change:
Measure Alignment
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.
Measure Section:
Definitions
Source of Change:
Standards/Technical Update
Updated Encounter with Abnormal Presentation definition to better align with measure intent by specifying that the delivery encounter addressed includes the hospitalization with emergency department and/or obstetric triage encounters if each transition occurs within one hour or less.
Measure Section:
Definitions
Source of Change:
ONC Project Tracking System (JIRA): CQM-6797
Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.
Measure Section:
Definitions
Source of Change:
Standards/Technical Update
Removed length of stay requirement from the Global Common Library to better align with measure intent and logic.
Measure Section:
Definitions
Source of Change:
Standards/Technical Update
Removed 'day of' timing from Initial Population to align date/time precision of Numerator and Denominator, fixing a known issue with the measure.
Measure Section:
Definitions
Source of Change:
Measure Lead
Modified 'Encounter with Abnormal Presentation' definition to improve readability.
Measure Section:
Definitions
Source of Change:
Measure Lead
Added 'same day as' logic to the Last 'EstimatedGestationalAge' function to capture assessment time rather than documentation time and to better align with hospital documentation and measure logic.
Measure Section:
Functions
Source of Change:
Measure Lead
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Functions
Source of Change:
Annual Update
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Value set Abnormal Presentation (2.16.840.1.113762.1.4.1045.105): Added 11 SNOMED CT codes (249089009, 249090000, 249091001, 249098007, 249099004, 249100007, 249104003, 249105002, 79255005, 1231436008, 289398000) based on terminology update. Deleted 3 SNOMED CT codes (199358001, 199362007, 199354004) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set Cesarean Birth (2.16.840.1.113883.3.117.1.7.1.282): Added 6 SNOMED CT codes (736018001, 736020003, 736026009, 736118004, 1197219005, 788180009) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set Delivery Procedures (2.16.840.1.113762.1.4.1045.59): Added 8 SNOMED CT codes (734275002, 734276001, 736018001, 736020003, 736026009, 736118004, 1197219005, 788180009) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update
Added value set Genital Herpes (2.16.840.1.113883.3.464.1003.110.12.1049) based on change in measure requirements/measure specification.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set (2.16.840.1.113762.1.4.1110.37): Renamed to Placenta Accreta Spectrum Previa or Vasa Previa based on applicability of value set and/or OID.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set Placenta Accreta Spectrum Previa or Vasa Previa (2.16.840.1.113762.1.4.1110.37): Added 4 ICD-10-CM codes (O43.223, O43.233, O43.239, O43.229) based on applicability of value set and/or OID. Added 7 SNOMED CT codes (11763009, 1230040001, 237296008, 25585008, 267197003, 1173098001, 119901000119109) based on applicability of value set and/or OID. Deleted 5 SNOMED CT codes (198899007, 198900002, 198905007, 198906008, 199895009) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update