Maternity Care
Maternity Care Clinical Advisory Group
Value Based Payment Recommendation Report
- Report is also available in Portable Document Format (PDF)
May 2016
| Contents |
|---|
Introduction
|
Maternity Clinical Advisory Group (CAG)
|
| Recommendation Report Overview & Components |
| Maternity Playbook |
| Playbook Overview – Maternity Care Description of episodes – Maternity Care
Attachment B: Top 10 PACs per Maternity Episode
Attachment D: Data Available for Maternity Bundle Analysis |
| Maternity Quality Measure Summary |
| Introduction Selecting quality measures: criteria used to consider relevance Categorizing and Prioritizing Quality Measures Maternity CAG Recommended Quality measures – Category 1 and 2 CAG Categorization and discussion of measures Appendix A: |
Introduction
Delivery System Reform Incentive Payment (DSRIP) Program & Value Based Payment (VBP) Overview
The New York State DSRIP program aims to fundamentally restructure New York State´s health care delivery system, reducing avoidable hospital use by 25%, and improving the financial sustainability of New York State´s safety net.
To further stimulate and sustain this delivery reform, at least 80-90% of all payments made from Managed Care Organizations (MCOs) to providers will be captured within VBP arrangements by 2020. The goal of converting to VBP arrangements is to develop a sustainable system which incentivizes value over volume. The Centers for Medicare & Medicaid Services (CMS) has approved the State´s multi-year VBP Roadmap, which details the menu of options and different levels of VBP that the MCOs and providers can select.
|top of page|Maternity Clinical Advisory Group (CAG)
CAG Overview
For many VBP arrangements, a subpopulation or defined set of conditions may be contracted on an episodic/bundle basis. Clinical Advisory Groups (CAGs) have been formed to review and facilitate the development of each subpopulation or bundle. Each CAG is comprised of leading experts and key stakeholders from throughout New York State often including representatives from: providers, universities, State agencies, medical societies and clinical experts from health plans.
The Maternity CAG held a series of three meetings throughout the State and discussed key components of the maternity VBP arrangement, including bundle definition, risk adjustment, and the maternity bundle outcome measures. For a full list of meeting dates, times and overview of discussion please see Appendix A in the Quality Measure Summary.
|top of page|Recommendation Report Overview & Components
The following report contains two key components:
- Maternity Bundle Playbook
The playbook provides an overview of the bundle definition and clinical description including codes and a first impression of available data. - Maternity Bundle Outcome Measure Summary
The outcome measure summary provides a description of the criteria used to determine relevancy, categorization and prioritization of outcome measures, and a listing of the recommended outcome measures.
Maternity Bundle Playbook
Maternity Care Definition: Pregnancy, Delivery & Newborn Care
Playbook Overview – Maternity Care
New York State´s Value Based Payment (VBP) Roadmap1 describes how the State will transition 80–90% of all payments from Managed Care Organizations to providers from Fee for Service (FFS) to Value Based Payments. ´Bundles´ or ´episodes´2 group together the wide range of services performed in the care for a patient with a specific condition. Episodes only include those services that are relevant to the condition, including services that are routine and typical for the care of the condition, as well as services that are required to manage complications that could potentially occur during the course of the (care for the) condition. Episodes open with a claim carrying a "trigger code" that may require a confirmatory claim before the signal is considered strong enough to suggest that an episode of care exists. An episode time window is then created to which all relevant claims are attributed. An episode of care thus created is patient-centered and time-delimited, and can be considered as a unit of accounting for purposes of creating a budget; as a unit of care for contracting purposes; as well as a unit for accountability for quality measurement.
New York State uses the HCI3 (Prometheus) bundled payment methodology, including the standard episode definitions to maximize compatibility and consistency within the State and nationally. More information on how the episodes are developed is available on HCI3´s website3. The HCI3 bundled payment methodology is also referred to as "the grouper."
This playbook describes the four episodes for maternity care, which include Pregnancy, Vaginal Delivery, C–Section, and Newborn. The playbook also explains how these are structured together into a Maternity Bundle as the unit of contracting and accountability purposes. The table provides an overview of this playbook.
| Section | Short Description |
|---|---|
| Description of Episodes | Description of the four episodes that together form the maternity episode |
| Maternity Care Quality Measures | The quality measures that need to be reported when contracting for maternity care |
| Attachment A: Glossary | List of all important definitions |
| Attachment B: Top 10 PAC´s per Maternity Episode | The top 10 PACs per maternity episode |
| Attachment C: Workbook With Codes for Episode | Overview of all maternity care specific ICD-9 codes |
| Attachment D: Data Available for Maternity Bundle Analysis | Data overview of the maternity care episode |
Description of episodes – Maternity Care
The maternity care episode targets Medicaid-only members and includes all pregnancy, delivery, post- delivery care and newborn related care from onset of the pregnancy to 60 days after discharge of the mother as well as 30 days after discharge of the newborn. The maternity bundle is built up combining three separate episodes: pregnancy, vaginal delivery or C–section, and newborn care..
Why is the maternity bundle created?
A comprehensive maternity bundle creates an integrated view on the care during the pregnancy, the delivery and the care received by the mother and the baby in the post-natal period. The creation of the maternity bundle is an attempt to capture care received from "womb to crib", stimulating, for example, the appropriateness of C-Sections and the reduction of early elective inductions. Additionally, the bundle aims to improve outcomes for both the mother and the newborn by tracking preterm and low birth weight babies and linking them back to "gaps in care" and potential improvements (in e.g. health education and reducing the number of teen pregnancies) during the ante-natal period.
How are the maternity episodes triggered?
The maternity bundle consists of four episodes: pregnancy, vaginal delivery, C-section delivery and newborn care. The delivery episodes, vaginal delivery and C-section delivery, are both triggered by procedure codes. The delivery episode then automatically triggers the pregnancy episode which retrospectively looks back 9 months (270 days) to capture relevant claims during the pregnancy. The newborn episode is triggered by the claim for the initial hospital stay of the newborn.
If there is no delivery episode, the maternity bundle is not triggered. For example, when the pregnancy is terminated or either the mother or the fetus (<20 weeks) dies during the pregnancy, none of the maternity episodes are triggered.
Budgets are set upon delivery, retrospectively for the pregnancy and prospectively for the care of the newborn and mother. Due to lack of clinically significant risk factors in the pregnancy episode, only the delivery is risk adjusted based on the mode of delivery (C-section vs. vaginal delivery).
How is the vaginal delivery episode triggered?
The vaginal delivery episode is triggered by one or more claims that carry a procedural code for vaginal delivery and meet the trigger criteria that is specified for this episode. There is only one trigger necessary (no confirming triggers needed).4 However, if the professional trigger claim does not have a corresponding facility claim, it is considered as an orphan claim and the episode does not trigger (incomplete episode).
How is the C-section episode triggered?
The C-section episode is triggered by one or more claims that carry a procedural code for C-section and meet the trigger criteria that is specified for this episode. There is only one trigger necessary (no confirming triggers needed).4 However, if the professional trigger claim does not have a corresponding facility claim, it is considered as an orphan claim and the episode does not trigger (incomplete episode).
Which services are included in the maternity care episodes?
The maternity care episodes include all services (inpatient services, outpatient services, ancillary, laboratory, radiology, pharmacy and professional billing services) related to the care of the pregnancy, delivery and newborn4, starting from the initial obstetrician (OB) visit. The diagram below shows the flow of an episode. All services for maternity care are included, while the episode omits encounters where services are provided for non-maternity care related diagnoses (see crossed out services in the example below).
What is excluded from the maternity bundle?
Maternity bundles will be excluded based on the following exclusion criteria:
- General Exclusions:
- An incomplete set of claims within the episode time window (when there are gaps in Medicaid coverage for enrollment reasons).
- Orphan claims (e.g., where the delivery has a professional claim but no corresponding facility claim).
- A delivery is outside the timeframe of the VBP contract.
- Age: All maternity bundles where the women are younger than 12 or 65 and older at the time of the delivery will be excluded.
- Cost Upper and Lower Limit: To create adequate risk models, individual episodes where the episode cost is below the first percentile or higher than the ninety–ninth percentile are excluded.
- Stillborn & Multiple Live Births: During the pilot period (2016/2017), maternity bundles with stillborns or multiple live births will be excluded and the consequences on the bundle will be analyzed.
Stop–Loss
High costs bundles: When a maternity bundle exceeds a certain cost level (to be determined at a later date), the additional costs are excluded. For example, if the ´stop–loss´ is set at $40,000, a bundle could never be counted as more than $40,000 towards the VBP contractor´s total cost of care. The main reason for this stop–loss is to prevent NICU admissions from skewing the average costs of maternity care, and exposing providers to unwarranted insurance risk.
What are the time–windows for a maternity care episode?
Starting with the pregnancy, all services during the period of the pregnancy are included. For the delivery, all care up to 60 days post discharge are included. For the newborn, all care up to 30 days post discharge are included.
Time–Window for Pregnancy
The pregnancy episode is triggered with the delivery, and the entire pregnancy episode is in the look–back period of the delivery episode and could last the entire pre–natal care period (up to 270 days prior to delivery).
Time–Window for Delivery (Vaginal Delivery or C-Section)
Starting from the delivery procedure, there is a 3-day look back period for care related to the delivery. It then captures all the care around the delivery, e.g., while the mother is in an inpatient facility or a birthing center and extends to a 60-day look forward post-discharge period.
Time–Window for Newborn
The newborn episode captures all the care provided to the newborn from their initial Medicaid claim (corresponding to the inpatient nursery stay) extending to 30 days post–discharge.
Which Potentially Avoidable Complications (PACs) are related to the Maternity Care episode?
Potentially avoidable complications (PACs) related to maternity care can arise during pregnancy, during the delivery period as well as during the post–natal period while the mother is still in the hospital or after discharge.
An episode contains services that are assigned as either typical or as potential complication. In order to be considered a potentially avoidable complication, or PAC, services must include complication diagnosis codes that either (1) directly relate to the index condition or (2) indicate a failure in patient safety. PACs can occur as hospitalizations, emergency room visits, and professional services related to these hospitalizations, but they can also occur in outpatient settings. As the term indicates, a PAC does not mean that something has gone wrong: it means that a type of care was delivered related to a clinical event that may have been preventable. As such, the goal is never to reduce PACs to zero, but to reduce PACs as much as possible, and to benchmark the risk–adjusted occurrences of these PACs between VBP contractors and MCOs.
Additionally, PACs can be identified by failure to comply with patient safety guidelines, such as HACs (CMS defined Hospital–Acquired Conditions) and PSIs (Agency for Healthcare Research and Quality (AHRQ) defined Patient Safety Indicators). Likewise, failure to avoid other situations related to patient safety (e.g. avoidable infection or drug interaction) may also be considered a PAC. In Maternity Care, PACs are relatively rare compared to e.g. the care for chronic conditions.
The top 10 PACs based on costs, for each of the maternity care episodes are listed in Appendix B. See Appendix C for the details of the most prevalent maternity–care related PACs in NYS Medicaid.
Which episodes roll up in the maternity bundle?
The overarching clinical logic of HCI3´s PROMETHEUS Analytics© is based on allowing a member to have multiple open episodes that may coexist concurrently and can be linked together when clinically relevant. Episodes can be analyzed individually based on their included services or rolled up into more comprehensive bundles through clinical association.
Specifically for maternity care, at level 4, all episodes care related to the mom (pregnancy, vaginal delivery and C–section) are rolled up under the pregnancy episode.
Which subtypes of the Maternity episode exist?
´Subtypes´ are subgroupings that could help stratify a population for analytic purposes and are used for, amongst others, risk adjustment purposes.
A few examples of common subtypes for the maternity care episodes are:
- High risk pregnancy, bad obstetric history
- Antepartum hemorrhage
- Gestational diabetes
- Cardiovascular disease in mother
- Low birth weight baby 1500 – 2500 grams
The overview of all subtypes of the maternity care episodes can be found in appendix C.
How is the risk adjustment of Maternity Care episode done?
Risk adjustment takes into account the profile of the population insured (e.g., member demographics such as gender and age, as well as any comorbid conditions the member may have). HCI3´s PROMETHEUS Analytics© severity-adjustment is utilized for risk-adjustment of individual episodes of care and is open to refinement during pilot years (and beyond). HCI3´s severity-adjustment is computed separately for each of the State´s nine managed care regions (provided by the DOH) which each have their own estimated models. For episodes not governed by traditional severity–adjustment, the regional average is also used as the expected cost for all episodes for members within each region.
In order to calculate risk adjusted expected costs, the total cost on a set of demographic and clinical risk variables is regressed, and the results are used to predict expected total cost based on those demographic and clinical factors.
|top of section| |top of page|Attachment A: Glossary
- Complication code: These are ICD diagnosis codes, which are used to identify a Potentially Avoidable Complication (PAC) services during the episode time window.
- Diagnosis codes: These are unique codes based on ICD–9 (or ICD–10) that are used to group and categorize diseases, disorders, symptoms, etc. These identify clinically–related inpatient, outpatient, and professional typical services to be included in the episode in conjunction with the relevant procedure codes. These may include trigger codes, signs and symptoms and other related conditions and are used to steer services into an open episode.
- Episode: An episode of medical care that spans a predefined period of time for a particular payer–provider–patient triad, as informed by clinical practice guidelines and/or expert opinion. The episode starts after there is a confirmed trigger for that episode (e.g. a diagnosis).
- Episode type: Episodes are grouped under four main categories:
- Chronic Condition – care for a chronic medical condition.
- Acute Medical – care for an acute medical condition.
- Procedural (Inpatient (IP) or Outpatient (OP)) – a major procedure and its follow–up care; the procedure may treat a chronic or acute condition.
- Other Condition – care for pregnancy and cancer episodes.
In addition, there is one generic episode type included: - System–related Failures – inpatient and follow–up care for a condition caused by a systemic patient–safety failure.
- Exclusions: Some episodes have specific exclusion criteria, which are either exclusions from the episode based on clinical reasons or exclusions from eligibility for Medicaid.
- ICD–10 codes: The ICD–9 diagnosis codes and the ICD–9 procedure codes for the above categories of codes have been cross–walked to ICD–10 codes leveraging the open–source GEM (Generalized Equivalence mapping) tables published by CMS.
- Index Condition: The index condition refers to the specific episode that the PAC relates to.
- Initial and Confirming Triggers: An initial trigger initiates an episode based on diagnosis and / or procedure codes found on institutional or non–institutional claims data. For many episodes, a second trigger, the confirming trigger, is necessary to actually trigger the episode. Sometimes an episode itself could serve as a trigger for another episode, e.g., pregnancy episode in delivery episode.
- Clinical Association: HCI3´s PROMETHEUS Analytics© allows episodes to be connected to one another based on clinical relevance. For any individual patient, conditions and treatments, all of which trigger different episodes, are often related to one another from a clinical perspective. Episodes can be linked together as either typical or complication.
- Look–back & Look–forward: From the point in which an episode is triggered, episode costs / volume are evaluated within the associated time window for a predetermined number of days before and after the trigger date. Costs, volume, and other episode components that fall within this range are captured within the episode.
- Pharmacy codes: These are codes used to identify relevant pharmacy claims to be included in the episode. HCI3´s PROMETHEUS Analytics© groups pharmacy NDC codes into higher categories using the National Library of Medicine´s open–source RxNorm system of drug classification.
- Potentially Avoidable Complication (PAC): Potentially avoidable complications (PACs) related to maternity care can arise during pregnancy, during the delivery period as well as during the post–natal period while the mother is still in the hospital or after discharge.
An episode contains services that are assigned as either typical or as potential complication. In order to be considered a potentially avoidable complication, or PAC, services must include complication diagnosis codes that either (1) directly relate to the index condition or (2) indicate a failure in patient safety. PACs can occur as hospitalizations, emergency room visits, and professional services related to these hospitalizations, but they can also occur in outpatient settings. As the term indicates, a PAC does not mean that something has gone wrong: it means that a type of care was delivered related to a clinical event that may have been preventable. As such, the goal is never to reduce PACs to zero, but to reduce PACs as much as possible, and to benchmark the risk–adjusted occurrences of these PACs between VBP contractors and MCOs.
Additionally, PACs can be identified by failure to comply with patient safety guidelines, such as HACs (CMS defined Hospital–Acquired Conditions) and PSIs (Agency for Healthcare Research and Quality (AHRQ) defined Patient Safety Indicators). Likewise, failure to avoid other situations related to patient safety (e.g. avoidable infection or drug interaction) may also be considered a PAC. In Maternity Care, PACs are relatively rare compared to e.g. the care for chronic conditions - Procedure codes: These are codes used to identify clinically–related services to be included in the episode in conjunction with the typical diagnosis codes. Procedure codes include ICD procedures, CPT, and HCPCS codes.
- Roll–Up: Some episodes are associated with each other through HCI3´s PROMETHEUS Analytics© clinical logic and grouped under an ´umbrella´ episode, including the grouped episode´s costs/volume.
- Subtypes (code): Episodes often have subtypes or variants, which are useful to adjust for the severity of that episode, and reduce the need to have multiple episodes of the same type.
- Time–window: This is the time that an episode is open for analytic purposes. It includes the trigger event, a look–back period and a look–forward period and could extend based on rules and criteria.
- Trigger code: A trigger code is the diagnosis or procedure code indicating the condition in question is present or procedure in question has occurred. Trigger codes are used to open new episodes and assign a time window for the start and end dates of each episode (depending on the episode type). Trigger codes can be ICD diagnosis or procedure codes, CPT or HCPCS codes, and could be present on an inpatient facility claim, an outpatient facility claim, or a professional claim.
Attachment B: Top 10 PACs per Maternity Episode
The top 10 PACs based on costs, for each of the maternity care episodes are listed below.
TOP 10 PACS FOR PREGNANCY
The top 10 PACs (based on cost) related to pregnancy in NYS Medicaid are:
- Failed induction, abnormal forces, obstructed labor
- Fetal distress
- Fetal abnormalities (decreased fetal movements)
- Urinary tract infection
- Thrombophlebitis, DVT during pregnancy
- Other major puerperal complications
- Sepsis, pyrexia during labor
- Infections of breast & nipple associated with childbirth
- Obstetrical embolism, air, amniotic fluid, pulmonary embolism
- Fever & chills
TOP 10 PACS FOR VAGINAL DELIVERIES
The top 10 PACs (based on cost) related to vaginal deliveries in NYS Medicaid are:
- Post–partum hemorrhage, retained placenta
- Obstetrical trauma
- Other major puerperal complications
- Puerperal sepsis
- Urinary tract infection
- Obstetrical wound complications
- Complications from anesthesia during labor/delivery
- Hypotension / syncope
- Fever & chills
- Acute esophagitis, acute gastritis, duodenitis
TOP 10 PACS FOR C–SECTIONS
The top 10 PACs (based on cost) related to C–sections in NYS Medicaid are:
- Obstetrical wound complications
- Disruption wound C–Section
- Puerperal sepsis
- Other major puerperal complications
- Post–partum hemorrhage, retained placenta
- Urinary tract infection
- Wound infections
- Complications of surgical procedures
- Wound dehiscence
- Obstetrical Embolism, Air, Amniotic Fluid
TOP 10 PACS FOR NEWBORNS
The top 10 PACs (based on cost) related to newborns in NYS Medicaid are:
- Respiratory complication in newborn
- Sepsis of newborn
- Other complications in newborn
- Complications of body temperature in newborn
- Metabolic complications in newborn
- Cerebral complications in newborn
- Infections in newborn
- Meconium aspiration syndrome
- Cardiac arrest in newborn
- Necrotizing enterocolitis
Attachment C: Workbook with codes for Maternity Care episode
The file below includes all ICD–9 pregnancy specific codes.
Workbook with ICD–9 codes
The file below includes all ICD–9 vaginal delivery specific codes.
Workbook with ICD–9 codes
The file below includes all ICD–9 C–section specific codes.
Workbook with ICD–9 codes
The file below includes all ICD–9 newborn specific codes.
Workbook with ICD–9 codes
ICD–10 codes are forthcoming.
|top of page|Attachment D: Data Available for Maternity Bundle Analysis
When contracting the maternity bundle the mother and child must be linked via an external data source, but for the purposes of this report the mothers´ and children´s costs are independently analyzed and aggregated.
Maternity Care Quality Measure Summary
Draft
Maternity Clinical Advisory Group (CAG)
Quality Measure Recommendations
Introduction
Over the course of three meetings, the Maternity CAG has reviewed, discussed and provided feedback on the proposed maternity bundle to be used to inform value based payment contracting for Levels 1–3.
A key element of these discussions was the review of current, existing and new quality measures used to measure relevant for the maternity bundle. This document summarizes the discussion of the CAG and their categorization of outcome measures.5
|top of page|Selecting quality measures: criteria used to consider relevance6
In reviewing potential quality measures for utilization as part of a VBP arrangement, a number of key criteria have been applied across all Medicaid member subpopulations and disease bundles. These criteria, and examples of their specific implications for the Maternity VBP arrangement, are the following:
Clinical relevance
Focused on key outcomes of integrated care process
I.e. outcome measures (postpartum depression) are preferred over process measures (screening for postpartum depression); outcomes of the total care process are preferred over outcomes of a single component of the care process (i.e. the quality of one type of professional´s care).
For process measures: crucial evidence–based steps in integrated care process that may not be reflected in the patient outcomes measured
I.e. focus on postpartum contraceptive care is key but will not be captured in outcomes of current maternity episode
Existing variability in performance and/or possibility for improvement
i.e., blood pressure measurement during pregnancy is unlikely to be lower than >95% throughout the State
Reliability and validity
Measure is well established by reputable organization
By focusing on established measures (owned by e.g. NYS Office of Patient Quality and Safety (OQPS), endorsed by the National Quality Forum (NQF), Healthcare Effectiveness Data and Information Set (HEDIS) measures and/or measures owned by organizations such as the Joint Commission, the validity and reliability of measures can be assumed to be acceptable
Outcome measures are adequately risk–adjusted
I.e. measuring ´% preterm births´ without adequate risk adjustment makes it impossible to compare outcomes between providers
Feasibility
Claims–based measures are preferred over non–claims based measures (clinical data, surveys)
I.e. ease of data collection data is important and measure information should not add unnecessary burden for data collection
When clinical data or surveys are required, existing sources must be available
I.e. the vital statistics repository (based on birth certificates) is an acceptable source, especially because OQPS has already created the link between the Medicaid claims data and this clinical registry
Data sources preferably are patient–level data
Measures that require random samples (e.g. sampling patient records or using surveys) are less ideal because they do not allow drill– down to patient level and/or adequate risk–adjustment, and may add to the burden of data collection. An exception is made for such measures that are part of DSRIP/QARR.
Data sources must be available without significant delay
I.e. data sources should not have a lag longer than the claims–based measures (which have a lag of six months). This is an issue with the vital statistics repository, for example, which have a one year lag (at least for the NYC data).
Meaningful and actionable to provider improvement in general
Measures should not only be related to the goals of care, but also something the provider can impact or use to change care.
|top of page|Categorizing and Prioritizing Quality Measures
Based on the above criteria, the CAG discussed the outcome measures in the framework of three categories:
- Category 1 – Category 1 is comprised of approved outcome measures that are felt to be clinically relevant, reliable and valid, and feasible.
- Category 2 – Category 2 outcome measures were felt to be clinically relevant, valid and probably reliable, but where the feasibility could be problematic. These outcome measures should be investigated during the 2016 or 2017 pilot but would likely not be implementable in the immediate future.
- Category 3 – Category 3 measures were decided to be insufficiently relevant, valid, reliable and/or feasible.
Ultimately the use of these measures, particularly in Category 1 and 2 will be developed and further refined during the 2016 (and possibly 2017 pilots). The CAG will be re–assembled on a yearly basis during at least 2016 and 2017 to further refine the Category 1 and 2 measures.
The HCI3 grouper creates condition–specific scores for Potentially Avoidable Complications (PACs) for each condition. The ´percentage of total episode costs that are PACs´ is a useful measure to look for potential improvements; it cannot be interpreted as a quality measure. PAC counts however, can be considered clinically relevant and feasible outcome measures. For Maternity Care, however, the PAC counts are low, and the events that the grouper considers to be PACs are not all considered validated outcome measures by the CAG. (Individual PACs may be ´mined´ to be considered to be future quality measures, such as post-partum depression etc.)
|top of page|______________________________________________________
1. The recommendations regarding these two episodes will be presented in a separate document. 1
2. The terms can be used interchangeably. Sometimes, the term ´bundle´ is used to refer to a combination of individual episodes. 2
3. http://www.hci3.org/content/online–courses 3
4. Appendix C lists all codes for the maternity episodes. Additional information can also be found on this link: http://www.hci3.org/programs–efforts/prometheus–payment/evidence_informed_case_rates/ecrs–and–definitions. Note that the codes may be different than those found in Attachment C which contains codes being used for NYS. 4
5. The following sources were used to establish the list of measures to evaluate: existing DSRIP/QARR measures; AHRQ PQI/IQI/PSI/PDI measures; CMS Medicaid Core set measures; other existing statewide measures; NQF endorsed measures; measures suggested by the CAG. 5
6. After the Measurement Evaluation Criteria established by the National Quality Forum (NQF), http://www.qualityforum.org/uploadedFiles/Quality_Forum/Measuring_Performance/Consensus_Development_Process%E2%80%99s_Principle/EvalCriteria2008–08–28Final.pdf 6
Maternity CAG Recommended Outcome Measures – Category 1 & 2
| No. | Measure | Measure Steward/Source | |
|---|---|---|---|
| Category 1 | 1 | Frequency of Ongoing Prenatal Care | National Committee for Quality Assurance |
| 2 | Prenatal and Postpartum Care (PPC) | National Committee for Quality Assurance | |
| 3 | % of Vaginal Deliveries With Episiotomy* | Christiana Care Health System | |
| 4 | Vaginal Birth After Cesarean (VBAC) Delivery Rate | Office of Quality and Patient Safety (eQARR) | |
| 5 | C–Section for Nulliparous Singleton Term Vertex (NSTV) (risk adjusted)* | The Joint Commission | |
| 6 | % of Early Elective Deliveries* | The Joint Commission | |
| Category 2 | 7 | Antenatal Steroids* | The Joint Commission |
| 8 | Antenatal hydroxyl progesterone | Texas Maternity Bundle | |
| 9 | Experience of Mother With Pregnancy Care | New | |
| 10 | Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery* | Hospital Corporation of America | |
| 11 | Intrapartum Antibiotic Prophylaxis for Group B Streptococcus (GBS)* | Massachusetts General Hospital | |
| 12 | Birth Trauma Rate – Injury to Neonate | Agency for Healthcare Research & Quality– Quality Indicators | |
| 13 | Live Births Weighing Less than 2,500 Grams (risk adjusted) | Bureau of Vital Statistics | |
| 14 | % Preterm births | Bureau of Vital Statistics | |
| 15 | Under 1500g Infant Not Delivered at Appropriate Level of Care* | California Maternal Quality Care Collaborative | |
| 16 | Postpartum Blood Pressure Monitoring | Texas Maternity Bundle | |
| 17 | LARC uptake | CMS – set of ´Contraceptive Use Performance Measures´ for Medicaid | |
| 18 | Neonatal Mortality Rate | New York State Prevention Agenda | |
| 19 | Hepatitis B Vaccine Coverage Among All Live Newborn Infants Prior to Discharge* | Centers for Disease Control and Prevention | |
| 20 | % of Babies Who Were Exclusively Fed with Breast Milk During Stay* | The Joint Commission | |
| 21 | Monitoring and reporting of NICU referral rates | New | |
| *=NQF Endorsed | |||
CAG Categorization and Discussion of Measures
| Topic | # | Quality Measure (* = NQF Endorsed) | Type of Measure | Measure Steward/ Source* | DSRIP | QARR | HEDIS | Data Required | Quality Measure Categorization & Notes | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Medicaid Claims Data | Vital Statis tics | Category | Notes | |||||||||
| PREGNANCY | Prenatal Care | 1 | Frequency of Ongoing Prenatal Care | Process | National Committee for Quality Assurance/HEDIS | X | X | YES | – | 1 | Scores high on all criteria. HEDIS measure in QARR. | |
| 2 | Prenatal and Postpartum Care (PPC) | Process | National Committee for Quality Assurance / HEDIS | X | X | YES | – | 1 | Scores high on all criteria. HEDIS measure in QARR. | |||
| Screening / Prevention | 3 | Behavioral Health Risk Assessment | Process | American Medical Association – convened Physician Consortium for Performance Measurement ® (AMA–PCPI) | NO | YES | 3 | Low relevance since this measure only looks at whether or not the screening was done. Vital statistics data on this topic have limited reliability. Postpartum depression is being considered as a Potentially Avoidable Complication (PAC) in the Maternity bundle. | ||||
| 4 | Antenatal Depression Screening | Process | Texas Maternity Bundle | NO | NO | 3 | As the previous measure, with the addition that this measure is not included in the vital statistics dataset. | |||||
| 6 | Risk– Appropriate Screening During Pre– Natal Care Visits (Gestational Diabetes) | Process | AHRQ guideline: National Collaborating Centre for Women´s and Children´s Health. Antenatal care: routine care for the healthy pregnant woman. | NO | YES | 3 | Clinically relevant, but should be focused on broader set of risk factors. More relevant to focus on outcome measure – many of the complications of not doing this screening properly will be captured as Potentially Avoidable Complications (PACs). Risk–appropriate screening is currently an OPQS quality improvement target. Measures that may be forthcoming from this project could at a later stage be considered by the CAG. | |||||
| 7 | Antenatal Steroids* | Process | The Joint Commission | NO | YES | 2 | Clinically very relevant because it is a key intervention to increase the incidence of fetal maturation (reduce respiratory distress reduce intraventricular hemorrhage, and reduce neonatal death) The size of the relevant population is small. In addition, the quality of these data in the vital statistics is deemed to be questionable. Given the clinical relevance, these issues merit further attention during the 2016 Pilot. One concern that was mentioned was that ´receiving the full course´ could be too high a goal. | |||||
| 8 | Antenatal Hydroxyl Progesterone | Process | Texas Maternity Bundle | NO | YES | 2 | Clinically very relevant because it is a key intervention to reduce the incidence of preterm births.The size of the relevant population is small. In addition, the quality of these data in the vital statistics is deemed to be questionable. This specific intervention is not yet an established process measure. Given the clinical relevance, these issues merit further attention during the 2016 Pilot. | |||||
| 9 | Antenatal Blood Pressure Monitoring | Process | Not available | NO | NO | 3 | Low feasibility and low clinical relevance because of expected uniformly high score. | |||||
| Organization | 10 | Shared Decision Making | Process | Informed Medical Decisions Foundation | NO | NO | 3 | This measure was suggested by clinical experts. Although the clinical relevance is high, the feasibility is low and this is currently not standard practice. | ||||
| Experience | 11 | Experience of Mother With Pregnancy Care | Outcome | New | NO | NO | 2 | To be further discussed during pilot. The experience (or perhaps even Patient Reported Outcomes) of maternity care is of course highly clinically relevant and a focus on this quality aspect is a core element of DSRIP and the NYS Medicaid VBP roadmap. The feasibility of this measure, however, is currently very low, because the required data for this measure is currently not even gathered. | ||||
| DELIVERY | Vaginal Delivery | 12 | % of Vaginal Deliveries With Episiotomy* | Process | Christiana Care Health System | NO | YES | 1 | Episiotomies are increasingly seen as mostly unnecessary. Scores high on all criteria. | |||
| 13 | 3rd or 4th Degree Perineal Laceration During Vaginal Delivery | Outcome | Beth Israel Deaconess Medical Center | NO | YES | 3 | The CAG considered this measure to create the wrong incentive: overuse of C–sections or episiotomies was seen as a worse side effect than the (small) chance on significant lacerations. Moreover, this is already captured as a PAC. | |||||
| 14 | Vaginal Birth After Cesarean (VBAC) Delivery Rate | Process | Office of Quality and Patient Safety (eQARR) | X | NO | YES | 1 | Key QARR measure, calculated by OQPS. | ||||
| C–Sections | 15 | C–Section for Nulliparous Singleton Term Vertex (NSTV) (risk adjusted)* | Outcome | Office of Quality and Patient Safety (eQARR) | X | proxy | YES | 1 | Key QARR measure, calculated by OQPS. | |||
| 16 | Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery* | Process | Hospital Corporation of America | NO | NO | 2 | Clinical relevance is high: preventing DVT in maternity care in general is one of the three major initiatives of the motherhood initiative in NYS, together with post–partum hemorrhage and high post–partum blood pressure. During the pilot, a discussion with ACOG NYS will be continued on the feasibility of linking their database to MDW data. | |||||
| 17 | Appropriate Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision for Women Undergoing Cesarean Delivery* | Process | Massachusetts General Hospital / Partners Health Care System | NO | NO | 3 | Information not available. Can´t tell when the antibiotic is given. Process measure; outcomes are captured in PACs. | |||||
| Prevention | 18 | Intrapartum Antibiotic Prophylaxis for Group B Streptococcus (GBS)* | Process | Massachusetts General Hospital | NO | NO | 2 | As DVT prophylaxis. | ||||
| Trauma | 19 | Birth Trauma Rate – Injury to Neonate | Outcome | Agency for Healthcare Research & Quality– Quality Indicators | YES | YES | 2 | Clinical relevance and feasibility are high. The CAG would like to consider adapting the exclusions (currently too narrow) and adding a stratification by weight. | ||||
| 20 | Obstetric Trauma Rate – Vaginal Delivery With Instrument | Outcome | Agency for Healthcare Research & Quality– Quality Indicators | YES | YES | 3 | The CAG considered this measure to create the wrong incentive: overuse of especially C–sections to reduce this score was seen as a worse side effect than the (small) chance on significant lacerations. Moreover, this is already captured as a PAC. | |||||
| 21 | Obstetric Trauma Rate – Vaginal Delivery Without Instrument | Outcome | Agency for Healthcare Research & Quality– Quality Indicators | YES | YES | 3 | As previous measure. | |||||
| Overall | 22 | % of Early Elective Deliveries* | Outcome | The Joint Commission | X | NO | YES | 1 | DSRIP measure. High score on all criteria | |||
| 23 | Live Births Weighing Less than 2,500 Grams (risk adjusted) | Outcome | Bureau of Vital Statistics | X | X | proxy | YES | 2 | Clinical relevance is high, and measure is widely used and part of QARR. Yet CAG members question how much influence providers really have on this outcome. Ethnicity can play a significant role. Adequacy of risk adjustment needs to be further investigated during pilot (there is already a very advanced model created by OQPS). | |||
| 24 | % Preterm births | Outcome | Bureau of Vital Statistics | X | NO | YES | 2 | Although this is a DSRIP measure, this is a Domain 4 measure, reported at State level and not risk– adjusted. Given the importance of this topic, this could be further investigated during the pilot. | ||||
| 25 | Under 1500g Infant Not Delivered at Appropriate Level of Care* | Process | California Maternal Quality Care Collaborative | NO | YES | 2 | Clinical relevance high. Also important measure to ´counteract´ potential unwanted effect of saving costs by underutilizing adequate but more costly care. Can create difficult discussions on access of care. To be investigated. | |||||
| POST DELIVERY MOTHER CARE | Monitoring | 26 | Prenatal and Postpartum Care (PPC) | Process | National Committee for Quality Assurance / HEDIS | X | X | YES | – | 1 | Measure discussed above (prenatal care). | |
| 27 | Postpartum Blood Pressure Monitoring | Process | Texas Maternity Bundle | NO | NO | 2 | Clinically relevant, but data is currently absent. | |||||
| Screening | 28 | Postpartum Depression Screening | Process | American College of Obstetricians and Gynecologists | NO | NO | 3 | It´s important to do the screening, but even more important to have the correct follow up. The follow up is not measured with this indicator. | ||||
| 29 | Postpartum Glucose Intolerance / Diabetes Screening | Process | Suggested by ACOG, CDC and ADA | NO | NO | 3 | It´s important to do the screening, but even more important to have the correct follow up. The follow up is not measured with this indicator. | |||||
| Contraceptive Use | 30 | Use of Most or Moderately Effective Contraceptive Services, Postpartum | Process | CMS – set of ´Contraceptive Use Performance Measures´ for Medicaid | YES | NO | 2 | Highly relevant, feasible and valid. Reliability requires additional investigation. CAG suggests broadening the measure to overall contraceptive use (not merely counseling). A caveat is that it is difficult to establish a percentage that is ´adequate´, since simply striving to ´as high as possible´ would create a dangerous incentive. | ||||
| NEWBORN | Overall | 31 | Neonatal Mortality Rate | Outcome | National Committee for Quality Assurance / HEDIS | YES | YES | 2 | Clinical relevance is high. Small numerators may create low reliability, and risk adjustment needs to be adequate. | |||
| 32 | Hepatitis B Vaccine Coverage Among All Live Newborn Infants Prior to Discharge* | Process | Centers for Disease Control and Prevention | YES | NO | 2 | Scores high on all criteria, except possibly the room for improvement. | |||||
| 33 | % of Babies Who Were Exclusively Fed with Breast Milk During Stay* | Process | The Joint Commission | NO | YES | 2 | High score on all criteria, the CAG suggests that some adaptations are made to the definition. ´Exclusive´ seems inappropriately strict. Combining breastfeeding with bottle feeding in the beginning can help rather than higher ongoing breastfeeding. Options could be to modify the measure to "predominantly breastfed" rather than "exclusively breastfed". These data are available in vital statistics. | |||||
| NICU | Referral Rates | 34 | Monitoring and reporting of NICU referral rates | Process | New | YES | 2 | It will be critical to monitor the referral rates to Level 4 to ensure providers are not over–referring babies to Level 4 level of care. | ||||
Appendix A:
Meeting Schedule
| Date | Agenda | |
|---|---|---|
| CAG #1 | 7/21/2015 | Part I
|
| CAG #2 | 8/11/2015 |
|
| CAG #3 | 9/9/2015 |
|
______________________________________________________
3. Neonatal Mortality Rate is a key public health measure that is part of the State´s Prevention Agenda (www.health.ny.gov/prevention/prevention_agenda/healthy_mothers/)
|top of page|
Follow Us