Sign of the times…the potential new eCQMs part 3

As I mentioned in my previous blogs, the sign of the times in health care can often be reflected in the proposed (and confirmed) new electronic Clinical Quality Measures (eCQMs). We have previously discussed the proposed eCQM for pressure injuries and hypoglycemia. Today I will discuss the proposed eCQM for Cesarean birth. The Final Rule is again sending a clear message to healthcare organizations where the focus on quality of care is heading. 

CMS notes the total rate of both emergent and elective C-sections has risen since the 1990s, with C-sections accounting for about one-third of U.S. deliveries in 2016. They also noted a wide variation of rates based on region, state and institution. They do note there are no practice guidelines for an optimal rate of C-sections, but international studies indicate lower rates than the U.S. Also noted is the fact that the increased rate of C-sections has not improved overall maternal-fetal outcomes.

It was also noted that resource consumption and reimbursement for C-sections are higher than with vaginal deliveries and there are higher incidences of complications for both mothers and infants with C-section than via vaginal delivery. They do agree there are times where it is clinically appropriate for both the health of the mother and infant to perform C-sections, but the wide range of rates of C-sections performed on nulliparous women across the country indicate that not all C-sections may have been necessary.

The proposed eCQM (PC-02) measures the rate of nulliparous women with a normal-term (greater than 37 weeks of gestation), singleton fetus in the vertex position (NTSV) undergoing C-section.  It includes women undergoing C-section for obstetric as well as other medical reasons.  The steward will be The Joint Commission.

The measure will still include patients with medical indications for elective C-section such as shoulder dystocia, chorioamnionitis, pelvic deformity, preeclampsia, fetal distress, prolapsed cord, placenta previa, abnormal lie, uterine rupture and macrosomia. Testing demonstrated that excluding them does not significantly increase a hospital’s adjusted C-section rate, partially because the majority of these indications are rare in the NTSV population. CMS also noted this measure is not meant to discourage C-sections when it is medically appropriate, but to reduce the number of medically unnecessary C-sections. 

The measure excludes patients with abnormal presentation, single still birth, multiple gestations recorded less than or equal to 42 weeks prior to the end of the encounter.

The measure is not risk-adjusted as The Joint Commission Technical Advisory Panel noted that when adjusted by age, sample size was too low.

This measure has been endorsed by the National Quality Forum (NQF) since 2008 (chart-based measure). However, the electronic version of this measure is undergoing NQF evaluation and endorsement.

Also note this measure is for all payers, not just Medicare patients.

As it appears clear this will be adopted in the future, it is imperative that providers clearly document all relevant maternal and fetal history and note appropriate indications for C-sections. Without documentation of risk factors, CMS, TJO and NQF cannot appropriately determine if there should be some sort of risk-adjustment, or which factors should be included in risk-adjustment.

There are clear signs of the times and I would refer you to our October Quality Webinar on the FY2020 Final Rule changes impacting quality (current changes, not proposed). Also, look for future blogs on the confirmed new eCQMs and other finalized changes to the quality programs.

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.

Register now for our upcoming November Quality webinar: Preventing the Preventables.

References

¹ Osterman, M.J.K., Martin, J.A. (2014). Trends in Low-risk Cesarean Delivery in the United States,1990–2013. National Vital Statistics Reports, 63(6): 1-16.

²Martin, J.A., Hamilton, B.E., Osterman, M.J.K., Driscoll, A.K., Drake, P. (2018). Births: Final Data for2016. National Vital Statistics Reports, 67(1): 1-55.

³ Kozhimannil, K.B., Law, M.R. & Virnig, B.A. (2013). Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Affairs, 32(3): 527-35.

⁴ National Collaborating Centre for Women’s and Children's Health. (2011). Caesarean Section: NICE Clinical Guideline (commissioned by the United Kingdom National Institute for Health and Clinical Excellence).

⁵ American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3): 179-93.