Summary of Changes Clarification of Eligible Providers All Advanced Practice Registered Nurses are eligible providers. This includes, but is not limited to, Certified Nurse Practitioner, Certified Nurse Specialist, and Certified Nurse Midwife. Description Methodology Rationale The percentage of cesarean deliveries for live, term, vertex positioned nulliparous births. Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Full population data is required. The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of state and national cesarean section (C-Section) rates. There are no data that higher rates improve any outcomes, yet the C-Section rates continue to rise. This measure seeks to focus attention on the most variable portion of the C-Section epidemic, the term labor C-Sections in nulliparous women. This population segment accounts for the large majority of the variable portion of the C-Section rate, and is the area most affected by subjectivity. There are clear cut quality improvement activities that can be done to address the differences. Over 60% of the variation among providers can be attributed to first birth labor induction rates and first birth early labor admission rates. 1 The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Labor and delivery guidelines can make a difference in labor outcomes. 2 Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates. 3,4,5 Safe and healthy pregnancies and births are a primary goal for society and particularly for expectant mothers and their families, healthcare providers, and payers. While most births are positive experiences with healthy outcomes, childbirth also brings substantial risks for both the mother and the infant. For consumers, Minnesota lacks publicly reported maternity measures to aid and inform decision making. Several other states have public reporting for maternity care measures, most commonly C-Section and vaginal birth after C-section delivery (VBAC) 1 Main, E.K., Moore, D., Farrell, B., Schimmel, L.D., Altman, R.J., Abrahams, C., et al., (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol. 194:1644-51. 2 Alfirevic, Z., Edwards, G., & Platt, M.J. (2004). The impact of delivery suite guidelines on intrapartum care in standard primigravida. Eur J Obstet Gynecol Reprod Biol.115:28-31. 3 Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of physician characteristics on the cesarean birth rate. Am J Obstet Gynecol. 161:146-9. 4 Goyert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician factor in cesarean birth rates. N Engl J Med.320:706-9. 5 Luthy, D.A., Malmgren, J.A., Zingheim, R.W., & Leininger, C.J. (2003). Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol.188:1579-85. Page 1
rates due to the high volume, high costs and increased morbidity associated with C- section procedures. Recently, new clinical guidelines offering more direction regarding the care and management of pregnant women and childbirth have been released along with new quality measures that can be used to highlight variation and underscore appropriate maternal care. Measurement Period Measurement period will be a fixed 12-month period: 07/01/2014 to 06/30/2015. Denominator Patients who meet each of the following criteria are included in the measure denominator: Female patient was nulliparous and of any age. Patient had a single liveborn delivery. Patient had vertex position delivery. Patient delivered a term (greater or equal to 37 weeks gestation) baby via a vaginal or cesarean birth. Patient had at least one prenatal care visit with an eligible provider in an eligible specialty in the medical group prior to the onset of labor. Patient was delivered by an eligible provider in an eligible specialty with the delivery occurring during the measurement period. Eligible clinics: All clinics that are part of a medical group in which the medical group has providers who perform cesarean section procedures. Eligible specialties: Family Medicine, General Practice, Obstetrics/Gynecology, Perinatology. Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Practice Registered Nurses (APRN). Recommendations to identify nulliparous, singleton, liveborn deliveries: 1. Nulliparous female patients: Nulliparous women are defined as women whose pregnancy is at least at 20 weeks gestational age and who have not previously had a pregnancy of at least 20 weeks gestational age. Medical groups/clinics will need to track and supply information about nulliparity either through medical codes or in the medical record. Identification of nulliparous deliveries can be accomplished by using one of the following suggested methods: a. Create a field in an electronic medical record or chart to indicate Page 2
nulliparity. b. Medical groups/clinics may use ICD-9 codes to identify nulliparous women if used consistently for all deliveries (see Table 1). Those ICD-9 codes are: V22.0 Supervision of normal first pregnancy. V23.81 Other high-risk pregnancy; Elderly primigravida. V23.83 Other high-risk pregnancy: Young primigravida. c. Use the enumeration of a female s obstetrical history where parity (P) = 0 (zero). 2. Singleton liveborn deliveries: Defined as a delivery with one liveborn baby. Identification of singleton liveborn deliveries can be accomplished by using one of the following suggested methods: a. ICD-9 code V27.0 (single liveborn; see Table 2). b. Create a field in an electronic medical record or chart to indicate single, liveborn. 3. Identification of deliveries and type of delivery: Type of delivery defined as vaginal or cesarean section delivery. Identification of type of delivery can be accomplished by using one of the following suggested methods: a. CPT procedure codes (see Table 3): 59400 routine care with vaginal delivery. 59409 vaginal delivery only. 59410 vaginal delivery only including postpartum care. 59510 routine care with cesarean delivery. 59514 cesarean delivery only. 59515 cesarean delivery only including postpartum care. b. Create a field in an electronic medical record or chart that indicates type of delivery. c. Select ICD-9 codes indicating that a delivery occurred. Please refer to the data collection guide for a list of suggested codes to be used to identify patients. Exclusions The following are exclusions: Patient had pregnancy with multiple gestations (ICD-9 codes 651.00 to 651.93, V27.2 to V27.7; see Table 4). Patient had pregnancy with a stillborn (ICD-9 codes 656.40 to 656.43, V27.1; see Table 4). Page 3
Patient had delivery with a non-vertex fetal position (ICD-9 codes 652.20 to 652.43, 652.80 to 6520.83, 669.60; see Table 5). Numerator The number of live, singleton, vertex positioned, term (greater or equal to 37 weeks gestation) newborns who were delivered via cesarean section. Codes Used to Identify Patients who Meet Inclusion Criteria Please use the tables below and refer to the tables located in the Data Collection Guide Appendices for more detailed information about how to identify patients who meet inclusion criteria. Table 1: ICD-9 Diagnosis Codes for Identifying Nulliparity ICD-9 Diagnosis Code V22.0 Supervision of normal first pregnancy V23.81 Other high-risk pregnancy; Elderly primigravida V23.83 Other high-risk pregnancy: Young primigravida Table 2: ICD-9 Diagnosis Codes for Identifying Single Liveborn ICD-9 Diagnosis Code V27.0 Single liveborn Table 3: CPT Procedure Codes for Identifying Deliveries and Delivery Type CPT Procedure Code CPT Procedure Code Description 59400 Routine care with vaginal delivery 59409 Vaginal delivery only 59410 Vaginal delivery only including postpartum care 59510 Routine care with cesarean delivery 59514 Cesarean delivery only 59515 Cesarean delivery only including postpartum care Codes Used to Identify Patients who Meet Exclusion Criteria Table 4: ICD-9 Diagnosis Codes for Identifying Stillborn and Multiple Gestation Births Page 4
ICD-9 Diagnosis Code Maternity Care Primary C-Section Rate Specifications V27.1 Outcome of delivery, single stillborn V27.2 Outcome of delivery, twins, both liveborn V27.3 Outcome of delivery, twins, one liveborn and one stillborn V27.4 Outcome of delivery, twins, both stillborn V27.5 Outcome of delivery, other multiple birth, all liveborn V27.6 Outcome of delivery, other multiple birth, some liveborn V27.7 Outcome of delivery, other multiple birth, all stillborn 651.00 Twin pregnancy, unspecified as to episode of care or not applicable 651.01 Twin pregnancy, delivered, with or without mention of antepartum condition 651.03 Twin pregnancy, antepartum condition or 651.10 Triplet pregnancy, unspecified as to episode of care or not applicable 651.11 Triplet pregnancy, delivered, with or without mention of antepartum condition 651.13 Triplet pregnancy, antepartum condition or 651.20 Quadruplet pregnancy, unspecified as to episode of care or not applicable 651.21 Quadruplet pregnancy, delivered, with or without mention of antepartum condition 651.23 Quadruplet pregnancy, antepartum condition or 651.30 Twin pregnancy with fetal loss and retention of one fetus, unspecified as to episode of care or not applicable 651.31 Twin pregnancy with fetal loss and retention of one fetus, delivered, with or without mention of antepartum condition 651.33 Twin pregnancy with fetal loss and retention of one fetus, antepartum condition or 651.40 Triplet pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not applicable 651.41 Triplet pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without mention of antepartum condition 651.43 Triplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or 651.50 Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not applicable Page 5
ICD-9 Diagnosis Code Maternity Care Primary C-Section Rate Specifications 651.51 Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without mention of antepartum condition 651.53 Quadruplet pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or 651.60 Other multiple pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not applicable 651.61 Other multiple pregnancy with fetal loss and retention of one or more fetus(es), delivered, with or without mention of antepartum condition 651.63 Other multiple pregnancy with fetal loss and retention of one or more fetus(es), antepartum condition or 651.70 Multiple gestation following (elective) fetal reduction, unspecified as to episode of care or not applicable 651.71 Multiple gestation following (elective) fetal reduction, delivered, with or without mention of antepartum condition 651.73 Multiple gestation following (elective) fetal reduction, antepartum condition or 651.80 Other specified multiple gestation, unspecified as to episode of care or not applicable 651.81 Other specified multiple gestation, delivered, with or without mention of antepartum condition 651.83 Other specified multiple gestation, antepartum condition or 651.90 Unspecified multiple gestation, unspecified as to episode of care or not applicable 651.91 Unspecified multiple gestation, delivered, with or without mention of antepartum condition 651.93 Unspecified multiple gestation, antepartum condition or 656.40 Intrauterine death, affecting management of mother, unspecified as to episode of care or not applicable 656.41 Intrauterine death, affecting management of mother, delivered, with or without mention of antepartum condition 656.43 Intrauterine death, affecting management of mother, antepartum condition or Table 5: ICD-9 Procedure Codes for Identifying Non-Vertex Fetal Positions Page 6
ICD-9 Diagnosis Codes Maternity Care Primary C-Section Rate Specifications 652.20 Breech presentation without mention of version; unspecified as to episode of care or not applicable 652.21 Breech presentation without mention of version; delivered, with or within mention of antepartum condition 652.23 Breech presentation without mention of version; antepartum condition or 652.30 Transverse or oblique presentation; unspecified as to episode of care or not applicable 652.31 Transverse or oblique presentation; delivered, with or within mention of antepartum condition 652.33 Transverse or oblique presentation; antepartum condition or 652.40 Face or brow presentation; unspecified as to episode of care or not applicable 652.41 Face or brow presentation; delivered, with or within mention of antepartum condition 652.43 Face or brow presentation; antepartum condition or 652.80 Other specified malposition or malpresentation; unspecified as to episode of care or not applicable 652.81 Other specified malposition or malpresentation; delivered, with or within mention of antepartum condition 652.83 Other specified malposition or malpresentation; antepartum condition or 669.60 Breech extraction, without mention of indication Page 7