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V.13.1 Special Report: Low Risk Primary C-sectionAnalysis

AHRQ Inpatient Quality Indictor (IQI) # 33

Primary Cesarean Delivery Rate, Uncomplicated

I. Introduction

This V13.1 Special Report is designed to focus your attention on the cesarean section rate of

your low risk population. There are two similar low risk c-section metrics being reported by the

perinatal community: The Joint Commission (TJC) PC 02 Cesarean Section measure and the

Agency for Healthcare Research and Quality (AHRQ) Inpatient Quality Indicator (IQI) #33

Primary Cesarean Delivery Rate, Uncomplicated. They differ in one notable way: PC 02 looks

ONLY at nulliparous women; IQI 33 does not. This difference is driven by the fact that TJC

measure requires parity as a data variable and IQI 33 relies on administrative data within which

parity is generally not available. As hospitals with 1,100 or more annual live births prepare to

submit PC 02 to TJC in 2014, we thought it would be important for hospitals to review their

comparative low risk c-section rate data, regardless of parity.

II. PC 02 Cesarean Section Measure

In April, 2010 The Joint Commission (TJC) put forth the Perinatal Care (PC) Measure Set which

included PC 02: Cesarean Section. PC 02 specifically addressed the c-section rate for women

defined as low risk: nulliparous, term, live singleton in a vertex position1. The PC 02 measure

developer, the California Maternal Quality Care Collaborative (CMQCC), recognized that the

national c-section rate had risen significantly over the last 15 to 20 years and that reducing

primary c-sections in low risk women offers the greatest opportunity to impact a change in that

rate. Dr. Main and his colleagues attribute 60% of the c-section rate variance across hospitals to

the first birth labor induction rates and first birth early labor admission rates.2

Since the introduction of the PC 02 measure, the national rate identified by TJC for the hospitals

submitting the PC measures has remained largely unchanged, currently 26% for Q1, 20133.

Beginning with January 2014 discharges, all hospitals with 1,100 or more live births will be

required to submit the Perinatal Care Measure Set to TJC; there are approximately 1,200

hospitals with obstetric services this size. This new requirement will greatly increase the number

of submitting hospitals (currently at ~ 179) and offer a much better indication of what the true

low risk nulliparous c-section rate is nationally.

The NPIC/QAS data submission specifications include all the required data elements for the

PC measures as “optional” variables. We encourage hospitals to submit as many of the PC

measure data elements as possible in either our standard format or as a supplemental file so

we can include more of these measures in our quarterly reports. As an example, if more

hospitals were able to provide parity information we could calculate PC 02 rates for each

hospital and provide subgroup/database comparisons.

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III. A comparison of the AHRQ IQI# 33: Primary Cesarean Delivery Rate,

Uncomplicated with TJC PC 02

As we mentioned, the Inpatient Quality Indicator # 33 Primary Cesarean Delivery Rate,

Uncomplicated4 is very similar to the PC 02 measure with one major exception: parity is not

required to calculate the rate. IQI 33 looks at term, live singleton, vertex presentation and

excludes women with a prior c-section but does not require that this be the mother’s first birth.

Other differences include:

a) The PC 02 algorithm identifies dx code 652.81- malposition as a contraindication to a

vaginal delivery, thus excluding these cases from the denominator (and numerator); IQI

33 does not exclude them. (Code 652.81- malposition was the only code recorded in 1.9

% of the IQI 33 cases in this analysis.)

b) IQI 33 uses breech procedure codes as well as the breech diagnosis codes to exclude

denominator cases; PC 02 uses only diagnosis codes.

c) IQI 33 excludes procedure code 74.91 Hysterotomy to terminate a pregnancy and codes

678.xx conjoined twins; PC 02 does not.

It does not appear that these differences (other than the first birth requirement) have a major

impact on variation in the PC 02 and IQI 33 rates.

IV. Description of Tables and Graphs

The objective for providing this Report is to further assist you in looking critically at your

AHRQ IQI # 33 rate. The tables in the analysis display data for your hospital compared to the

six NPIC/QAS subgroup averages and the database average. The report includes data for

discharge date range 4/1/12 – 3/31/13 and for the trend period 2008 – Q1 2013. Medical record

numbers for the cases contributing to your hospital’s rates are available by emailing

[email protected]. We are also happy to answer any questions you may have regarding this

report.

Table 1: Overview

Section A: Total Deliveries displays the count of total deliveries, total deliveries without

a prior uterine scar (dx code 654.2x – previous cesarean delivery) and total deliveries

with a prior uterine scar.

Section B: Total C-section Deliveries shows the number of c-section deliveries (MS

DRGs765 and 766), the rate (percent of total deliveries), average length of stay (ALOS)

for c-sections and average charge.

Section C: Primary C-section Deliveries displays the count of c-section deliveries

without a prior uterine scar. The rate of primary c-sections is shown as a percent of total

mailto:[email protected]

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c-sections and as a percent of all deliveries without a prior uterine scar. The primary c-

section ALOS and average charge are also displayed.

Section D: Repeat C-section Deliveries shows the number of c-section deliveries with a

prior uterine scar. The rate of repeat c-sections is displayed as a percent of total c-sections

and as a percent of all deliveries with a prior uterine scar. The repeat c-section ALOS and

average charge are also displayed.

Table 2: AHRQ IQI # 33 – Primary Cesarean Delivery Rate, Uncomplicated

Section A: Primary Cesarean Deliveries repeats the information for all c-section

deliveries without a prior uterine scar displayed in Table 1, Section C.

Section B: IQI 33 - Primary Cesarean Delivery Rate, Uncomplicated (Low Risk) begins with the number of total deliveries. The next display is the count of total

deliveries excluded from the IQI 33 measure population due to ICD-9 coding for

previous cesarean delivery, abnormal presentation, preterm delivery, fetal death, multiple

gestation or breech procedure (see measure Technical Specifications for specific

diagnosis and procedure codes). The number of remaining deliveries in the measure

population is displayed as the Final Denominator, followed by the Total Numerator

(uncomplicated first-time cesarean deliveries without a hysterotomy procedure), the Rate

of Uncomplicated Primary C-sections (IQI 33), ALOS and average charge. Also

displayed in this section is the number of IQI 33 numerator cases with a procedure code

for induction (73.01- induction of labor by artificial rupture of membranes; 73.1 – other

surgical induction of labor; 73.4 – medical induction of labor, excluding medication to

augment active labor) and the percent of total uncomplicated primary c-sections.

Table 3: AHRQ IQI # 33 Coded Complications and Comorbidities

Section A: Total IQI 33 Numerator Cases shows the total number of uncomplicated

primary c-sections (IQI 33 numerator, Table 2, Section B).

Section B: Coded Reasons for performing the C-section displays the percent of total

uncomplicated primary c-section cases distributed by the following mutually exclusive

categories of coded reasons for performing the c-section: dystocia (652.1x, 652.5x,

652.81, 653.xx, 660.0x-660.3x, 660.6x-660.9x, 662.0x-662.2x); non-reassuring fetal

tracing (656.3x, 659.7x); fetal growth (656.5x-656.6x); umbilical cord complication

(663.0x-663.9x); pre-eclampsia/eclampsia (642.4x-642.7x); hemorrhage, abruption,

placenta previa (641.0x- 641.9x); failed induction (659.0x -659.1x); premature rupture of

membranes (658.1x); and all other coded reasons.

Section C: Coded Comorbidities shows the percent of uncomplicated primary c-section

cases coded with one or more of the following conditions: obesity complicating

pregnancy (649.1x); gestational diabetes (648.8x); pregnancy induced hypertension

(642.3x); infections complicating pregnancy (647.xx); pre-gestational diabetes (648.0x

and/or 250.xx); cardiovascular disease (648.5x -648.6x); essential hypertension (642.2x).

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Table 4: AHRQ IQI # 33: Primary Cesarean Delivery Rate, Uncomplicated, Trend

Analysis 2008-2013(Q1) displays your hospital’s data for the period 2008-2013(Q1) compared

to the averages for the six subgroups and the Trend Database, a subset of 53 hospitals that have

participated in the NPIC/QAS database for the same period. The table shows the rate for each

year and the percent change from 2008 -2012.

Graph 1: AHRQ IQI # 33: Primary Cesarean Delivery Rate, Uncomplicated, 2008 -

2013(Q1) graphs the information displayed in Table 4 for your hospital and the trend database.

The graph also displays the 2009 AHRQ comparative provider rate.

Trendlines for the time period are displayed on the graphs for your hospital and the trend

database. If your hospital has not submitted data for the entire period, trendlines will only be

displayed for the years that data was submitted.

Below each graph is a table which includes all the data displayed for the trend analysis period:

the trend database average rate, the hospital’s rate with upper and lower confidence intervals and

the hospital’s count of numerator and denominator cases for each year.

REFERENCES

1 Specifications Manual for Joint Commission National Quality Measures - PC (v2013B)

www.jointcommission.org

2

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? Am J Obstet Gynecol. 194: 1644-51

3As of 9/12/13 – National Core Comparison Group File (179 hospitals reporting). TJC is in a

continual process of updating this information and evaluating potential improvements to data

collection

4AHRQ QI™ Version 4.5, May 2013.

http://www.jointcommission.org/

Sample

AR AO C G NL NS

A. Total Deliveries 1 3,557 4,247 3,662 8,556 2,642 2,917 736 4,130

Total Deliveries without a prior uterine scar 2 3,008 3,513 3,020 7,042 2,140 2,373 613 3,396

Total Deliveries with a prior uterine scar 549 734 642 1,514 502 543 123 734

B. Total C-Section Deliveries 992 1,421 1,202 3,091 916 1,087 242 1,444

C-section Rate 27.9% 33.3% 33.5% 35.9% 35.5% 37.0% 32.8% 34.8%

ALOS 5.0 4.3 4.3 4.1 3.8 3.6 3.1 4.0

Average Charge $27,220 $28,817 $25,570 $25,159 $20,024 $17,577 $15,711 $23,145

C. Primary C-Section Deliveries

(CS deliveries without a prior uterine scar) 551 796 656 1,740 489 587 130 800

% of Total C-sections 55.5% 56.6% 56.1% 56.4% 54.3% 54.0% 52.1% 55.3%

% of Total Deliveries w/o a prior uterine scar 18.3% 22.8% 22.9% 24.6% 23.8% 24.6% 20.8% 23.4%

ALOS 5.8 4.8 4.8 4.6 4.4 3.9 3.4 4.4

Average Charge $30,759 $31,847 $27,789 $27,579 $22,141 $19,058 $16,921 $25,341

D. Repeat C-Section Deliveries

(CS deliveries with a prior uterine scar) 441 624 546 1351 428 500 113 644

% of Total C-sections 44.5% 43.4% 43.9% 43.6% 45.7% 46.0% 47.9% 44.7%

% of Total Deliveries with a prior uterine scar 80.3% 84.5% 83.9% 88.2% 86.2% 91.7% 93.0% 87.6%

ALOS 4.0 3.7 3.7 3.4 3.2 3.2 2.7 3.4

Average Charge $22,798 $24,930 $22,698 $22,055 $17,411 $15,842 $14,353 $20,386

1 MS DRGs 765 and 766 (C-Sections); 774; 775; 767; 768.

2 Dx code 654.2x - Previous cesarean delivery.

V13.1 Special Report: Low Risk Primary C-section Analysis

Table 1: Overview

Subgroup Averages Database

Average

Hospital

SAMPLE

Date Range of Hospital Data: 4/1/2012 - 3/31/2013

Subgroup: AR - Academic, Regional Perinatal Centers

Date Range of Comparison Data: 4/1/2012 - 3/31/2013

Sample

AR AO C G NL NS

A. Primary C-Section Deliveries

(CS deliveries without a prior uterine scar) 551 796 656 1,740 489 587 130 800

% of Total Deliveries without a prior uterine scar 18.3% 22.8% 22.9% 24.6% 23.8% 24.6% 20.8% 23.4%

ALOS 5.8 4.8 4.8 4.6 4.4 3.9 3.4 4.4

Average Charge $30,759 $31,847 $27,789 $27,579 $22,141 $19,058 $16,921 $25,341

B. IQI 33 - Primary Cesarean Delivery Rate,

Uncomplicated (Low Risk) 1

Total Deliveries 3,557 4,247 3,662 8,556 2,642 2,917 736 4,130

Total IQI 33 Exclusions 2 943 1,202 1,004 2,395 872 802 188 1,163

Final Denominator 2,614 3,045 2,658 6,161 1,770 2,115 548 2,966

Total Numerator 361 552 465 1,247 328 433 98 569

Rate of Uncomplicated Primary C-Sections (IQI 33) 13.8% 18.1% 17.5% 20.2% 18.5% 20.5% 17.8% 19.2%

ALOS 5.2 4.3 4.4 4.0 3.6 3.8 3.5 4.0

Average Charge $28,589 $29,589 $26,126 $25,366 $20,315 $18,673 $16,957 $23,845

Total IQI 33 numerator cases with an induction code 3

123 197 169 377 82 121 28 180

Percent of total IQI 33 numerator cases 34.1% 35.5% 34.4% 30.6% 23.9% 28.5% 31.6% 31.5%

1 Also displayed on Table QM 1: Maternal Indicators in the V13.1 NPIC/QAS Quarterly Report.

3 73.01 Induction of labor by artificial rupture of membranes; 73.1 Other surgical induction of labor; 73.4 Medical induction of labor, excluding medication to augment active

labor.


Table 2: AHRQ Inpatient Quality Indicator (IQI) #33 - Primary Cesarean Delivery Rate, Uncomplicated

2 See AHRQ QI™ Version 4.5, Inpatient Quality Indicators #33, Technical Specifications: denominator exclusions include any woman with a prior c-section delivery;

abnormal presentation; preterm delivery; fetal death; multiple gestation diagnosis; or breech procedure.

Hospital

SAMPLE

Database

Average

Subgroup Averages




Sample

AR AO C G NL NS

A. Total IQI 33 Numerator Cases 361 552 465 1,247 328 433 98 569

B. Coded Reasons for performing the C-Section

(percent of total IQI 33 numerator cases

by mutually exclusive categories)

Dystocia 1 49.3% 56.1% 54.6% 57.2% 48.8% 57.7% 56.5% 55.7%

Non-reassuring fetal tracing (656.3x; 659.7x) 38.0% 23.9% 25.5% 20.0% 29.8% 19.7% 20.0% 22.8%

Fetal growth (656.5x; 656.6x) 1.9% 5.0% 5.7% 6.6% 5.0% 6.6% 8.5% 6.1%

Umbilical cord complication (663.0x-663.9x) 3.6% 2.7% 2.2% 3.0% 1.7% 3.9% 3.7% 2.9%

Pre-eclampsia/Eclampsia (642.4x-642.7x) 1.1% 2.1% 2.4% 1.8% 3.3% 1.6% 1.9% 2.1%

Hemorrhage; Abruption; Placenta previa

(641.0x-641.9x) 1.1% 1.7% 1.7% 1.5% 1.2% 1.2% 1.7% 1.5%

Failed Induction (659.0x; 659.1x) 0.6% 0.9% 0.9% 0.9% 0.8% 1.4% 0.5% 1.0%

Premature rupture of membranes (658.1x) 0.0% 0.3% 0.5% 0.3% 0.2% 0.2% 0.5% 0.3%

All others 4.4% 7.3% 6.7% 8.7% 9.2% 7.8% 6.6% 7.6%

C. Coded Comorbidities

(percent of total IQI 33 numerator cases

coded with one or more of the following)

Obesity complicating pregnancy (649.1x) 9.7% 9.0% 12.6% 7.9% 15.3% 11.3% 11.6% 10.8%

Gestational Diabetes (648.8x) 9.4% 10.3% 9.8% 9.5% 8.2% 8.1% 9.2% 9.3%

Pregnancy induced hypertension (642.3x) 5.8% 7.4% 7.1% 6.6% 8.2% 5.7% 4.4% 6.6%

Infections complicating pregnancy (647.xx) 6.1% 5.4% 7.1% 4.5% 10.1% 5.0% 5.3% 5.9%

Pre-gestational Diabetes (648.0x and/or 250.xx) 4.2% 3.0% 3.1% 1.8% 3.2% 1.2% 0.9% 2.2%

Cardiovascular disease (648.5x-648.6x) 1.1% 1.5% 1.5% 1.0% 2.2% 0.6% 0.4% 1.2%

Essential hypertension (642.2x) 0.0% 0.1% 0.1% 0.1% 0.2% 0.0% 0.1% 0.1%

1 Dx codes 660.0x-660.3x; 660.6x-660.9x; 662.0x-662.2x; 652.1x; 652.5x; 652.81; 653.xx


Table 3: AHRQ IQI #33 Coded Complications and Comorbidities

Hospital

SAMPLE

Subgroup Averages Database

Average




Sample

AR AO C G NL NS

2008 12.7% 17.1% 17.1% 21.1% 19.4% 24.7% 17.5% 19.8%

2009 13.3% 17.4% 17.8% 21.7% 19.4% 24.3% 18.2% 20.3%

2010 13.8% 16.8% 18.5% 20.8% 18.9% 23.2% 18.2% 19.7%

2011 13.4% 17.2% 17.7% 20.1% 18.4% 22.0% 17.7% 19.2%

2012 14.0% 17.5% 17.9% 20.1% 18.6% 22.3% 17.4% 19.3%

2013 (Q1) 15.7% 17.5% 18.9% 19.8% 18.8% 20.7% 12.2% 19.1%

Percent Change

2008 - 201210.1% 2.2% 4.3% -4.8% -4.5% -9.8% -0.7% -2.6%


Table 4: AHRQ IQI #33 Trend Analysis 2008 - 2013 (Q1)

Hospital

SAMPLE

Subgroup Averages Trend

Database

Average




Sample

Graph 1: AHRQ IQI #33 - Primary Cesarean Delivery Rate, Uncomplicated2008 - 2013 (Q1) with TrendlinesNPIC ID: SAMPLETrend Rate Hosp Numerator

Hosp Denominator Hosp Rate LCI UCI

2008 19.8% 349 2742 12.7% 0.012254348 0.0130557372009 20.3% 368 2760 13.3% 0.012469228 0.0132527992010 19.7% 353 2555 13.8% 0.013155191 0.0139902132011 19.2% 354 2644 13.4% 0.0127586 0.0135747122012 19.3% 368 2627 14.0% 0.013055634 0.0138630432013 19.1% 95 605 15.7% 0.02808511 0.03148045

Correl Coefficient -0.833999622415.215% -932.289%

-0.197% 0.471%

Trend Trendline X Vals: Hosp Trendline X Vals:

2008 20.1% 2008 12.7%

2013 19.1% 2013 15.0%

2008 2009 2010 2011 2012 2013 (Q1)

Trend Rate 19.8% 20.3% 19.7% 19.2% 19.3% 19.1%

Hospital Rate 12.7% 13.3% 13.8% 13.4% 14.0% 15.7%

Hospital Numerator 349 368 353 354 368 95

Hospital Denominator 2742 2760 2555 2644 2627 605

Lower CI 11.5% 12.1% 12.5% 12.1% 12.7% 12.9%

Upper CI 14.0% 14.7% 15.2% 14.7% 15.4% 18.9%

* Source: 2009 Nationwide Inpatient Sample (NIS), V4.4, August 2012.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2007 2008 2009 2010 2011 2012 2013

Ra

te

Graph 1: AHRQ IQI #33 - Primary Cesarean Delivery Rate, Uncomplicated

2008 - 2013 (Q1) with Trendlines

NPIC ID: SAMPLE

Hospital Rate with 95% Confidence Intervals Trend Hospitals Average Rate

Hospital Rate: Stable Over Time Trend Rate: Significant Downward Trend, p = 0.039

AHRQ Provider Rate (18.3%) *

Sample

AHRQ QI™ Version 4.5, Inpatient Quality Indicators #33, Technical Specifications, Primary Cesarean Delivery Rate, Uncomplicated www.qualityindicators.ahrq.gov

Primary Cesarean Delivery Rate, Uncomplicated

Technical Specifications Inpatient Quality Indicators #33 (IQI #33) AHRQ Quality Indicators™, Version 4.5, May 2013 Provider-Level Indicator Type of Score: Rate

Description

First-time Cesarean deliveries without a hysterotomy procedure per 1,000 deliveries. Excludes deliveries with complications (abnormal presentation, preterm delivery, fetal death, multiple gestation diagnoses, or breech procedure). [NOTE: The software provides the rate per delivery. However, common practice reports the measure as per 1,000 deliveries. The user must multiply the rate obtained from the software by 1,000 to report the number of Cesarean deliveries per 1,000 deliveries.]

Numerator Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with

either: • DRG or MS-DRG codes for Cesarean delivery; or • any-listed ICD-9-CM procedure codes for Cesarean delivery without any-listed ICD-9-

CM procedure codes for hysterotomy

Cesarean delivery DRG codes: 370 CESAREAN SECTION W CC 371 CESAREAN SECTION W/O CC Cesarean delivery MS-DRG codes: 765 CESAREAN SECTION W CC/MCC 766 CESAREAN SECTION W/O CC/MCC ICD-9-CM Cesarean delivery procedure codes: 740 CLASSICAL C-SECTION 741 LOW CERVICAL C-SECTION 742 EXTRAPERITONEAL C-SECT

744 CESAREAN SECTION NEC 7499 CESAREAN SECTION NOS

ICD-9-CM Hysterotomy procedure code: 7491 HYSTEROTOMY TO TERMIN PG

Denominator All deliveries, identified by DRG or MS-DRG code.

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http://www.qualityindicators.ahrq.gov/

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AHRQ QI™ Version 4.5, Inpatient Quality Indicators #33, Technical Specifications, Primary Cesarean Delivery Rate, Uncomplicated www.qualityindicators.ahrq.gov

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Delivery DRG codes: 370 CESAREAN SECTION W CC 371 CESAREAN SECTION W/O CC 372 VAGINAL DELIVERY W COMPLICATING

DIAGNOSES 373 VAGINAL DELIVERY W/O

COMPLICATING DIAGNOSES

374 VAGINAL DELIVERY W STERILIZATION &/OR D&C

375 VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C

Delivery MS-DRG codes: 765 CESAREAN SECTION W CC/MCC 766 CESAREAN SECTION W/O CC/MCC 767 VAGINAL DELIVERY W STERILIZATION

&/OR D&C 768 VAGINAL DELIVERY W O.R. PROC

EXCEPT STERIL &/OR D&C

774 VAGINAL DELIVERY W COMPLICATING DIAGNOSES

775 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES

Exclude cases: • with any-listed ICD-9-CM diagnosis codes for abnormal presentation, preterm, fetal

death, or multiple gestation • with any-listed ICD-9-CM procedure codes for breech • with any-listed ICD-9-CM diagnosis codes for previous Cesarean delivery • with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year

(YEAR=missing) or principal diagnosis (DX1=missing)

See Inpatient Quality Indicators Appendices: • Appendix A – Abnormal Presentation, Preterm, Fetal Death and Multiple Gestation

Diagnosis Codes • Appendix B – Breech Procedure Codes

ICD-9-CM Previous Cesarean delivery diagnosis codes: 65420 PREV C-DELIVERY UNSPEC 65421 PREV C-DELIVERY-DELIVRD

65423 PREV C-DELIVERY-ANTEPART

http://www.qualityindicators.ahrq.gov/

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